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The impact of mental health legislation on psychiatric services
International Journal of Law and Psychiatry, Printed in the U.S.A. All rights reserved.
Vol. 5. pp. 377.389,1982
0160-25271821030377-13503.0010 Copyright * 1983 Pergamon Press Ltd
The Impact of Mental Health Legislation on Psychiatric Services J. Hoenig* U. Sreenivasan** D. Leiberman***
In January, 1971, the Province of Newfoundland enacted new mental health legislation. The new Mental Health Act was not proclaimed until 1974 and came into force on January 1, 1975. The act deals mainly with, among other matters, the detention of patients suffering from psychiatric disorders. Newfoundland was a latecomer as far as mental health law reform is concerned. The need for reform had become apparent throughout the western world in the interwar period, and steps had been taken in many countries to amend older laws (1). The old law in Newfoundland was that of Britain, which was essentially the Lunacy Act of 1890 and parts of the Mental Treatment Act of 1930. When Newfoundland became a Province of Canada in 1949, mental health legislation was included in the Health and Public Welfare Act of 1952. The act included few advances and had not gone far beyond the British 1890 and 1930 acts. This situation was not fundamentally different from that in other parts of Canada. In many parts of the world, attempts were made to bring the law in line with the fact that a wide range of new and effective treatments had been adopted. Until the early 193Os, all psychiatry had to offer were institutional care asylum - and psychotherapy, palliative measures to help and protect the patient until a natural remission occurred, or, as frequently happened, the disorder became chronic, and the patient institutionalized. In the 193Os, the new therapies made it possible to treat patients in settings other than mental hospitals, hospital stays were becoming much shorter, and the legal procedures had often become detrimental to treatment. In 1955, the World Health Organisation (2) published a technical report which offered guidelines for new legislation. Several countries began to draft laws along such guidelines. The first province in Canada which introduced a modern mental health act was Saskatchewan in 1961. The National Scientific Planning Council of the Canadian Mental Health Association recommended the establishment of a Committee on Legislation and Psychiatric Disorder, which reviewed the existing situation and formulated guidelines for legislation (3). They presented 25 “principles,” each stating a *Professor of Psychiatry, **Associate Professor Psychiatry, Memorial university of Newfoundland,
of Child and Adolescent Psychiatry,/***Professor St. John’s, Newfoundland, Canada klB 3U6.
377
of
378
J. HOENIG, U. SREENIVASAN, and D. LEIBERMAN
general guideline followed by an explanation, which together made up a solid and imaginative foundation for mental health legislation. Following the publication of that report, the provinces, one-by-one, began to legislate modem mental health acts. It began with Saskatchewan in 1961, followed by British Columbia in 1964, Alberta and Manitoba in 1965, Ontario and Nova Scotia in 1967, Prince Edward Island in 1968, New Brunswick in 1969, and Newfoundland in 1971. In the 1971 act, the procedures dealing with involuntary admission were formulated to conform to three principles (4), namely: 1. A committed patient can be treated in any hospital. Exclusive designation of certain hospitals for that purpose was abolished. 2. Civil committal and discharge were made medical procedures. The participation of the judiciary and the hospital administration were no longer required. I 3. Multiple safeguards were created. The certificate of committal lapses at short intervals and must be renewed after reassessment of the patient. A quasi-legal tribunal was created to hear appeals from patients or relatives, with powers to order instant release of the patient. Evaluation of the Effect of the Act Committal legislation is clearly of great importance, as our figures of the number of people affected will show. If anyone should still entertain doubts about this, a study of the public debate on this issue, which is widespread, intense, and often heated, should dispel those doubts. (5-14). Yet, relatively few investigations have been carried out into the effect different kinds of legislation have on the actual management of patients. A few studies of this kind have been done in the U.K. and elsewhere (15-18) and a few in the U.S.A. (19-28); but very little has been done in Canada (29-33). The recent introduction of new legislation in this province is, in many ways, fundamentally different from what preceded it, and offers a good opportunity for an investigation of this nature. Method Before the new act, the Hospital for Nervous and Mental Disorders (now called the Waterford Hospital) was the only hospital in the province which could admit committed patients. Although other hospitals are allowed to do so
‘The trend in all postwar mental health legislation of making the committal procedure more medical has recently been partly reversed in several provinces, making committal procedures more judicial, or restricting the conditions for committal. The province of Newfoundland too has in 1980 appointed a committee to make recommendations for change, in particular to restrict the powers of the attending physician to discharge patients. It is regrettable that such changes are brought about purely as a result of social pressures simply pushing the pendulum one way or the other rather than basing reforms on empirical investigations like the present one. It will however be interesting in due course to monitor the effect of these new changes on the Mental Health Services.
THE IMPACT OF MENTAL HEALTH LEGISLATION
379
since 1975, none of the hospitals have been able to make the necessary structural alterations to accommodate such patients, and over 90% of all committed patients in the province still go to the Waterford. The study concentrates therefore on the patients admitted to that hospital. Four separate years at three annual intervals were chosen, two before and two after the act came into effect. The years were 1969, 1972, 1975, and 1978. The charts of all admissions in each of these years were examined, and a number of items referring to clinical, demographic, and socioeconomic factors were recorded on item-sheets for computer analysis. The present report omits all patients who were sent to the hospital by court order. Thus, of the involuntary admissions, only the civil committment cases are included. Other comparison figures are derived from Statistics Canada reports and from the Division of Mental Health Services of the province. Findings Admission rates shown in Table 1 differ considerably from those in Canada as a whole. In 1969, the per capita rate of psychiatric admissions in Newfoundland was less than half that for Canada. For men, the rate rose between 1969 and 1972 by 50%, and showed a further steep rise of 45% in 1975, the year of the new Mental Health Act. Even more striking is the impact of the new act in the case of women. Their admission figures had always been lower than those for men, and showed no rise between 1969 and 1972; but in 1975 there was a steep increase of 129%. In Canada as a whole, there had been an increase in admission rates between 1969 and 1972 of 8% for men and 10% for women. From 1972 to 1975, rates for men rose by 20070, and for women by 26%. The table shows that, by 1978, the rates for the province approached those for Canada as a whole. The change is remarkable, particularly for women.
TABLE 1 Admission Rates per 100,000 Population (including justice admissions) Canada
Sex
Admissions
Newfoundland
Rate per 100,000 pop.
Admissions
Rate per 100,000 pop.
