Fewer people with mental illnesses would endure the trauma of being sectioned if advance choice documents – setting out a treatment plan while they are well – were included in Mental Health Act reforms, a leading psychiatrist has said.
Advance choice documents are the only proven way to reduce the number of people detained under the Mental Health Act in England and Wales, which is one of the reforms’ core objectives, said Dr Lade Smith, the president of the Royal College of Psychiatrists.
Research suggests that the use of these documents can reduce compulsory detention rates in psychiatric units, often known as sectioning, by 25%, minimising traumatic experiences for people with bipolar, schizophrenia and other psychotic illnesses.
“It’s high time there was reform of the Mental Health Act because the rates of detention are increasing, especially for marginalised groups, those who are poor or from a minoritised ethnic community, especially black Caribbean … Advance choice docs were a recommendation of the review, I don’t know why they haven’t gone through,” said Smith.
Advance choice documents are especially effective in reducing the significantly higher detention rates for black people with mental illnesses, as they can help patients feel more autonomous and reduce unconscious bias.
The documents can also speed up and improve recovery, and reduce the time spent in hospital, which can have a negative impact on patients’ jobs, homes or relationships, said Smith.
Advance choice documents are similar to those used in palliative care. Patients work with a healthcare professional when they are well to outline the signs that they are experiencing a manic or psychotic episode, effective treatments, and their personal preferences.
This could include background information and trigger questions to help healthcare practitioners establish delusional thought patterns; medications and doses which have been effective previously; and requests to be put in hospital for their own safety, or – more unusually – that of others.
Although the documents are now included in NHS guidance, take-up remains low, due to limited awareness, logistical challenges and a misconception that patients may ask for ineffective treatments, such as Reiki healing, said Smith.
“Ideally, there should be a mandatory requirement of services to offer advance choice documents to anybody who’s ever been detained under the Mental Health Act – that’s what we’d like to see,” she said.
King’s College London is aiming to boost awareness with a new site, which will be used as a resource on the NHS to spur a culture shift towards shared decision-making.
Dr Tania Gergel, a researcher at UCL who is leading on the Advance Choice project, said this would represent a move away from the “paternalistic” model of psychiatry, reflecting that “people have a very good understanding of their illness”.
In interviews for the project, she found examples where clinicians refused to follow the advance choice document. One patient had written that an antipsychotic worked for them at a lower dose, while the usual prescribed dose made them physically unwell, but this was ignored and recovery was only achieved through a traumatic process of trial and error after being sectioned.
Others said they hated being injected, which is common in forcible detentions, including in their buttocks while being held down in the middle of a ward. “People can feel that who they are as a person becomes completely erased,” said Gergel.
Gergel, who has bipolar, believes that advance choice documents have saved her life, as she experiences severe mixed manic and psychotic episodes in which she quickly becomes uncontrollably suicidal. She has struggled to stay safe as she is good at concealing her symptoms.
Her document contains trigger questions to help doctors tease out her delusions, and includes a “self-binding” agreement, meaning that when these symptoms are present she needs to be treated and supervised immediately for her own safety. It adds that conventional medications have not worked for her and that she needs electroconvulsive therapy (ECT) – this helped doctors secure hospital approval to give it to her during pregnancy, a treatment typically avoided despite no evidence of harm to the baby.
She said the document helps her understand intellectually why it’s important to stay in hospital, even if she feels a desire to abscond.
Since writing it, she said her episodes have been “much calmer”. “It has really worked, and has meant I’ve stayed safe although I’ve been deeply suicidal. When I reflect afterwards, no matter how difficult the episode has been, the trauma is nothing compared to when it was formal detention and literally being held down.”
A Department of Health and Social Care spokesperson said the draft mental health bill did not include provisions for a statutory advance choice document because “it is important that a person can make advance choices in a way that best meets their needs, which may not always be in a written document”. Instead, the draft bill gives advance choices the same legal weight without requiring a statutory document.
• In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. The charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
• This article was amended on 13 February 2024. An earlier version referred to “advanced choice” documents when “advance choice” is the proper term.
