Mental illness assessment, management of depression and self harm; the Mental Health Act

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Chapter 15 Mental illness assessment, management of depression and self harm; the Mental Health Act

Rosie Doy, Derek Burroughs, John Scott

Introduction 253
Primary survey 254
Secondary survey 255
Mental health assessment 255
Depression 257
Treatment and referral 258
Principles of effective shared and out-of-hours care 260
Differentiating between suicide and deliberate self-harm 260
The Mental Health Act 261
Definitions 262
Treatment options 263
Assessment of valid consent 265
Summary of principles 266

Introduction

Mental health problems present in between 30% and 60% of primary care consultations.1 One in six men and one in four women will suffer from a mental illness at some point in their lives.2,3 GPs, for example, find that at least 30% (or 1.5 days per week) of their working week concerns mental health consultations. For depression alone, prevalence amongst the adult population in the UK varies between 17–71 per thousand for men and 25–124 per thousand for women.

Unfortunately these patient presentations in primary care are frequently complex and do not always fit easily into diagnostic categories.4 The objectives of this chapter are listed in Box 15.1.

Box 15.1 Chapter objectives

image The recognition of primary survey positive patients and those with complex but not immediately life-threatening presentations (primary survey negative patients)
image The secondary survey, history taking and examination of the patient with signs or symptoms of mental illness
image To describe mental health assessment and differential diagnoses with specific reference to depression and deliberate self harm
image To discuss alternatives to admission, treatment and options for referral
image To clarify definitions of mental disorder
image To summarise the Mental Health Act (1983)
image Assessment of valid consent and capacity

Primary survey

A mental illness may cause a patient to take an overdose or injure themselves in such a way that they develop immediately life-threatening ABCD problems. These problems are covered in Chapter 14.

An immediately life-threatening psychiatric situation is where the patient wants to kill themselves, or harm others (Box 15.2), but will not comply with treatment. Management will depend on a large number of factors – not only your assessment of the problem but also the extent and availability of local services.

Box 15.2 Indicators of life-threatening behavioral problems (a positive primary survey)

image The patient is threatening to kill or seriously harm themselves
image The patient is a risk or danger to themselves or to others
image The patient, through lack of appreciation of the consequences, is likely to come to harm
image The patient, through lack of capacity, is vulnerable to abuse from others
image The patient has become acutely confused

Enlisting the support of family and carers is often the simplest and best way to resolve such conflicts. However if this does not work you will have to call for assistance. This may be the patient’s own primary care team or the mental health team. In extreme situations where you judge that there is an immediate threat to the wellbeing of the patient, or others, you should call the police.

The Mental Health Act (MHA), in Section 63, states that the detained (or ‘sectioned’) patient’s consent is not needed for medical treatment for mental disorder (when this is under the direction of the Responsible Medical Officer). This is detailed as being:

a immediately necessary to save the patient’s life; or
b which (not being irreversible) is immediately necessary to prevent a serious deterioration of his condition; or
c which (not being irreversible or hazardous) is immediately necessary to alleviate serious suffering by the patient; or
d which (not being irreversible or hazardous) is immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others.

However, the MHA does not necessarily permit the compulsory treatment of a physical disorder in a patient who is not consenting.

Secondary survey

If it is obvious that the patient is going to have to be assessed by another professional then only a brief evaluation will be required. However the following steps need to be taken to ensure the patient is suffering from a mental illness and not a physical disorder. Acute infections, intoxications, drug withdrawal syndromes, diabetes and neurological conditions are common physical conditions that may present with symptoms of mental illness/disorder. An acute confusional state may present very rapidly, especially in older patients. In the elderly this frequently can result from chest or urinary tract infections, recent life change, or progressive dementia.

Medical assessment is indicated if:

image fever
image history of recent fit
image impaired or depressed level of consciousness
image known diabetic
image loss of awareness of surroundings
image recent onset of confusion, disorientation and memory impairment
image signs of head injury/recent history of head injury (2 weeks)
image suspected chest or urinary tract infection.

RED FLAG

Before making a psychiatric diagnosis ensure the patient is not suffering from a physical disorder

Mental health assessment

While it is difficult to completely separate the mental health assessment into ‘history’ and exam sections, it aids understanding to use the SOAPC system. Effective mental health assessment requires a very sensitive consultation style to gain the patient’s trust and showing the patient that you recognise their distress and experience. Some key principles for the mental health interview are identified in Box 15.3. Consultation skills that improve identification of emotional distress include frequent eye contact, relaxed posture, use of open questions at the beginning of the -consultation, use of minimal verbal prompts while actively listening and avoiding giving information too early in the consultation.

Box 15.3 Common signs and symptoms of mental illness

image Changes in the nature of mood (affect)
image Disorders of perception – hallucinations and illusions
image Disorders of thinking (cognition) – delusions, negative thinking
image Patient’s appearance and behaviour
image Speech and communication

Subjective – history

History taking can be difficult and at times confusing but the use of the standard template for history will help give structure and avoid omission. Elicit the main presenting complaint(s) and the onset and progress of symptoms. Is this an acute problem or more long term? Are there factors that make the symptoms better or worse? Is there a previous history of similar problems and is the patient currently undergoing treatment for these symptoms? Note the drug history, including the patient’s compliance with any treatment. Is there any history of abuse of alcohol or illicit drugs? Note the past medical and psychiatric history.