1969
M F
51,132 46,063
484 438
601 562
229 223
1972
M F
55,469 50,742
508 465
902 555
332 212
1975’
M F
67,763 64,238
595 562
1312 1273
468 472
1978
M F
61,417 58,000
526 491
1603 1516
555 541
*The Mental Health Act was instituted act’s impact.
in 1975. Figures for and subsequent
to 1975 reflect the
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J. HOENIG, U. SREENIVASAN, and 0. LEIBERMAN
There also has been a shift within the province (Table 2) from the heavy use of the provincial mental hospital to the use of general hospital psychiatric units. In 1969, 87% of all male patients and 74% of all women were treated in the mental hospital. 1972 saw a slight decrease of that percentage, particularly regarding women. After the introduction of the Mental Health Act, the figures for men decreased to 35070, and for women to 20%. Thus, the psychiatric hospital began to play a smaller role in the network of mental health services both in relative and in absolute numbers. The total admissions had fallen from 1972 to 1975 by 28% (35% for men and 16% for women), and by another 28% from 1975 to 1978 (20% for men, 39% for women). This shift is all the more remarkable as the number of general hospital psychiatric beds had not risen by very much (34). In 1970 there were 761 beds in the psychiatric hospital and 121 in general hospitals. The psychiatric hospital closed 261 beds in 1973 and another 100 in 1978, leaving only 400 beds. The general hospitals added only 11 beds in 1973 and 24 beds in 1978. Thus, the total bed count fell from 882 in 1970 to 556 in 1978. The rate of compulsory civil commitment has fallen even more sharply (Table 3). In 1969, as many as 61.8% of all civil admissions were by certificate. In 1972 this figure had decreased to 45.7%. After the introduction of the new Mental Health Act it went down further to 33.3%. In 1978 there was a slight increase to 40.7%, but such admissions remained well below the 1972 level. In absolute figures this did not represent a rise but a further fall. Following the increase in general hospital psychiatric services, the vast majority of all compulsory admissions continued to go to the mental hospital. In 1976, for instance, only 9 certified admissions, out of a total of 273), did not go to that hospital. As mentioned earlier, the new act permits certified admissions to any hospital in the province, even to cottage hospitals, but few hospitals have been able to install the necessary facilities which would make it possible to look after involuntary patients for more than a very short period.
TABLE 2 Newfoundland Admlssions (Civil) Sex
Psychiatric Hospital
General Hospitals
Total
Other
M F
477 402
(87%) (74%)
74 (13%) 142 (26%)
-
551 544
(100%) (100%)
M F
655 348
(80 O/o) (64%)
160 (20 O/o) 192 (36%)
-
815 540
(100%) (100%)
1975*
M F
426 293
(35 O/o) (20%)
732 (60%) 935 (77%)
54 (5%) 34 (3%)
1212 1208
(100%) (100%)
1978
M F
342 180
(23%) (12%)
1067 (72%) 1266 (85%)
62 (4%) 52 (3%)
1470 1499
(100%) (100%)
1969 1972
*The Mental Health Act was instituted act’s impact.
in 1975. Figures for and subsequent to 1975 reflect the
THE IMPACT
OF MENTAL
HEALTH
381
LEGISLATION
If one calculates the involuntary admissions as rates of all psychiatric admissions in the province, the figures fall from 47.2% in 1969 to 6.8% in 1978, with the steepest decline occurring after the introduction of the new act in 1975. Thus, the introduction of the act brought about a sharp decline in the number of patients who were-compulsorily admitted, while the number of patients in the province treated for psychiatric disorders had increased drastically. Although the diversification of the psychiatric services and their expansion into a large number of general hospitals had begun much earlier (34), the impact had become substantial only in the late 1960s and early 197Os, when the number of admissions to the mental hospital began to show an absolute decrease. The question now arose as to whether the decrease in the need for certified admissions benefitted particular groups of patients more than others, and if so which types of patients. Factors Associated With the Decrease in Compulsory Admissions The admissions to the psychiatric hospital in each of the four years under study were divided into certified and voluntary, and correlations were sought with clinical factors such as diagnoses; with demographic factors such as sex and age; with social factors such as marital state and type of household; with economic and educational factors such as employment status, literacy and schooling; and with geographic factors such as distance of residence from the hospital, and size of community. Any one of these circumstances could modify the impact of a new committal procedure and make it easier for certain groups over the other groups of patients to be treated by voluntary admission to hospital. Diagnosis
Table 4 shows the distribution of the main diagnostic groups and the proportion of certified admissions. The organic psychosyndromes, schizophrenias and neuroses, and personality disorders all show a significant reduction in the proportion of certified admissions. the schizophrenics and the neuroses and personality disorders seem to show the same decrease in certification as does the
TABLE 3 Certification Rates Province All Admissions 1969 1972 1975’ 1978
1163 1457 2585 3116
Psychiatric Certified 549 462 240 212
‘The Mental Health Act was instituted act’s impact.
(47.2%) (31.7%) (9.3%) (6.8%)
All Admissions 888 1010 723 521
in 1975. Figures for and subsequent
Hospital Certified 549 462 241 212
(61.8%) (45.7%) (33.3%) (40.7%)
to 1975 reflect the
The percentage figures indicate the proportion of ail admissions which were certified. *The Mental Health Act was instituted in 1975. Figures for and subsequent to 1975 reflect
impact.
+ 3SD
NS
- 3SD
NS
+ 3SD
61.8% 45.7% 33.3% 40.7%
Cert.
SD f 8.9
SD -c 7.0
888 1010 723 521
65.2% 45.9% 34.4% 28.9%
Comparison 196911978
181 307 174 145
N
Total Cert.
NS
the act’s
54.8% 36.6% 27.5% 34.1%
N
NS
168 152 160 85
Cert.
NS
57.9% 38.0% 31.1% 51 .O%
N
Others
NS
157 155 121 143
62.5% 48.8% 36.8% 46.6 %
Cert.
Neuroses & Personality Disorders
+ 3SD
288 297 223 133
72.3% 59.8% 33.3% 40.0%
94 102 45 15
N
Cert.
Affective Psychoses
Co’mparison 196911975
Significance
1969 1972 1975’ 1978
N
Cert.
Schizophrenia
N
Organic Epilepsy
TABLE 4 Admissions By Diagnoses (% Certified)
8
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OF MENTAL
HEALTH
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383
total group. The affective psychoses, however, show some fluctuations over the years. At first, there was a fall of the same order as that for the total group, but a large increase in 1978 made the 1978 figures not significantly different from the 1969 ones. The affective_psychoses thus show a significantly smaller decline in the certification rate than do figures for the total group. The reason for this is probably that the manic patients, who make up a fair proportion, are usually the most difficult ones to convince of the need of hospitalization and must be brought under treatment by certification. Changes in mental health legislation have little impact on the management of such patients. The largest decline in certification rates is found in the organic psychosyndromes and “others,” which inlude retardation and various non-psychotic disorders. Sex
It has already been noted in the national figures that psychiatric admission is not equally distributed in men and women. Significantly more men were certified in 1969 (p < 0.03). Over the years, however, that difference tends to disappear. The number of men coming into hospital voluntarily shows an absolute as well as a relative rise. Although there remains a higher percentage of voluntary admissions for women, that difference is not significant.
