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Disturbed behaviour and the Mental Health Act
Professor of Primary Medical Care, Southampton University Medical School, Southampton, UK
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
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Abstract |
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 TOP Abstract Disturbed behaviour, the Mental...Assessment and management of...Acute confusionCompulsory admission and...References |
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When a patient becomes very agitated or violent, threatens suicide or starts to behave oddly, the GP is usually called—by the patient, relatives or friends or police attending the disturbance. As a GP, it is important to know how to handle such situations and under what circumstances the Mental Health Act applies.
Management of acutely disturbed behaviour spans several GP Curriculum statements:
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Assessment and management of disturbed behaviour |
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TOPAbstractDisturbed behaviour, the Mental...Assessment and management of...Acute confusionCompulsory admission and...References |
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Assessment of disturbed behaviour in the community can be difficult. Before seeing the patient, gather as much information as possible, for example from the patient notes, the patient's own GP if you do not know the patient yourself, relatives or even neighbours. Always remember to look after your own safety (Box 1).
When seeing the patient, ask the patient and any other attendants if there is any history of drugs or alcohol excess. Listen to the patient and the accounts of any other people with the attendant. Talk calmly and choose your words carefully, avoiding any confrontations. Establish
- Whether the patient is coherent and making sense. You may be called to patients who are coherent and lucid, but simply angry, upset or having a panic attack. Often talking down is all that is required in such situations. Alternatively, the patient may have an acute confusional state, for example as a result of a urinary tract infection or have the characteristic irrational thoughts and perceptions of psychotic illness.
- Whether there is an obvious trigger for the behaviour. Threats of suicide are often triggered by rows or specific events; disturbed behaviour may be triggered by a bout of drinking or drug taking; acute confusion may be secondary to organic illness such as a urinary tract infection or a hypoglycaemic episode in a known diabetic.
- Whether the patient has a history of mental health problems—for example dementia, depression, schizophrenia or bipolar affective disorder. If the patient has a history of mental health problems, has the patient had similar episodes in the past and, if so, how were they treated?
Box 1. Looking after your own safety
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Physical examination, except from a distance, may be impossible but try to look for possible organic causes of acutely disturbed behaviour, especially if the patient is having visual hallucinations. However, never put yourself at risk in order to examine a patient.
Causes of disturbed behaviour
- Physical illness causing acute confusional state—infection (for example urinary tract infection, chest infection), hypoglycaemia, hypoxia, head injury, epilepsy
- Drugs—alcohol (or alcohol withdrawal), prescribed drugs (for example steroid psychosis), illicit drugs (such as amphetamines)
- Psychiatric illness—schizophrenia, mania, anxiety and/or depression, dementia, personality disorder (for example attention seeking, uncontrolled anger)
Acute management
When your assessment is complete, decide if hospitalization is required and whether this can be done on a voluntary or involuntary basis (compulsory admission under the Mental Health Act). Admission is warranted if the patient is an immediate danger to him- or herself or others or if the cause of the behaviour is unclear and further investigation is needed. Instigate management of any treatable causes identified—for example treat a urinary tract infection causing confusion or arrange for a patient with an acute flare up of a psychotic illness to be urgently reviewed by the community mental health team. Discuss and explain your suggested management plan with the patient and any attendants.
Whether to sedate disturbed patients is a contentious issue. Avoid sedation wherever possible as it may make an already confused patient worse or make further assessment more difficult. However, on occasions, it is necessary to sedate a patient to cover the period before admission or to alleviate symptoms if admission is inappropriate. Avoid sedating patients with chronic obstructive airways disease or epilepsy or if the patient has been taking illicit drugs, barbiturates or alcohol. Suitable drugs to use for sedation include
- Oral: diazepam 5–10 mg, lorazepam 1 mg (can also be given sublingually), chlorpromazine 50–100 mg and
- Intramuscular: chlorpromazine 50 mg, haloperidol 1–3 mg.
Acute dystonia can occur soon after giving chlorpromazine or haloperidol. It presents with torticollis or abnormal posturing of the neck (particularly backward arching), grimacing and/or tongue protrusion. Dystonia can be relieved with intramuscular procyclidine (5–10 mg repeated as needed after 20 minutes to a maximum dose of 20 mg).
