INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2006; 21: 1213–1214.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1606

RESEARCH LETTER

Appeals by the elderly against compulsory detentionunder the Mental Health Act 1983

Amar Shah* and Suzanne Joels

Royal Free Hospital, London, UK

INTRODUCTION

One of the key safeguards of patients’ civil liberties isthe right to appeal against compulsory detention. Aprevious study by Rimmer et al. (2002) showed thatyounger patients are more likely to appeal againstdetention than older patients, and found that a fullunderstanding of rights was associated with increasedlikelihood to appeal, particularly in the elderly.

Use of the Mental Health Act to detain ‘compliantincapacitated patients’ (as described in the House ofLords’ Bournewood judgement) may result in thisgroup not exercising their right of appeal due to theirincapacity. This poses a particular problem in theelderly population, where a diagnosis of dementiaresulting in admission under the Mental Health Act islikely to be associated with enduring mental incapacity.

The aim of this study was to determine the rate ofappeal by the elderly against compulsory detentionunder the Mental Health Act 1983.

METHOD

Data was gathered on all admissions under Section 2and Section 3 of the Mental Health Act betweenDecember 2002 and December 2005 at the Royal FreeHospital NHS Trust. Records of the Mental HealthAct Office were used to ascertain which of thesepatients appealed against their detention. An appealto the Mental Health Review Tribunal and/or Hospital

Managers was counted as one appeal. For any contin-uous period of compulsory admission, a maximum ofone appeal was counted. Admission and dischargesummaries were used to identify an ICD-10 primarydiagnosis for all patients aged over 65 years.

RESULTS

Three hundred and eighty-nine patients were admittedto the Royal Free Hospital NHS Trust underSections 2 or 3 of the Mental Health Act (MHA)1983 during the study period. Of these, 344 wereunder 65 years of age, and 45 were aged over 65years. Using chi-squared analysis, there were no sig-nificant differences in the sex ratio, and the rates ofdetention under Section 2 and Section 3 betweenthe two groups.

The under 65s were significantly more likely toappeal against detention than the over-65s, 34%compared to 18% (Odds Ratio 2.4, 95% ConfidenceInterval 1.09–5.35).

Within the detained elderly group, 36% of patientswith schizophrenia appealed against detention, 18%of those with an affective disorder appealed, and 7%of patients with dementia appealed against compul-sory detention (Table 1).

DISCUSSION

Key findings of the study

Our study shows that under 65s are almost two and ahalf times more likely to appeal against detentionunder the Mental Health Act than the over 65s. Thisstatistically significant result compares favourably

Received 30 January 2006Copyright # 2006 John Wiley & Sons, Ltd. Accepted 11 April 2006

*Correspondence to: A. Shah.E-mail: amar121@hotmail.com

with the findings of a one-year study by Rimmeret al. (2002) that younger patients are three timesmore likely to appeal against detention.

Ninety-three percent of elderly patients with adiagnosis of dementia did not appeal against deten-tion. Despite including all detained patients over athree year period, the number of detained elderlypatients was small. This renders it unlikely to identifystatistically significant results when analysing sub-groups within the elderly. Nevertheless, this is astrong finding which may provide an explanation forthe low rate of appeal amongst the detained elderlypopulation.

Implications for clinical practice and the need forstatutory advocacy

Access to a Mental Health Review Tribunal is a keyright and should be available to all detained patientswithout prejudice. Article 5(4) of the Human RightsAct 1998 further strengthens this right. There is con-siderable unease concerning the application of theMental Health Act in those suffering from organicbrain syndromes and cognitive impairment whichleave an enduring lack of capacity. This study sug-gests that the reduced rate of appeal among detainedelderly patients may be attributable to the behaviourof people with dementia, perhaps through difficultiesin comprehension, communication and informationretention. It is essential that this group of vulnerablepatients is given every opportunity to exercise theirrights, and not prejudiced by virtue of their illness.

The Mental Capacity Act 2005 includes the provi-sion of a statutory right to advocacy for such indivi-duals. The draft Mental Health Bill provides for anew specialist independent advocacy service avail-able to patients detained formally. However, theseextra facilities will rely on the patient requestingaccess to the service, which may be impossible for apatient with dementia. Further work is needed to iden-tify how a statutory advocacy service for detainedpatients with dementia could overcome the intrinsicdeficits of cognitive impairment to ensure that thefundamental rights of these patients are not neglected.

REFERENCE

Rimmer M-A, O’Connor S, Anderson D. 2002. Appeal againstdetention under the Mental Health Act 1983: relationship toage and incapacity. Int J Geriatr Psychiatry 17: 884–885.

Table 1. ICD-10 primary diagnoses for all detained elderlypatients

Diagnosis Elderly patients Elderly patients whowho appealed did not appeal

Dementia 1 12Alzheimer’s 0 9Vascular 1 3

Depression 0 9Bipolar affectivedisorder 3 4Manic episode 2 2Depressive episode 1 2

Paranoid schizophrenia 4 7Persistent delusionaldisorder 0 2Mixed anxiety anddepressive disorder 0 1Schizoaffective disorder 0 1Organic personalitydisorder 0 1Amnesic syndrome 0 1Total 8 37

1214 a. shah and s. joels

Copyright # 2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2006; 21: 1213–1214.