Psychiatrists deeply disquieted by proposed legal changes

Members of the College of Psychiatrists have reiterated their concerns about elements of the
Mental Health Bill. Niamh Cahill reports 

Certain provisions in the Mental Health Bill 2024 represent “the greatest threat to our patients’ wellbeing for some considerable time”, according to the President of the College of Psychiatrists of Ireland, Dr Lorcan Martin.

Significant concerns about the Bill were reiterated by psychiatrists at their College’s Winter Conference in Limerick, which was attended by more than 300 delegates on 7-8 November.

Dr Martin, a Consultant in General Adult Psychiatry, told the meeting that the ongoing revision of mental health legislation is a “major challenge facing the specialty”. He urged members to take action to highlight what he termed as the shortcomings in the Bill.

“There is an obligation on all of us… to try to make this right by whatever means we have at our disposal. I would encourage every one of you to answer that call, whether it’s writing to public representatives or galvanising patients and families.”

Dr Martin began his address with an overview of the Bill’s passage to date and the College’s activities in response. The draft heads of the Bill were released in 2021, and the Bill was published in July 2024.

Areas of concern

Following widespread discussion within the College and the formation of a working group, six key areas of concern were identified. 

At the conference, these areas were explained in detail during a presentation by Dr Joanne Fegan, Consultant in Old Age Psychiatry.

The first area centred on the issue of consent to treatment and involuntarily admitted patients. The Bill provides that where an adult admitted involuntarily is assessed as lacking capacity to give consent to a proposed treatment (and there is no authorised decision-making representative or relevant healthcare directive in place), the responsible consultant psychiatrist is required to make an application to the Circuit Court prior to any treatment being provided. The Bill provides for the provision of treatment where it is immediately necessary to protect the person’s life, or to address an immediate and serious risk to their health, while the capacity assessments are ongoing or before a determination by the court.

Speaking to the Medical Independent (MI), Dr Martin explained how the legislation would negatively affect patients.

“You can admit [patients] to hospital, but [in certain circumstances] you will have to go to court to treat them and that could take weeks. So you could have someone sitting unwell in hospital for weeks on end. You could have a bizarre situation where the doctor will detain, but the judge will decide on whether or not the patient is to be treated.”

The College believes that patients in the community will also be negatively impacted as consultants will have to spend considerable time in the courts arguing for treatment for inpatients.

Dr Martin also informed MI that the involuntary admission of patients was “a last resort” and not common. 

The second issue related to the requirement for a mental healthcare professional (other than a consultant psychiatrist) to conduct a psychosocial assessment (PSA) on people being considered for involuntary admission. The PSA would be additional to the assessment of the patient by a consultant psychiatrist.

Dr Fegan told members that there was no objection to conducting a PSA, but that the timing of the assessment could place further distress on patients during the acute illness phase.

“Carrying out a PSA at these times could cause harm and distress for someone with severe acute symptoms, who is already undergoing comprehensive assessment,” Dr Fegan remarked.

The regulations concerning care plans was identified as another concern for the College.

Dr Martin told MI that the Bill proposes that the Minister for Health can “dictate the content of a patient’s care plan”.

The Department stated this provision is intended to improve access to and quality of care plans and is not intended to allow the Minister to interfere in clinical care.

The fourth area related to the proposed powers of the review board as contained in the Bill. According to Dr Fegan, the Bill’s wording suggested that the “date and time of the review board could be directed without consideration of the treating consultant’s schedule or caseload”, essentially acting as a legal summons.

This could disrupt the provision of community-based psychiatric care, she added. The College believes that wording around the review board’s powers should be changed to ensure consideration of the treating consultant’s caseload to protect community services.

‘Mental disorder’

Separately, the definition of mental disorder as stated in the Bill is too broad and vague, Dr Fegan said.

In the Bill, ‘mental disorder’ means any mental disorder, illness, or disability,  whether of a continuous or intermittent nature, which affects the person’s thinking, perception, emotion, mood, or judgment and impairs the mental function of the person.

“We are specialists in our field, the definition of what we treat needs to reflect this. We need to be clear,” Dr Fegan told delegates during her presentation.

“The lack of adequate primary care services means that people present to psychiatric services in the absence of an appropriate alternative or due to a lack of understanding about what we do. This comes at the expense of those with serious mental illness.”

Dr Martin echoed these concerns to MI, stating that the definition “is worrying because really it should be limited to people with severe mental illness”.

Concerns about the definition were also raised in the context of the level of funding for mental healthcare, which stands at 5.7 per cent of the overall health budget.

Dr Martin told MI that this percentage of funding represented an all-time low. 

“As a percentage of the health budget, the mental health budget is the lowest ever. We’re down to 5.7 per cent this year from 5.8 per cent last year. Even Sláintecare says we should have 10 per cent and international standards say 12-13 per cent. In 1984 we had 13 per cent of the health budget so it’s decreasing at a time when expectations are getting higher,” he said.

Dr Martin stressed the difference between mental distress and mental illness.

“What psychiatry manages is mental illness; mental distress is a different thing. Unfortunately, because there isn’t a lot of support there for people who are distressed, a lot of that winds up in psychiatry, when really it doesn’t need to at all.”

The final issue centred on the proposed inspection of all community mental health services, including the Child and Adolescent Mental Health Service. Dr Fegan outlined that while inspections were welcome, the recognised gaps needed to be addressed with adequate funding and resourcing.

Several other, minor concerns about the Bill were outlined before Dr Fegan highlighted positive aspects of the legislation.

A favourable aspect was the proposed appointment of a board to oversee the Mental Health Commission, Dr Fegan said.

The presentation concluded with a long list of “next steps” for the College as the Bill has already passed the second stage in Dáil Eireann.

The College plans to issue media statements and write to the Oireachtas health committee and other relevant stakeholders and organisations. 

MI understands that College representatives have since met with Department officials, who requested a written submission. The College stated it looked forward to further engagement with the Department. 

When the Bill was published in July, Minister for Health Stephen Donnelly said it would facilitate more person-centred care and protect the rights of people with mental health difficulties.