EM · Mental Health Act and compulsory treatment
The Mental Health Act and compulsory treatment in the emergency department
Also known as Mental Health Act · Involuntary detention · Compulsory treatment · Statutory schedule · Sectioning · Community treatment order · Police powers and the mentally ill
The Mental Health Act and compulsory treatment in the emergency department — the statutory framework separate from capacity law that authorises detention and treatment of a person with a mental illness who meets defined criteria (mental illness of nature or degree warranting treatment, risk to health or safety or to others, refusal or inability to consent, and no less-restrictive alternative). Covers the assessment by two clinicians, the statutory schedule or section, the duration of detention and the tribunal review, police powers, the duration of each order, and the appeals machinery. Distinguishes capacity versus the Mental Health Act, and informal versus formal admission. Includes the pharmacological management of the dangerous detained patient. ANZ state and territory Acts (NSW Schedule 1, Victoria Assessment and Temporary Treatment Orders, Queensland authorities), UK Mental Health Act 1983 Sections 2, 3, 4, 5, 135 and 136, US state statutes. ACEM-primary, globally tagged.
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Red flags
- Delirium is a medical illness, not a mental illness under most Acts — do not detain a delirious patient under the Mental Health Act; treat under the doctrine of necessity and investigate the cause
- A capacitous patient who meets the criteria may still be detained — capacity and the Mental Health Act are distinct legal frameworks, and a competent refusal of psychiatric treatment does not prevent detention
- A single doctor’s certificate is unlawful where the Act requires two independent assessments — complete the statutory document correctly, serve it on the patient, and state their rights
- Never sedate and detain without excluding an organic cause — hypoglycaemia, sepsis, intracranial bleed and drug toxicity kill the patient held on a psychiatric schedule without investigation
- Exceeding the statutory time limit without renewal, or omitting tribunal review, makes the continued detention unlawful — know the duration of each order in your jurisdiction
- Do not discharge a high-risk patient solely because they 'have capacity' — apply the Mental Health Act criteria to risk, not to capacity alone
Meet the patient
A 32-year-old man is brought to your department by police at two in the morning. He was found on a railway platform, shouting that the trains are transmitting government signals and that he must 'stop the signal' to save the country. His mother tells you by phone that he has been withdrawing for three months, not eating, not sleeping, talking to people who are not there. He is agitated, dishevelled, smells of alcohol, and tries to leave every few minutes. The bedside glucose is 6.1. The vital signs are normal. He meets every criterion for detention — and he has capacity for some decisions and not for others.[1]
The two questions that decide his next four hours are the two that decide every Mental Health Act encounter: does he meet the criteria? (the four-limb test answers that) and what is the right legal authority for the treatment he needs? (capacity, the Act, or necessity — never all conflated). Hold those two questions and everything below slots into place.[1]
References7ShowHide
- [1]Large MM, Nielssen O, Ryan CJ, Hayes R. Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia Soc Psychiatry Psychiatr Epidemiol, 2008.PMID 18060340
- [2]Large MM, Nielssen OB, Lackersteen SM Did the introduction of 'dangerousness' and 'risk of harm' criteria in mental health laws increase the incidence of suicide in the United States of America? Soc Psychiatry Psychiatr Epidemiol, 2009.PMID 19099169
- [3]Ryan CJ, Callaghan S The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act Australas Psychiatry, 2017.PMID 27558219
- [4]Duffy J, Boyle S, Del Villar K What Does Least Restrictive or Less Restrictive Mean in Mental Health Law? Contradictions and Confusion in the Case of Queensland, Australia Am J Law Med, 2023.PMID 38344792
- [5]Allen NG, Khan JS, Alzahri MS, et al. Ethical Issues in Emergency Psychiatry Emerg Med Clin North Am, 2015.PMID 26493529
- [6]Sondhi A, Luger L, Toleikyte L, et al. Patient perspectives of being detained under section 136 of the Mental Health Act: Findings from a qualitative study in London Med Sci Law, 2018.PMID 29742992
- [7]Wilson MP, et al. The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup. West J Emerg Med, 2012.PMID 22461918