All age groups have experienced a significant reduction in certification rates, the 40-plus groups more so than the younger ones (p < 0.0001). The reduction barely reaches significance in the adolescents. The drop which occurred after the new act is significant @ < O.Ol), but the trend was already established by 1972. Compared with the total group, the greatest decline in the certification rate was found in the over-60 age group. The 40-59 group showed a greater decline in 1975, but had fallen back into line by 1978. Marital State Both the single and the married show a marked decrease in certified admissions (p < 0.0001). Marital status does not seem to influence the certification rate, not even in the group which includes the widowed, divorced and separated. In that group the proportion of involuntary admissions also changes significantly, but to a lesser degree than in other groups. Household One might expect that patients living with their families are more likely to be admitted informally, as the doctor’s task in overcoming resistance to entering hospital should be eased if family members help to reassure the patient. Liberal mental health legislation should more readily invoke such help. We found, however, that patients living with their relatives are consistently admitted more
384
J. HOENIG, U. SREENIVASAN, and D. LEIBERMAN
often under certificate than patients living with non-relatives @ < 0.001). Patients living in households with non-relatives much more frequently enter hospitals voluntarily (p < 0.005). Patients who lived alone also showed a high proportion of involuntary admissions, but without a significant decrease over the 10 years, unlike the two other groups. The abnormally small decline in the certification ratio suggests that legislation did not affect the group living alone. The significantly greater decline in certification rates for patients living with non-relatives in 1975 was not sustained.
Schooling One’s expectation that certification would be more frequently necessary in persons with lower educational attainments are belied by the figures. Patients with 6th-grade education or higher had involuntary admission rates of the same order, and show an equal decrease in certification @ < O.OOl), which had begun before the new act was in force. Patients with tertiary education have always shown a higher though non-significant certification ratio, and in that group there are no significant changes over the 10 years. Only the group with the lowest educational attainment showed a significantly sharper decline in certification rates, compared to the total in 1975, but this was not sustained.
Literacy As regards literacy, the proportion of certified admissions seem to follow the general trends in other categories, but to a lesser degree. The absolute decrease in illiterate and semi-literate patients may reflect an improvement in the educational standards in the province. Compared to the total group, the proportion of involuntary admissions shows a significant decrease in the illiterate groups. The literate group shows a highly significant increase. This seems to be the only group in which the new act seems to have increased committment. Employment Unemployment, introducing greater instability into a person’s life, might conceivably make certification more frequently necessary. However, our figures show that this is not so. In fact, the employed were more often certified 0, < 0.001) both in 1969 and in 1978. None of the differences in decline differ significantly from the total group.
Distance With the provision of psychiatric services in many parts of the province, one would expect voluntary patients to be treated to a larger extent locally, thus causing not an absolute, but a relative increase in certified admissions to the psychiatric hospital among patients living at greater distance from that
385
THE IMPACT OF MENTAL HEALTH LEGISLATION
hospital. This indeed turned out to be so (Table 5). In St. John’s, there have always been more voluntary patients, and such admissions increased up until 1978. Patients from the Avalon Peninsula also showed a decrease in involuntary admissions. In 1969, the farther away the patient’s residence from the hospital, the higher the certification rate. This was still so in 1978. The speed of decline in the rate between 1969 and 1978 was also significantly less in the two groups who live farthest away. Certification of patients from St. John’s and the Avalon Peninsula shows an accelerated decrease between 1969 and 1975, but this was not maintained. These differences illustrate the changing role of the psychiatric hospital. Cooperative patients tend now to be treated as voluntary admissions in general hospitals nearer home, and only the severly ill and certified patients tend to still be admitted to the psychiatric hospital.
Type of Community Patients from urban areas have always had a lower certification rate (although not significantly so), and this pattern is still in evidence in 1978, although the certification rate has significantly decreased in all three groups. Compared to the rate of decrease in the total group, the only subgroup which shows a significantly higher speed of decrease is the urban one.
Length of *Hospitalization Finally, the effect of all these changes on the length of stay in hospital is also strikingly favorable. Table 6 shows that in 1969, a larger proportion of voluntary patients were discharged within a month after admission, namely 45.7% as
TABLE 5 Admissions By Distance From Hospital (% Certified) St. John’s 14 miles N 1969 1972 1975’ 1978
Avalon 15-99 miles
Certified
401 510 354 289
54.6% 30.4% 31.9% 30.4 %
N
loo-499
Certified
179 211 210 120
62.6 % 46.9% 26.7% 46.7%
N
Certified
262 247 132 89
Labrador 500 miles
miles
69.5% 58.7% 40.9% 60.7%
N
Certified
44 21 26 21
77.3% 61.9% 65.4 % 71.4%
Significance Comparison 196911975
+ 2SD
Comparison 196911978
NS
‘The Mental Health Act was instituted act’s impact.
-
3SD NS
-
NS
-
3SD
3SD
-
3SD
in 1975. Figures for and subsequent to 1975 reflect the
J. HOENIG, U. SREENIVASAN, and D. LEISERMAN
386
TABLE 6 Length of Stay Certified 1 month
1969 1972 1975* 1978
N
%
194 216 112 107
35.4% 46.8% 46.8% 50.5%
Voluntary Total
1 month N
549 462 241 212
‘The Mental Health Act was instituted act’s impact.
155 329 232 175
Total Significance
O/O
45.7% 60.0% 48. i v. 56.6 O/o
339 548 482 309
P< 0.001
NS
In 1975. Figures for and subsequent to 1975reflect
the
compared to 35.3% in the certified group @ < 0.001). In 1978, the propdrtion of short-stay patients had increased among the voluntaries to 56.6070, and among the certified admissions to 50.5%. There has thus been a general decrease in the length of stay, and the difference between voluntary and certified patients is no longer significant due to the larger decrease among the certified patients. Discussion The importance of innovations in mental health legislation for civil admissions is not universally accepted. Visotsky et al. (35), analyzing the impact of a new mental health code enacted in Illinois in 1963, concluded that “philosophy, not laws, determine admission practices.” Zwerling et al. (24), wanting to find out the extent to which involuntary hospitalization might be overused, declared a “no-committment-unless-absolutely-necessa~-week,” during which emergency room psychiatrists were urged to commit only patients in absolute need of hospitalization. Comparison with figures in the preceding and subsequent weeks showed no significant difference from those of the “no-committment week.” In each week about 40% of all admissions to two Bronx hospitals were involuntary. Zwerling concludes that decisions about committal are the result of “societal attitudes,” which change only if society itself changes. In another study, however, Zwerling et al. (23) - comparing a group of voluntary with a group of involuntary patients - found differences in six respects: The involuntary admissions showed (1) more anti-social trends, (2) more anger, (3) more assaultive acts, (4) more hyperactivity, (5) more “physical problems,” and (6) a relative absence of depression. Demographic data were equal in the two groups except with respect to the household from which patients came. Those living alone tended to come voluntarily, those with parents came in more often by certification. This would suggest that clinical factors determine the need for certification, and laws cannot change those factors. It is difficult to reconcile this with Zwerling’s earlier conclusion that societal attitudes determine the committal rate. Gove et al. (20) conducted a similar comparison in the state of Washington. They, too, found that the two groups differed mainly in respects attributable to the clinical factors.
