Anthony O'Brien: Compulsory care goes only so far in preventing suicide

Coroner Dr Wallace Bain. Photo / APN

Anthony O'Brien, senior lecturer at the school of nursing, faculty of medical and health sciences, University of Auckland, explains the difficulties of treatment without consent.

The call by the Rotorua coroner for changes to the law to enable easier access to compulsory mental health treatment is understandable given the tragedy of suicide. As reported by the Herald, Coroner Wallace Bain's call followed three recent deaths of young people from suicide, shortly after being released from care.

In all three cases, Dr Bain felt it was highly likely that the young person would attempt suicide. As a result, Dr Bain has asked the Director of Mental Health for the definition of mental disorder to be widened.

However, we should be cautious about relying on legislation, and compulsory treatment in particular, to prevent suicide. There are also risks involved in compulsory treatment, including the potential that this might lead to more deaths from suicide as people avoid mental health services out of fear that they might be detained without consent.

The legislation that allows people with mental illness to be detained in hospital for assessment and treatment is the Mental Health (Compulsory Assessment and Treatment) Act 1992.

Section 11 allows for five days' compulsory assessment and treatment if a person is considered a serious risk to themselves or to another person by reason of mental disorder.

In most cases of suicidal crisis, if the act is used, the five-day period allows sufficient time to assist the person to gain control of the crisis and engage with health and social support services.

For the purposes of the act, mental disorder is defined in broad terms which are not limited to mental illness.

Considerable discretion is extended to clinicians in interpreting the legislation. It is therefore unlikely that people thought to need compulsory treatment are being discharged because the definition of mental disorder is too narrow. The overwhelming majority of people who harm themselves or make a suicide attempt are treated without the use of the Mental Health Act, in most cases by community mental health services.

Although the Mental Health Act allows clinicians to detain people for treatment, additional factors affect decision-making. These include the Code of Health and Disability Consumers' Rights and various policy commitments to provide choice in healthcare, rather than compulsion.

In every case, clinicians must balance the risk of a future suicide attempt with the accepted principle of treating the person in the least restrictive environment.

Clinicians must also work to engage the person in care and respect their choices, something that becomes more difficult when treatment is imposed legally.

The Mental Health Act can and does override other legislation where issues of safety are acute, but it is better seen as a last resort rather than a default response to suicide risk.

Use of mental health legislation in New Zealand is highly variable across district health boards. Between 2006 and last year, the use of section 11 in the Wanganui region was three times the rate in Southland.

However, higher use of section 11 is not related straightforwardly to lower rates of suicide. This indicates that the problem of suicidality requires a range of responses and that use of the Mental Health Act has a limited role to play, albeit an important one in some circumstances.

Also, while compulsory treatment may be critical in some crises, it carries its own risks. It enables assessment and treatment to be provided without consent, something rarely seen in other areas of healthcare, and is considered a significant breach of normally accepted patient rights.

If people perceive that the Mental Health Act is used too readily they may be less inclined to use mental health services, something that research has shown to occur in some countries.

Another possible unintended consequence of broadening the definition of mental disorder would be that more people are detained in mental health units that currently report 100 per cent occupancy rates. This would likely lead to clinical resources being directed to hospital care, and away from frontline services in the community.

Suicide is a distressing event for families, friends and all those affected. It represents the nadir of despair, loss of hope and abandonment of any sense of a future.

As a society, we should do everything possible to prevent suicide and to provide care and support for those who find themselves driven to contemplate ending their lives.

In a small number of cases, this will involve compulsory assessment and treatment under the Mental Health Act.

The current definition of mental disorder permits such a response, but a broader definition and greater use of the act seems unnecessary and unlikely to lead to improved mental healthcare.