Information from carers is often of great importance in the assessment. If carers are not present and you are having difficulty, you may have to trace them and discuss the issues (preferably with consent of the patient). Box 15.4 summarises the assessment of a patient with psychiatric symptoms.

Box 15.4 Mental health – history

image Presenting problem
image History of onset and progress of presenting problem
image Previous medical history
image Drug history/allergies/compliance with treatment
image Past psychiatric history
image Previous contact with services
image Carer information

Objective information – mental state examination

Perform a brief physical exam, including noting the vital signs (especially pulse, temperature and Glasgow Coma Score). Listing the elements of a mental state examination is an excellent way to bring some structure to what can be a confusing and difficult task. These key elements are listed in Box 15.5. The assessment of social support is often of the greatest importance in deciding a management plan.

Box 15.5 Elements of a mental state examination

image A – appearance
image B – behaviour (normal, flat, manic, tremor)
image C – cognition, concentration, memory, attention span, thought process (logical, flight, tangential)
image D – Delusions and ideation (suicidal, homicidal), hallucinations
image E – energy and motivation
image Also assess risk to self and others, of deliberate self harm (DSH), impulsivity, signs of abuse of drugs or alcohol, current carer or family support, coping strategies

This process can be difficult but allow the patient to explain the problem in their own words. Be non-judgemental. Try to help the patient focus on the issues to enable them to gain self-control. Seek clarification by the use of paraphrasing, reflection and summarising. Share your impressions. Do not be afraid to use periods of silence.

TIP

Talk to the family and get their viewpoint

Analysis

At the end of the assessment you should be able to judge if the patient has:

image a physical disorder
image a disorder of mood (commonly depression)
image acute anxiety or panic
image acute confusion
image a psychotic disorder
image or is threat to themselves or others.

Depression

Depression is the most common mental disorder in primary care and covers a range of mental health diagnoses and problems. These are all distinguished by lowered mood and a loss or decrease of interest and pleasure in daily life and experiences. Additionally, there are disorders of thinking, problem-solving and behavioural and physiological symptoms.5 Box 15.6 lists the diagnostic criteria for severe depression but it is often difficult to discriminate between normal mood variations, dysthymia (Box 15.7) and cyclothymic (Box 15.7) episodes and mild to moderate clinical depression.

Box 15.6 Recognition and classification of severe (major) clinical depression

At least 5 of the following symptoms are consistently experienced by the client on a daily basis over a 2-week period:

image persistent sad mood
image loss of interest or pleasure in activities that were once enjoyed
image significant weight loss or gain without dieting, increased or reduced appetite
image insomnia or hypersomnia
image psychomotor agitation or retardation
image fatigue or listlessness, loss of energy
image feelings of worthlessness and inappropriate guilt
image reduced ability to concentrate, make decisions or think recurrent thoughts of death or suicidal ideation

Box 15.7 Differential diagnoses – mood disorders

image Clinical depression

image severe
image moderate
image mild

image Bipolar disorder (manic depression)
image Dysthymic episodes – chronic low grade depression (for at least 2 years)
image Cyclothymia – cycling variations in mood; much less extreme than in manic depression
image Seasonal affective disorder
image Post-natal depression
image Psychotic depression

It is not clear how effective practitioners are at preventing suicide. A number of patients who successfully commit suicide will have consulted a healthcare professional in the immediately preceding period. At least 30% see their GP in the 4 weeks prior to their deaths.6 Improving the recognition of severe depression and its treatment has been the focus –of several studies and training packages for GPs but the long-term data show little sustained difference.

It is often helpful to support the patient in ‘telling their story’ – what a typical day is like, what makes it better or worse and listening carefully not only to ‘what’ they say but ‘how’ they express their narrative.

RED FLAG

Patients with mental illness have an increased risk of suicide

Each year people with depression account for two-thirds of all deaths from suicide nationally (Box 15.8). Risk assessment tools and rating scales can be very helpful, e.g. the Suicide and Self-Harm Risk Assessment Scale (see Chapter 14).