THE IMPACT
OF MENTAL
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LEGISLATION
387
These contentions do not receive support from our findings, which show a steep decline in certification after the introduction of a new law. Other countries, such as the United Kingdom, show consequences of new legislation similar to ours (15, 18). Mental health legislation attracts the attention of diverse pressure groups, many of which take a one-sided view, sometimes to the point of fanaticism. The changes in legislation which have taken place after the second world war were initiated mainly by medical opinion anxious to bring the committal laws in line with the changed situation in psychiatric therapeutics. Lately, however, since the introduction of the new legislation, non-medical particularly those that sympathize with the anti-psychiatry groups, “movement,” have voiced a wish to change the law once again. Their intentions vary greatly from a wish to abolish all legislation (36, 39) to restricting committability to “dangerousness” (29), to widening the powers for committal beyond the present conditions (37, 38). A strange position has been taken up by certain so-called “human rights” groups who want to make the committal procedure an exclusively judicial process, not a medical one - a clear reversal from 1890. The fierceness with which all these diverse viewpoints are pressed is matched only by lack of information, or worse still, the degree of misinformation from which many participants suffer. To counter such often injudicious pressures for change, it is not enough to offer alternative opinions. What is needed to steady the legislature on a course which best serves the patients and their families and society at large are objective investigations of the effect of certain laws on the community. Such investigations, however, are far too few. Conclusions The present investigation of the impact of the new Mental Health Act, with liberalized committal procedures and safeguards for the patient, shows that the act did indeed coincide with a great deal of change in the delivery of psychiatric services, and - although some of these changes may be due to other factors it is very likely that a great deal can be ascribed to the effect of the act itself. The following changes have taken place: 1. Many more patients had access to psychiatric services in 1978 than did in 1969. The number of admissions per 100,000 population, which used to be less than half of that of Canada, has now caught up with the Canadian figures. It is not likely that this represents an increase in psychiatric morbidity in the province, but suggests rather that in 1969 a large number of patients had no access to psychiatric treatment. The increase had begun before the proclamation of the act, but after it was passed by the Legislature in 1971. Much public discussion and education had taken place between 1971 and 1975. There was a sharp increase in admissions in 1975, when the act came into force. The changes particularly affected women patients. No doubt, the better accessibility became possible by the addition of general hospital beds in various parts of the province, a process which began in 1965, although the total increase of such beds between 1970 and 1978 amounts only to a total of 35. During the same period, 360 psychiatric hospital beds were closed. 2. With the increase in admissions, there was a very striking decline in the
388
J. HOENIG,
U. SREENIVASAN,
and 0. LEIBERMAN
proportion of patients who were admitted as involuntary patients. The decline from 47.2% to 6.8% is not just a function of the five-fold increase in total admissions; there has been a drop in the actual numbers of certifications from 549 in 1969 to 212 in 1978, a drop of 61%. Again, the drop is most marked immediately after the proclamation of the new act, and the role of the new legislation on these figures cannot easily be overlooked. Considering the serious effect certification can have on the patient’s subsequent life, this drop in the number of committals to less than half is of immense benefit. The proportion of involuntary admissions compares well with figures elsewhere. Unfortunately, Statistics Canada does not publish such figures, and they are therefore difficult to come by. Page et al. (40) claim that committal figures in Canada have not fallen, but the statement is not documented. In the United Kingdom, where very similar legislation exists, the proportion in 1976 was 11.7% involuntary civil admissions. 3. It has been shown that the small, general hospital psychiatric units were able to deal with the patients who formerly must have been treated in the psychiatric hospital, many patients having in the past required involuntary admission. A small number of patients were actually treated in the general hospital while admitted under an order. 4. The length of hospital stay was reduced for the voluntary admissions, and even moreso for the certified admissions. This reduction in the length of stay became particularly marked in 1975, after the introduction of the new act, showing that the automatic lapse of the certificate shortly after admission, and the other safeguards, has led to an earlier discharge of these patients than had formerly been the case.
Reference Notes 1. Curran, W.J. Comparative analysis of mental health legislation in 43 countries: A discussion of historical trends, International Journal of Law and Psychiatry, 1978, 1, 79-921. 2. Expert Committee on Mental Health. Fourth report, legislation affecting psychiatric treatment, Technical Report Series No. 98. Geneva, WHO, 1955. 3. Chaulk, F.C.R. et al. The law and mental disorder, Canadian Mental Health Association, Toronto, 1%2. 4. Mental Health Act, No. 80 (1971), Ralph Davis, Queen’s Printer, London. 5. Clare, A.W. In defence of compulsory psychiatric intervention, Lance!, 1980, 1197-l 198. 6. Shore, J. The committment process for psychiatric patients, Western Journal of Medicine, 1978, 128, 207-2 11. 7. Curran, W.J. Community mental health and the committment laws, American Journal of Public Health, 1967, 57. 1565-1570. 8. Hassenfeld. I.N. and Grunberg, F. What are the real issues in involuntary treatment?, American Journal of Psychiatry, 1975, 132. 758. 9. Watt, D.C. Reviewing the mental health act, Lancer, 1978, 1206. 10. Inhumanity to man, &it&h Medical Journal, 1977, 4, 591-592. 11. Francis, H. Reviewing the mental health act, Lance& 1978, 721. 12. Jenner, F.A. Compulsory psychiatry, Lance& 1978, 1150. 13. White, A. Letter to Lancet, 1978, p, 1150. 14. Wilkinson, D.G. Letter to Lancet, 1978, p. 1150. 15. Davis, D.R. Compulsion under part IV of the Mental Health Act of 1959, International Journal of Law and Psychiatry, 1979, 2, 169-183.
