With an eye towards expanding the power of doctors to commit mentally ill patients, ensure patients are complying with treatment while out of hospital and move some mental health care from the hospitals into the community, Alberta’s legislature amended the Mental Health Act this past Nov. The changes are significant enough that a recent meeting at the Foothills hospital was attended by so many mental health workers, the coffee ran out. It appears they won’t be ignored by the rest of the population, either.
In the midst of a series of bills quickly passed towards the end of last year, the Alberta Progressive Conservative government voted in Bill 31. The bill includes a number of amendments to the current mental health act. Though the bill has passed, it will take some time–months to a year–before the specific regulations are drawn up. This point was made early at the Foothills meeting.
“Trying to predict the proclamation–which is when it comes into force–is a little bit like reading the entrails of a goat,” said Dr. Michael Trew, the meeting’s emcee.
The fact that the regulations are still being drawn up makes it difficult to specify the precise implications of the amendments, but the gist of the bill is known. The amendments expand the definition of individuals that can be committed to in-patient care to include those perceived as facing physical of mental deterioration. Previously, individuals could be “formed” if they were seen as a danger to themselves or others.
“[This bill] expands the definition of illness,” said Trew. “We can intervene actively for people that are deteriorating in the community.”
Patients can appeal the decision to a review panel and then the Court of Queen’s Bench.
The other important change to the Mental Health Act, is the addition of Community Treatment Orders. CTOs allow doctors to force patients to take their medication or otherwise comply with their treatment while in the community. According to Bill 31, in order to qualify for a CTO an individual must have been held as a patient in hospital for 60 days in the last two years, or have been held on three or more separate occasions within that two-year period, or have been previously subject to a CTO. A CTO must be agreed upon by two doctors, including a psychiatrist.
For a CTO to be issued, treatment must be available in the community. Given the current lack of infrastructure and staff, this is a big concern. A speaker representing the Canadian Mental Health Association remarked that the current lack of capacity in the system would make implementing the amendments exceedingly difficult, perhaps impossible. Her comments were echoed by Trew.
“We still have the very real challenges of the amount of services, including housing and personnel, to be able to help people in the community,” said Trew.
It has been suggested that the proclamation of the bill will be joined by an expansion of funding.
“We’ve heard that there are going to be some targeted resources to help implement this, but we’re waiting to see,” said Trew. “That has been a concern all along, it would be very hard for the government not to be aware of those concerns.”
Enforcing CTOs will require staff to be out in the community monitoring compliance amongst patients.
“At this point, what we have is case managers,” said Dr. Pamella Manning. “I don’t suppose they will be the people doing that. There may well need to be a special category of staff to do that.”
Manning suggested the Assertive Community Treatment teams may take on the job. These teams, as well, face severe staffing shortages.
Despite acknowledging these concerns and suggesting that more work may need to be done on the bill, the changes are viewed by many in the medical community as a step in the right direction.
“My personal belief is that it is a good idea,” said patient advocate David Chakravorty. “For the very severe, challenged individuals, it might keep them in their apartment instead of evicting them.”
Trew also recognized this, stressing that though many will see it as either not enough or too much, it is nonetheless positive.
“This is an attempt to help people have a more full life,” said Trew. “There will always be cases where people believe whatever legislation is misused and their will always be other legislation that we can use.”
The new legislation brings with it a lot of ethical considerations. The issue of forcing someone to comply with treatment, which can include medication as well as certification to hospital care against their will, is expected to produce some concerns. Chakravorty remarked that there were certainly going to be individuals who consider these practices an unethical violation of an individual’s rights. He suggested the problem may be solved by bringing such individuals downtown and showing them the mentally ill living on the streets. Trew advised that doctors needed to be very careful when certifying patients and issuing CTOs.
“Ethically, we always need to be aware of the balance between individual’s rights and the effect of mental illness on choice,” said Trew. “All professionals are really called upon to be aware of those ethical issues and do the best we can to treat people as individual people and not just another case.”
Part of that delicate balance involves the issue of whether a person is deemed competent or not.
Dr. Toba Oluboka, formerly a practitioner in Ontario where CTOs have been around since 2000, explained that CTOs can be used for both individuals judged competent and those judged not competent.
“What we have done in Ontario, with Brian’s law, is that if the patient is judged competent, then it’s the patient who has to consent to treatment,” said Oluboka. “If the patient is judged not competent [consent comes from] the substitute decision maker.”
The exact protocol for establishing who is to be the substitute decision maker will not be known until the regulations are released. Likely, though, it will be an individual who is either a close relative of the patient or who has been explicitly appointed to that role by the patient. Oluboka noted that a CTO might be issued to a competent individual because it allows those who are unsure of their ability to comply with treatment to ensure the same quality standards and guarantee of treatment that they would get in a hospital setting, while remaining in the community.
Concerns were raised regarding the effectiveness of this new form of treatment for individuals suffering concurrent disorders–the dual affliction of mental illness and substance abuse.
“People expect that it will make a big difference for people with drugs and alcohol,” said Manning. “But the way things are seen these days, it is their choice. If the person doesn’t want to do anything about it, then there is little we can do about it. That is going to be an area of contention for a lot of people.”
CTOs are good for a period of six months and can be renewed an unlimited number of times. They can be cancelled by the psychiatrist if the conditions for there issue are no longer met.
Chakravorty noted that CTOs are already utilized in a number of countries and regions around the world. He remarked that approximately 2 out of every 100,000 individuals in Ontario are on CTOs. In Australia, the figure is around 60 out of every 100,000. The reason for the disparity is the much more stringent criteria for placing individuals on CTOs in Ontario than in Australia. It was suggested at the meeting that the criteria for issuing CTOs in Alberta will also be strict.