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Acute confusion |
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TOPAbstractDisturbed behaviour, the Mental...Assessment and management of...Acute confusionCompulsory admission and...References |
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Acute confusional state or delirium is a common condition seen in general practice—particularly among elderly patients. It may occur de novo or be superimposed upon the chronic confusion of dementia, resulting in sudden worsening of cognition. Characteristic features are as follows:
- A global cognitive deficit with onset over hours or days
- A fluctuating level of consciousness typically worse at night or in the late afternoon
- Impaired memory—on recovery amnesia of the events is usual
- Disorientation in time and place
- Odd behaviour—the patient may be underactive, drowsy and/or withdrawn or hyperactive and agitated
- Disordered thinking—often slow and muddled and often accompanied by delusions (for example patients may accuse relatives of taking things)
- Disturbed perceptions—hallucinations (particularly visual hallucinations) are common
- Mood swings
Causes and differential diagnosis of acute confusional state
Some possible causes of acute confusional state are listed in Table 1. The differential diagnosis of acute confusional states includes deafness (the patient just appears to be confused due to poor understanding), dementia and primary mental illness such as schizophrenia or anxiety states. Patients with dementia tend to have a longer history and do not have fluctuations in their conscious level. However, in practice, it may be difficult to distinguish an acute confusional state from dementia, especially if you are seeing a patient unknown to you who is alone and can give no history.
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Management of acute confusional state
If possible, do a thorough physical examination to exclude treatable causes. However, examination can be difficult. Whether investigation is necessary depends on examination findings and whether or when the patient is being admitted. Possible investigations to consider in the community include
- Urine testing—dipstick for glucose, ketones, blood, protein, nitrites and white cells; laboratory sample for microscopy, culture and sensitivities
- Blood testing—finger-prick blood test to exclude hypoglycaemia, laboratory samples for full blood count, erythrocyte sedimentation rate (ESR), blood glucose and renal, liver and thyroid function
- Electrocardiogram and/or
- Chest X-ray.
Wherever possible, treat the cause of the confusion. For example, give antibiotics to treat an acute urinary tract infection. Try to avoid sedation as this can make confusion worse. Acute confusion can be very frightening for carers. Remember to reassure and support them. Explain why the patient is confused. Ensure that carers are given a clear plan of action, including instructions on when and how to call for further assistance. Arrange to review the patient within a relatively short time frame (for example later the same day or the following morning). Involve the district nursing team, if appropriate, to provide equipment such as cot sides or incontinence aids or just to provide nursing advice and moral support to carers. Admit the patient if
- The patient lives alone
- The patient will be left unsupervised for any duration of time
- If carers (or the residential home) are unprepared or unable to continue looking after the patient
- If the cause does not become clear despite investigation or the patient fails to improve with treatment and/or
- If the history and/or examination indicate a cause requiring acute hospital treatment. In this case, admit as an emergency.
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Compulsory admission and treatment under the Mental Health Act |
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TOPAbstractDisturbed behaviour, the Mental...Assessment and management of...Acute confusionCompulsory admission and...References |
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Most people requiring inpatient care for a mental health disorder agree to hospital admission and become ‘informal’ patients. A minority (about 5%) require compulsory admission and detention. In England and Wales, this is done under the Mental Health Act of 2007. In Northern Ireland, similar provisions apply under the Mental Health Act (Northern Ireland) Order 1986. The Mental Health Act (Care and Treatment) (Scotland) 2003 is described in more detail below. Patients admitted, detained and/or treated under these provisions and are termed ‘Sectioned’—in reference to the Section of the Mental Health Act under which they are detained.
Patients can only be sectioned if they are suffering from a mental disorder, and need treatment for that condition or pose a risk to themselves or others as a result of that condition, and decline voluntary admission (Fig. 1). The Mental Health Acts only allow for compulsory assessment and treatment of a patient's mental health problems. The patient may refuse consent for investigation and/or treatment of other health problems while sectioned.
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Wherever possible, deputizing doctors should always try and contact the patient's own GP before sectioning a patient. In practice, sectioning means calling in the duty psychiatrist and duty social worker. It can be a time-consuming and frustrating business. Always try to obtain voluntary admission—it is better for you and the patient.