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16. Dabrowski, S., Gerard, K. et al. Inability of patients to give valid consent to psychiatric hospitalization, International Journal of Law and Psychiatry, 1978, I, 437-441. 17. Dabrowski, S., Gerard, K. et al. Involuntary hospitalization in Poland, Psychiatric Journal of the University of Ottawa, 1979, 4, 322-328. 18. H.M.S.O., “Review of Mental Health Act 1959,” Cmnd. 7320, London, 1978. 19. Lindbergh, S.S. and Goldenberg, E.E. A study of involuntary patients in Seattle, Hospital Community Psychiatry, 1977, 28, 834-837. 20. Gove, W.R. and Fain, T. A comparison of voluntary and committed psychiatric patients, Archives of General Psychiatry, 1977, 34, 669-676. 21. McGarry, A.L. and Bendt, R.H. Criminal vs. civil committment of psychotic offenders: A seven year follow-up, American Journal of Psychiatry, 1969, 125, 1387-1394. 22. McGarry, A.L. and Kaplan, H.A. Overview: current trends in mental health law, American Journal of Psychiatry, 1973, 130, 621-630. 23. Zwerling, I.M., Karasu, T., Plutchik, R. and Kellerman, S. A comparison of voluntary and involuntary patients in a state hospital, American Journal of Psychiatry, 1975, 45, 81-87. 24. Zwerling, I.M., Conte, H.R., Plutchik, R. and Karasu, T.B. No-Committment Week: A feasibility study, American Journal of Psychiatry 1978, 135, 1198-1201. 25. Spensley, J., Barter, J.T., Werme, P.H. and Langsley, D.G. Involuntary hospitalization: What for and how long?, American Journal of Psychiatry, 1974, 131, 219-223. 26. Miller, D. and Schwartz, M. County lunacy commission hearings, Social Problems, 1966, 14, 26-35. 27. Scheff, T. The Social Reaction to Deviance. Ascriptive Elements in the Psychiatric Screening of Mental Patients in a Midwestern State, Social Problems, 1964, II, 401-413. 28. Wilhelm, Y.M. A look at psychiatric committment, Perspectives of Psychiatric Care, 1971, 9, 41-58. 29. Page, S. and Firth, J. Civil committment practices in 1977, Canadian Journal of Psychiatry, 1979, 24, 329-335. 30. Love, E.J. and Hobbs, G.E. Changing patterns of mental hospital patients, 1940-1%2, Canadian Journal of Psychiatry, 1971, 16, 77-82. 31. Reitsma, M. Civil liberties and the mentally ill, Canada’s Mental Health, 1973, 21, 8-12. 32. Swadron, B.B., Detention of the mentally disordered, Toronto, Butterworths, 1964. 33. Beck, M.N. 25 and 35 year follow-up of 1st admissions to mental hospital, Canadian Psychiatric Association Journal, 1968, 13, 219-229. 34. Pottle, C.H. A brief review of psychiatric/mental health services (Newfoundland and Labrador) 1945-1979, Newsletter, 1980. 35. Visotsky, H.M. and Slotkin, E.J. Philosophies, not laws, determine admission practices, Hospital Community Psychiatry, 1967, IS, 338-339. 36. Ennis, B., Prisoners ofpsychiatry, New York, Harcourt Brace Jovanovich, 1972. 37. Report: Patients’ families protest liberal laws on committments, Psychiatric News, July 18, 1973, 19. 38. Longdon Commission Report: Press Release by the Minister of Justice, August 19, 1980. 39. Szasz, T. The case against compulsory psychiatric interaction, Lancer, I, 1035-1036. 40. Page, S. and Yates, E. Civil committment and the danger mandate, Canadian Psychiatric Association Journal, 1973, IS, 267-271.
Vol. 5. pp. 377.389,1982
0160-25271821030377-13503.0010 Copyright * 1983 Pergamon Press Ltd
The Impact of Mental Health Legislation on Psychiatric Services J. Hoenig* U. Sreenivasan** D. Leiberman***
In January, 1971, the Province of Newfoundland enacted new mental health legislation. The new Mental Health Act was not proclaimed until 1974 and came into force on January 1, 1975. The act deals mainly with, among other matters, the detention of patients suffering from psychiatric disorders. Newfoundland was a latecomer as far as mental health law reform is concerned. The need for reform had become apparent throughout the western world in the interwar period, and steps had been taken in many countries to amend older laws (1). The old law in Newfoundland was that of Britain, which was essentially the Lunacy Act of 1890 and parts of the Mental Treatment Act of 1930. When Newfoundland became a Province of Canada in 1949, mental health legislation was included in the Health and Public Welfare Act of 1952. The act included few advances and had not gone far beyond the British 1890 and 1930 acts. This situation was not fundamentally different from that in other parts of Canada. In many parts of the world, attempts were made to bring the law in line with the fact that a wide range of new and effective treatments had been adopted. Until the early 193Os, all psychiatry had to offer were institutional care asylum - and psychotherapy, palliative measures to help and protect the patient until a natural remission occurred, or, as frequently happened, the disorder became chronic, and the patient institutionalized. In the 193Os, the new therapies made it possible to treat patients in settings other than mental hospitals, hospital stays were becoming much shorter, and the legal procedures had often become detrimental to treatment. In 1955, the World Health Organisation (2) published a technical report which offered guidelines for new legislation. Several countries began to draft laws along such guidelines. The first province in Canada which introduced a modern mental health act was Saskatchewan in 1961. The National Scientific Planning Council of the Canadian Mental Health Association recommended the establishment of a Committee on Legislation and Psychiatric Disorder, which reviewed the existing situation and formulated guidelines for legislation (3). They presented 25 “principles,” each stating a *Professor of Psychiatry, **Associate Professor Psychiatry, Memorial university of Newfoundland,
of Child and Adolescent Psychiatry,/***Professor St. John’s, Newfoundland, Canada klB 3U6.
377
of
378
J. HOENIG, U. SREENIVASAN, and D. LEIBERMAN
general guideline followed by an explanation, which together made up a solid and imaginative foundation for mental health legislation. Following the publication of that report, the provinces, one-by-one, began to legislate modem mental health acts. It began with Saskatchewan in 1961, followed by British Columbia in 1964, Alberta and Manitoba in 1965, Ontario and Nova Scotia in 1967, Prince Edward Island in 1968, New Brunswick in 1969, and Newfoundland in 1971. In the 1971 act, the procedures dealing with involuntary admission were formulated to conform to three principles (4), namely: 1. A committed patient can be treated in any hospital. Exclusive designation of certain hospitals for that purpose was abolished. 2. Civil committal and discharge were made medical procedures. The participation of the judiciary and the hospital administration were no longer required. I 3. Multiple safeguards were created. The certificate of committal lapses at short intervals and must be renewed after reassessment of the patient. A quasi-legal tribunal was created to hear appeals from patients or relatives, with powers to order instant release of the patient. Evaluation of the Effect of the Act Committal legislation is clearly of great importance, as our figures of the number of people affected will show. If anyone should still entertain doubts about this, a study of the public debate on this issue, which is widespread, intense, and often heated, should dispel those doubts. (5-14). Yet, relatively few investigations have been carried out into the effect different kinds of legislation have on the actual management of patients. A few studies of this kind have been done in the U.K. and elsewhere (15-18) and a few in the U.S.A. (19-28); but very little has been done in Canada (29-33). The recent introduction of new legislation in this province is, in many ways, fundamentally different from what preceded it, and offers a good opportunity for an investigation of this nature. Method Before the new act, the Hospital for Nervous and Mental Disorders (now called the Waterford Hospital) was the only hospital in the province which could admit committed patients. Although other hospitals are allowed to do so
‘The trend in all postwar mental health legislation of making the committal procedure more medical has recently been partly reversed in several provinces, making committal procedures more judicial, or restricting the conditions for committal. The province of Newfoundland too has in 1980 appointed a committee to make recommendations for change, in particular to restrict the powers of the attending physician to discharge patients. It is regrettable that such changes are brought about purely as a result of social pressures simply pushing the pendulum one way or the other rather than basing reforms on empirical investigations like the present one. It will however be interesting in due course to monitor the effect of these new changes on the Mental Health Services.
THE IMPACT OF MENTAL HEALTH LEGISLATION
379
since 1975, none of the hospitals have been able to make the necessary structural alterations to accommodate such patients, and over 90% of all committed patients in the province still go to the Waterford. The study concentrates therefore on the patients admitted to that hospital. Four separate years at three annual intervals were chosen, two before and two after the act came into effect. The years were 1969, 1972, 1975, and 1978. The charts of all admissions in each of these years were examined, and a number of items referring to clinical, demographic, and socioeconomic factors were recorded on item-sheets for computer analysis. The present report omits all patients who were sent to the hospital by court order. Thus, of the involuntary admissions, only the civil committment cases are included. Other comparison figures are derived from Statistics Canada reports and from the Division of Mental Health Services of the province. Findings Admission rates shown in Table 1 differ considerably from those in Canada as a whole. In 1969, the per capita rate of psychiatric admissions in Newfoundland was less than half that for Canada. For men, the rate rose between 1969 and 1972 by 50%, and showed a further steep rise of 45% in 1975, the year of the new Mental Health Act. Even more striking is the impact of the new act in the case of women. Their admission figures had always been lower than those for men, and showed no rise between 1969 and 1972; but in 1975 there was a steep increase of 129%. In Canada as a whole, there had been an increase in admission rates between 1969 and 1972 of 8% for men and 10% for women. From 1972 to 1975, rates for men rose by 20070, and for women by 26%. The table shows that, by 1978, the rates for the province approached those for Canada as a whole. The change is remarkable, particularly for women.
TABLE 1 Admission Rates per 100,000 Population (including justice admissions) Canada
Sex
Admissions
Newfoundland
Rate per 100,000 pop.
Admissions
Rate per 100,000 pop.
1969
M F
51,132 46,063
484 438
601 562
229 223
1972
M F
55,469 50,742
508 465
902 555
332 212
1975’
M F
67,763 64,238
595 562
1312 1273
468 472
1978
M F
61,417 58,000
526 491
1603 1516
555 541
*The Mental Health Act was instituted act’s impact.
in 1975. Figures for and subsequent
to 1975 reflect the
380
J. HOENIG, U. SREENIVASAN, and 0. LEIBERMAN
There also has been a shift within the province (Table 2) from the heavy use of the provincial mental hospital to the use of general hospital psychiatric units. In 1969, 87% of all male patients and 74% of all women were treated in the mental hospital. 1972 saw a slight decrease of that percentage, particularly regarding women. After the introduction of the Mental Health Act, the figures for men decreased to 35070, and for women to 20%. Thus, the psychiatric hospital began to play a smaller role in the network of mental health services both in relative and in absolute numbers. The total admissions had fallen from 1972 to 1975 by 28% (35% for men and 16% for women), and by another 28% from 1975 to 1978 (20% for men, 39% for women). This shift is all the more remarkable as the number of general hospital psychiatric beds had not risen by very much (34). In 1970 there were 761 beds in the psychiatric hospital and 121 in general hospitals. The psychiatric hospital closed 261 beds in 1973 and another 100 in 1978, leaving only 400 beds. The general hospitals added only 11 beds in 1973 and 24 beds in 1978. Thus, the total bed count fell from 882 in 1970 to 556 in 1978. The rate of compulsory civil commitment has fallen even more sharply (Table 3). In 1969, as many as 61.8% of all civil admissions were by certificate. In 1972 this figure had decreased to 45.7%. After the introduction of the new Mental Health Act it went down further to 33.3%. In 1978 there was a slight increase to 40.7%, but such admissions remained well below the 1972 level. In absolute figures this did not represent a rise but a further fall. Following the increase in general hospital psychiatric services, the vast majority of all compulsory admissions continued to go to the mental hospital. In 1976, for instance, only 9 certified admissions, out of a total of 273), did not go to that hospital. As mentioned earlier, the new act permits certified admissions to any hospital in the province, even to cottage hospitals, but few hospitals have been able to install the necessary facilities which would make it possible to look after involuntary patients for more than a very short period.
TABLE 2 Newfoundland Admlssions (Civil) Sex
Psychiatric Hospital
General Hospitals
Total
Other
M F
477 402
(87%) (74%)
74 (13%) 142 (26%)
-
551 544
(100%) (100%)
M F
655 348
(80 O/o) (64%)
160 (20 O/o) 192 (36%)
-
815 540
(100%) (100%)
1975*
M F
426 293
(35 O/o) (20%)
732 (60%) 935 (77%)
54 (5%) 34 (3%)
1212 1208
(100%) (100%)
1978
M F
342 180
(23%) (12%)
1067 (72%) 1266 (85%)
62 (4%) 52 (3%)
1470 1499
(100%) (100%)
1969 1972
*The Mental Health Act was instituted act’s impact.
in 1975. Figures for and subsequent to 1975 reflect the
THE IMPACT
OF MENTAL
HEALTH
381
LEGISLATION
If one calculates the involuntary admissions as rates of all psychiatric admissions in the province, the figures fall from 47.2% in 1969 to 6.8% in 1978, with the steepest decline occurring after the introduction of the new act in 1975. Thus, the introduction of the act brought about a sharp decline in the number of patients who were-compulsorily admitted, while the number of patients in the province treated for psychiatric disorders had increased drastically. Although the diversification of the psychiatric services and their expansion into a large number of general hospitals had begun much earlier (34), the impact had become substantial only in the late 1960s and early 197Os, when the number of admissions to the mental hospital began to show an absolute decrease. The question now arose as to whether the decrease in the need for certified admissions benefitted particular groups of patients more than others, and if so which types of patients. Factors Associated With the Decrease in Compulsory Admissions The admissions to the psychiatric hospital in each of the four years under study were divided into certified and voluntary, and correlations were sought with clinical factors such as diagnoses; with demographic factors such as sex and age; with social factors such as marital state and type of household; with economic and educational factors such as employment status, literacy and schooling; and with geographic factors such as distance of residence from the hospital, and size of community. Any one of these circumstances could modify the impact of a new committal procedure and make it easier for certain groups over the other groups of patients to be treated by voluntary admission to hospital. Diagnosis
Table 4 shows the distribution of the main diagnostic groups and the proportion of certified admissions. The organic psychosyndromes, schizophrenias and neuroses, and personality disorders all show a significant reduction in the proportion of certified admissions. the schizophrenics and the neuroses and personality disorders seem to show the same decrease in certification as does the
TABLE 3 Certification Rates Province All Admissions 1969 1972 1975’ 1978
1163 1457 2585 3116
Psychiatric Certified 549 462 240 212
‘The Mental Health Act was instituted act’s impact.
(47.2%) (31.7%) (9.3%) (6.8%)
All Admissions 888 1010 723 521
in 1975. Figures for and subsequent
Hospital Certified 549 462 241 212
(61.8%) (45.7%) (33.3%) (40.7%)
to 1975 reflect the
The percentage figures indicate the proportion of ail admissions which were certified. *The Mental Health Act was instituted in 1975. Figures for and subsequent to 1975 reflect
impact.
+ 3SD
NS
- 3SD
NS
+ 3SD
61.8% 45.7% 33.3% 40.7%
Cert.
SD f 8.9
SD -c 7.0
888 1010 723 521
65.2% 45.9% 34.4% 28.9%
Comparison 196911978
181 307 174 145
N
Total Cert.
NS
the act’s
54.8% 36.6% 27.5% 34.1%
N
NS
168 152 160 85
Cert.
NS
57.9% 38.0% 31.1% 51 .O%
N
Others
NS
157 155 121 143
62.5% 48.8% 36.8% 46.6 %
Cert.
Neuroses & Personality Disorders
+ 3SD
288 297 223 133
72.3% 59.8% 33.3% 40.0%
94 102 45 15
N
Cert.