Procedure for sectioning a patient in England and Wales
Applications can be made for admission for assessment under Section 2, admission for treatment under Section 3, emergency admission under Section 4 or guardianship under Section 7 (Table 1). Keep a supply of forms that you might need for sectioning in a readily accessible place. These should include Forms 3, 7 and 10 (GP recommendation for Sections 2, 4 and 3, respectively) and Form 5 (application for Section 4 for a ‘nearest relative’).
Applications can be made by an approved social worker (ASW) or the nearest relative of the person concerned (Box 3). The applicant (ASW or nearest relative) must have seen the patient within 2 weeks of the date of the application or within 24 hours in the case of Section 4. Wherever possible, the ASW should make the application rather than the nearest relative to avoid affecting family relationships.
| Box 2. Causes of acute confusion Infection - particularly urinary tract infection and pneumonia; rarely meningitis or encephalitis Drugs - opioids, steroids, sedatives, L-dopa, anticonvulsants, recreational drugs Metabolic - hypoglycaemia, uraemia, liver failure, hypercalcaemia, other electrolyte imbalance (rarer) Alcohol or drug withdrawal Hypoxia - severe pneumonia, exacerbation of chronic obstructive pulmonary disease, heart failure Intracranial - space occupying lesion, raised intracranial pressure, head injury (especially subdural haematoma) Thyroid disease - hyper- or hypothyroidism Carcinomatosis Epilepsy - temporal lobe epilepsy, post-ictal state Nutritional deficiency - B12, thiamine or nicotinic acid deficiency
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| Box 3. Definition of ‘nearest relative’ for the purposes of the Mental Health Act Nearest relative is defined in the Mental Health Act as the first surviving person over 18 years of age out of
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Applications must be based on two medical recommendations, except Section 4 which only needs one. Doctors may examine the patient together or separately, but there must be less than 6 days between examinations. Recommendations must be signed on or before the date of application. Where two medical recommendations are required, the doctors should not be from the same hospital or practice, and one of the doctors must be ‘approved’ under the Mental Health Act. One doctor, if practicable, must have prior knowledge of the patient (ideally a GP but GPs are not obliged to attend outside the practice area). If neither doctor has prior knowledge of the patient, the applicant must state on the application why this was so. The medical recommendations and application must concur on at least one form of mental disorder.
Procedure for sectioning a patient in Scotland
The Mental Health Act (Care and Treatment) (Scotland) 2003 provides for compulsory admission of patient with mental disorders under Part 5 for 72 hours. The application must be made by a fully registered medical practitioner in consultation with a mental health officer, unless this is impracticable. In hospital, Part 6 (lasting 28 days) can be applied and then, if necessary, Part 7 (Compulsory Treatment Order) for a further 6 months.
Key points
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References |
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TOPAbstractDisturbed behaviour, the Mental...Assessment and management of...Acute confusionCompulsory admission and...References |
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Kendrick T, Simon C. Oxford GP library: mental health (2006) Oxford: Oxford University Press ISBN: 0198570570.
Mental Health Act 2007. Available from: www.opsi.gov.uk/acts/acts2007/pdf/ukpga_20070012_en.pdf [date last accessed 16.12.2007].
RCGP GP Curriculum. Available from: www.rcgp-curriculum.org.uk.
Simon C, Everitt H, Kendrick T. Oxford handbook of general practice (2005) 2nd Edition. Oxford: Oxford University Press ISBN: 019856581x.
Simon C, O'Reilly K, Proctor R, Buckmaster J. Emergencies in primary care (2007) Oxford: Oxford University Press ISBN: 0198570686.
Statement 7: Care of Acutely Ill People. www.rcgp-curriculum.org.uk/PDF/curr_7_Acutely_ill_people.pdf.
Statement 9: Care of Older Adults. www.rcgp-curriculum.org.uk/PDF/curr_9_Care_of_older_adults.pdf.
Statement 13: Care of People with Mental Health Problems. www.rcgp-curriculum.org.uk/pdf/curr_13_Mental_Health.pdf.
The Mental Health Act (Care and Treatment) (Scotland) 2003. Available from: www.opsi.gov.uk/legislation/scotland/acts2003/asp_20030013_en_1 [date last accessed 16.12.07].
The Mental Health Act Online. Available from: www.markwalton.net/guidemha/index.asp date last accessed 16.12.07].
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