Affective Psychoses
Co’mparison 196911975
Significance
1969 1972 1975’ 1978
N
Cert.
Schizophrenia
N
Organic Epilepsy
TABLE 4 Admissions By Diagnoses (% Certified)
8
THE IMPACT
OF MENTAL
HEALTH
LEGISLATION
383
total group. The affective psychoses, however, show some fluctuations over the years. At first, there was a fall of the same order as that for the total group, but a large increase in 1978 made the 1978 figures not significantly different from the 1969 ones. The affective_psychoses thus show a significantly smaller decline in the certification rate than do figures for the total group. The reason for this is probably that the manic patients, who make up a fair proportion, are usually the most difficult ones to convince of the need of hospitalization and must be brought under treatment by certification. Changes in mental health legislation have little impact on the management of such patients. The largest decline in certification rates is found in the organic psychosyndromes and “others,” which inlude retardation and various non-psychotic disorders. Sex
It has already been noted in the national figures that psychiatric admission is not equally distributed in men and women. Significantly more men were certified in 1969 (p < 0.03). Over the years, however, that difference tends to disappear. The number of men coming into hospital voluntarily shows an absolute as well as a relative rise. Although there remains a higher percentage of voluntary admissions for women, that difference is not significant.
All age groups have experienced a significant reduction in certification rates, the 40-plus groups more so than the younger ones (p < 0.0001). The reduction barely reaches significance in the adolescents. The drop which occurred after the new act is significant @ < O.Ol), but the trend was already established by 1972. Compared with the total group, the greatest decline in the certification rate was found in the over-60 age group. The 40-59 group showed a greater decline in 1975, but had fallen back into line by 1978. Marital State Both the single and the married show a marked decrease in certified admissions (p < 0.0001). Marital status does not seem to influence the certification rate, not even in the group which includes the widowed, divorced and separated. In that group the proportion of involuntary admissions also changes significantly, but to a lesser degree than in other groups. Household One might expect that patients living with their families are more likely to be admitted informally, as the doctor’s task in overcoming resistance to entering hospital should be eased if family members help to reassure the patient. Liberal mental health legislation should more readily invoke such help. We found, however, that patients living with their relatives are consistently admitted more
384
J. HOENIG, U. SREENIVASAN, and D. LEIBERMAN
often under certificate than patients living with non-relatives @ < 0.001). Patients living in households with non-relatives much more frequently enter hospitals voluntarily (p < 0.005). Patients who lived alone also showed a high proportion of involuntary admissions, but without a significant decrease over the 10 years, unlike the two other groups. The abnormally small decline in the certification ratio suggests that legislation did not affect the group living alone. The significantly greater decline in certification rates for patients living with non-relatives in 1975 was not sustained.
Schooling One’s expectation that certification would be more frequently necessary in persons with lower educational attainments are belied by the figures. Patients with 6th-grade education or higher had involuntary admission rates of the same order, and show an equal decrease in certification @ < O.OOl), which had begun before the new act was in force. Patients with tertiary education have always shown a higher though non-significant certification ratio, and in that group there are no significant changes over the 10 years. Only the group with the lowest educational attainment showed a significantly sharper decline in certification rates, compared to the total in 1975, but this was not sustained.
Literacy As regards literacy, the proportion of certified admissions seem to follow the general trends in other categories, but to a lesser degree. The absolute decrease in illiterate and semi-literate patients may reflect an improvement in the educational standards in the province. Compared to the total group, the proportion of involuntary admissions shows a significant decrease in the illiterate groups. The literate group shows a highly significant increase. This seems to be the only group in which the new act seems to have increased committment. Employment Unemployment, introducing greater instability into a person’s life, might conceivably make certification more frequently necessary. However, our figures show that this is not so. In fact, the employed were more often certified 0, < 0.001) both in 1969 and in 1978. None of the differences in decline differ significantly from the total group.
Distance With the provision of psychiatric services in many parts of the province, one would expect voluntary patients to be treated to a larger extent locally, thus causing not an absolute, but a relative increase in certified admissions to the psychiatric hospital among patients living at greater distance from that
385
THE IMPACT OF MENTAL HEALTH LEGISLATION
hospital. This indeed turned out to be so (Table 5). In St. John’s, there have always been more voluntary patients, and such admissions increased up until 1978. Patients from the Avalon Peninsula also showed a decrease in involuntary admissions. In 1969, the farther away the patient’s residence from the hospital, the higher the certification rate. This was still so in 1978. The speed of decline in the rate between 1969 and 1978 was also significantly less in the two groups who live farthest away. Certification of patients from St. John’s and the Avalon Peninsula shows an accelerated decrease between 1969 and 1975, but this was not maintained. These differences illustrate the changing role of the psychiatric hospital. Cooperative patients tend now to be treated as voluntary admissions in general hospitals nearer home, and only the severly ill and certified patients tend to still be admitted to the psychiatric hospital.
Type of Community Patients from urban areas have always had a lower certification rate (although not significantly so), and this pattern is still in evidence in 1978, although the certification rate has significantly decreased in all three groups. Compared to the rate of decrease in the total group, the only subgroup which shows a significantly higher speed of decrease is the urban one.
Length of *Hospitalization Finally, the effect of all these changes on the length of stay in hospital is also strikingly favorable. Table 6 shows that in 1969, a larger proportion of voluntary patients were discharged within a month after admission, namely 45.7% as
TABLE 5 Admissions By Distance From Hospital (% Certified) St. John’s 14 miles N 1969 1972 1975’ 1978
Avalon 15-99 miles
Certified
401 510 354 289
54.6% 30.4% 31.9% 30.4 %
N
loo-499
Certified
179 211 210 120
62.6 % 46.9% 26.7% 46.7%
N
Certified
262 247 132 89
Labrador 500 miles
miles
69.5% 58.7% 40.9% 60.7%
N
Certified
44 21 26 21
77.3% 61.9% 65.4 % 71.4%
Significance Comparison 196911975
+ 2SD
Comparison 196911978
NS
‘The Mental Health Act was instituted act’s impact.
-
3SD NS
-
NS
-
3SD
3SD
-
3SD
in 1975. Figures for and subsequent to 1975 reflect the
J. HOENIG, U. SREENIVASAN, and D. LEISERMAN
386
TABLE 6 Length of Stay Certified 1 month
1969 1972 1975* 1978
N
%
194 216 112 107
35.4% 46.8% 46.8% 50.5%
Voluntary Total
1 month N
549 462 241 212
‘The Mental Health Act was instituted act’s impact.
155 329 232 175
Total Significance
O/O
45.7% 60.0% 48. i v. 56.6 O/o
339 548 482 309
P< 0.001
NS
In 1975. Figures for and subsequent to 1975reflect
the
compared to 35.3% in the certified group @ < 0.001). In 1978, the propdrtion of short-stay patients had increased among the voluntaries to 56.6070, and among the certified admissions to 50.5%. There has thus been a general decrease in the length of stay, and the difference between voluntary and certified patients is no longer significant due to the larger decrease among the certified patients. Discussion The importance of innovations in mental health legislation for civil admissions is not universally accepted. Visotsky et al. (35), analyzing the impact of a new mental health code enacted in Illinois in 1963, concluded that “philosophy, not laws, determine admission practices.” Zwerling et al. (24), wanting to find out the extent to which involuntary hospitalization might be overused, declared a “no-committment-unless-absolutely-necessa~-week,” during which emergency room psychiatrists were urged to commit only patients in absolute need of hospitalization. Comparison with figures in the preceding and subsequent weeks showed no significant difference from those of the “no-committment week.” In each week about 40% of all admissions to two Bronx hospitals were involuntary. Zwerling concludes that decisions about committal are the result of “societal attitudes,” which change only if society itself changes. In another study, however, Zwerling et al. (23) - comparing a group of voluntary with a group of involuntary patients - found differences in six respects: The involuntary admissions showed (1) more anti-social trends, (2) more anger, (3) more assaultive acts, (4) more hyperactivity, (5) more “physical problems,” and (6) a relative absence of depression. Demographic data were equal in the two groups except with respect to the household from which patients came. Those living alone tended to come voluntarily, those with parents came in more often by certification. This would suggest that clinical factors determine the need for certification, and laws cannot change those factors. It is difficult to reconcile this with Zwerling’s earlier conclusion that societal attitudes determine the committal rate. Gove et al. (20) conducted a similar comparison in the state of Washington. They, too, found that the two groups differed mainly in respects attributable to the clinical factors.
THE IMPACT
OF MENTAL
HEALTH
LEGISLATION
387
These contentions do not receive support from our findings, which show a steep decline in certification after the introduction of a new law. Other countries, such as the United Kingdom, show consequences of new legislation similar to ours (15, 18). Mental health legislation attracts the attention of diverse pressure groups, many of which take a one-sided view, sometimes to the point of fanaticism. The changes in legislation which have taken place after the second world war were initiated mainly by medical opinion anxious to bring the committal laws in line with the changed situation in psychiatric therapeutics. Lately, however, since the introduction of the new legislation, non-medical particularly those that sympathize with the anti-psychiatry groups, “movement,” have voiced a wish to change the law once again. Their intentions vary greatly from a wish to abolish all legislation (36, 39) to restricting committability to “dangerousness” (29), to widening the powers for committal beyond the present conditions (37, 38). A strange position has been taken up by certain so-called “human rights” groups who want to make the committal procedure an exclusively judicial process, not a medical one - a clear reversal from 1890. The fierceness with which all these diverse viewpoints are pressed is matched only by lack of information, or worse still, the degree of misinformation from which many participants suffer. To counter such often injudicious pressures for change, it is not enough to offer alternative opinions. What is needed to steady the legislature on a course which best serves the patients and their families and society at large are objective investigations of the effect of certain laws on the community. Such investigations, however, are far too few. Conclusions The present investigation of the impact of the new Mental Health Act, with liberalized committal procedures and safeguards for the patient, shows that the act did indeed coincide with a great deal of change in the delivery of psychiatric services, and - although some of these changes may be due to other factors it is very likely that a great deal can be ascribed to the effect of the act itself. The following changes have taken place: 1. Many more patients had access to psychiatric services in 1978 than did in 1969. The number of admissions per 100,000 population, which used to be less than half of that of Canada, has now caught up with the Canadian figures. It is not likely that this represents an increase in psychiatric morbidity in the province, but suggests rather that in 1969 a large number of patients had no access to psychiatric treatment. The increase had begun before the proclamation of the act, but after it was passed by the Legislature in 1971. Much public discussion and education had taken place between 1971 and 1975. There was a sharp increase in admissions in 1975, when the act came into force. The changes particularly affected women patients. No doubt, the better accessibility became possible by the addition of general hospital beds in various parts of the province, a process which began in 1965, although the total increase of such beds between 1970 and 1978 amounts only to a total of 35. During the same period, 360 psychiatric hospital beds were closed. 2. With the increase in admissions, there was a very striking decline in the
388
J. HOENIG,
U. SREENIVASAN,
and 0. LEIBERMAN
proportion of patients who were admitted as involuntary patients. The decline from 47.2% to 6.8% is not just a function of the five-fold increase in total admissions; there has been a drop in the actual numbers of certifications from 549 in 1969 to 212 in 1978, a drop of 61%. Again, the drop is most marked immediately after the proclamation of the new act, and the role of the new legislation on these figures cannot easily be overlooked. Considering the serious effect certification can have on the patient’s subsequent life, this drop in the number of committals to less than half is of immense benefit. The proportion of involuntary admissions compares well with figures elsewhere. Unfortunately, Statistics Canada does not publish such figures, and they are therefore difficult to come by. Page et al. (40) claim that committal figures in Canada have not fallen, but the statement is not documented. In the United Kingdom, where very similar legislation exists, the proportion in 1976 was 11.7% involuntary civil admissions. 3. It has been shown that the small, general hospital psychiatric units were able to deal with the patients who formerly must have been treated in the psychiatric hospital, many patients having in the past required involuntary admission. A small number of patients were actually treated in the general hospital while admitted under an order. 4. The length of hospital stay was reduced for the voluntary admissions, and even moreso for the certified admissions. This reduction in the length of stay became particularly marked in 1975, after the introduction of the new act, showing that the automatic lapse of the certificate shortly after admission, and the other safeguards, has led to an earlier discharge of these patients than had formerly been the case.
Reference Notes 1. Curran, W.J. Comparative analysis of mental health legislation in 43 countries: A discussion of historical trends, International Journal of Law and Psychiatry, 1978, 1, 79-921. 2. Expert Committee on Mental Health. Fourth report, legislation affecting psychiatric treatment, Technical Report Series No. 98. Geneva, WHO, 1955. 3. Chaulk, F.C.R. et al. The law and mental disorder, Canadian Mental Health Association, Toronto, 1%2. 4. Mental Health Act, No. 80 (1971), Ralph Davis, Queen’s Printer, London. 5. Clare, A.W. In defence of compulsory psychiatric intervention, Lance!, 1980, 1197-l 198. 6. Shore, J. The committment process for psychiatric patients, Western Journal of Medicine, 1978, 128, 207-2 11. 7. Curran, W.J. Community mental health and the committment laws, American Journal of Public Health, 1967, 57. 1565-1570. 8. Hassenfeld. I.N. and Grunberg, F. What are the real issues in involuntary treatment?, American Journal of Psychiatry, 1975, 132. 758. 9. Watt, D.C. Reviewing the mental health act, Lancer, 1978, 1206. 10. Inhumanity to man, &it&h Medical Journal, 1977, 4, 591-592. 11. Francis, H. Reviewing the mental health act, Lance& 1978, 721. 12. Jenner, F.A. Compulsory psychiatry, Lance& 1978, 1150. 13. White, A. Letter to Lancet, 1978, p, 1150. 14. Wilkinson, D.G. Letter to Lancet, 1978, p. 1150. 15. Davis, D.R. Compulsion under part IV of the Mental Health Act of 1959, International Journal of Law and Psychiatry, 1979, 2, 169-183.
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OF MENTAL
HEALTH
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