Box 15.8 Additional risk factors for suicide

image Up to 4 weeks following discharge from services
image Recent self harm; history of violent self harm (half of those who commit suicide will have self-harmed in the past10,11)
image Depression – paradoxically as a patient starts to recover from severe depression they regain the capacity to act
image Choice of method
image Young Asian women
image Some occupations and social groups – dentists, doctors, farmers
image Unemployed, homeless or living alone, students, divorced, separated or widowed (men)
image Relationship problems
image Chronic illness: including HIV/AIDS, cancer, diabetes, post-stroke (especially when communication centres affected), Parkinson’s disease, Huntington’s disease and Alzheimer’s disease (where some insight remains)
image Care givers without adequate social support/finances – especially carers of those who are severely cognitively impaired
image Chronic pain

RED FLAG

Believe the patient when they say they will try to kill or harm themselves

Treatment and referral

Prior to the Mental Health National Service Framework (MHNSF) the traditional management of the at-risk suicidal patient was by admission to an acute mental health unit. In non-scheduled and out-of-hours care, this may be difficult due to bed shortages, high acute in-patient bed –occupancy (often in excess of 100%) and implementing MHA processes for detaining at-risk patients unwilling to agree to admission. Currently there is growth in managing these patients in the community with Crisis Resolution and Home Treatment Teams (CRHTTs) (Box 15.9). These offer intensive community-based interventions in the patient’s own home (MHNSF target of 335 CRHTTs by 2005). Where such teams exist, a referral both ‘in-hours’ and ‘out-of-hours’ to the local CRHTT should be made. The CRHTT will undertake a comprehensive mental health and risk assessment. As appropriate, a treatment, support or monitoring package will be implemented.

Box 15.9 Treatment options

1 Admission to hospital:

image severe depression, especially when suicide has been attempted or serious suicide ideation is present and the patient requires close or constant observation

2 ED and EAU Mental Health Assessment Liaison Team:

image full psychosocial assessment (as recommended by NICE10,11) and referral or brief interventions offered as appropriate; may offer specific alcohol and substance misuse service

3 Home Treatment and Crisis Resolution via local mental health OOH services:

image full psychosocial assessment and service provision for the patient with mental illness who can be supported/treated at home without admission

4 Medication:

image this will usually be following a full mental health assessment fluoxetine or paroxetine may be prescribed for moderate to severe depression

5 Talking treatments:

image referral to mental health team/GP – not appropriate for people with severe depression

Other alternatives to admission that may be available include acute day hospital care, psychiatric intensive care beds and assertive outreach or assertive community treatment teams. Services are, however, very variable between primary care trusts and the community practitioner will need to be familiar with the local organisation. It is therefore useful remembering that liaison nurses in emergency and MAU departments of acute general hospitals are a useful information resource for both in-patient and primary care practitioners.

Principles of effective shared and out-of-hours care

The interface between emergency care and mental health teams can be one of the most difficult to organise. This can be aided by planning. Where a patient is known, especially if they have frequent needs for emergency care, develop crisis care plans with agreed contact points. Agree out-of-hours (OOH) arrangements and ensure they are available to all relevant team members including locums.

Clarify criteria for referral and discharge between primary and secondary care; between OOH and mental health crisis teams. Develop mental health registers in primary care and joint inter-professional and multi-agency education, e.g. suicide assessment and risk management.

Consistent and regular communication with regular liaison meetings will facilitate a systematic review of shared care and complex patients. Rotations between OOH services and mental health services and regular audit will also help closer working.

Differentiating between suicide and deliberate self-harm

The MHNSF indicates that overall the rate of suicide is dropping.7 Men are 3× more likely than women to commit suicide; women are 3–4× times more likely to present with deliberate self-harm by overdosing, cutting or other means.8 Whilst suicide is rare, a population of 250 000 would have about 25 suicides per annum. The term deliberate self-harm (DSH) indicates that the person hurts themselves, either to signal distress, in crisis and where coping strategies are limited and to release/manage overwhelming feelings.9 Whilst there may be no ‘intention’ to kill themselves the person who is self-harming does increase the risk of death with each occasion of this behaviour. NICE identify that there are -150 000 attendances at A&E each year resulting from DSH – therefore being one of the top five causes of acute medical admission.10

So why do patients self-harm? Four main themes regarding motivation emerge from experiential and empirical research evidence. Some find this the best way of handling and expressing overwhelming feelings or of escaping numbness/unreality and confirming one’s existence. It can be a method of obtaining or maintaining a sense of control. In some it is a continuation of past abusive patterns (adapted from Doy8). Behaviour always has a meaning – we often do not appreciate what it means for the person.

RED FLAG

Do not diminish the behaviour or judge it as (only) attention-seeking

At times of crisis it is easy to disempower the person who has self-harmed by dismissing their often frustrating and repetitive behaviour as ‘manipulative’. Such patients are often overwhelmed and chaotic with limited coping strategies, low self-esteem and perceptions of a lack of control and safety in their lives.

If the client is not primary survey positive undertake a psychosocial and needs assessment and a risk assessment (see Chapter 14). Recognise the distress associated with deliberate self-harm and treat the person with respect. Assume the patient has the capacity to make decisions about their care unless there is evidence to the contrary. Offer full information and seek consent to make appropriate referrals.

You may provide the patient with alternatives to self-harming including help-line contact and for pre-hospital workers to consider referral for psychotherapy. Many social care or voluntary agencies may be effective in supporting the patient with relationship, accommodation, financial, substance misuse, abuse and violence issues (Box 15.10).

Box 15.10 Relevant services and help lines

image Bristol Crisis Line (national part-time help line)
image Community Mental Health Team
image CRHTT
image Mental Health Liaison Nurses – ED; MAU
image National Self-Harm Network
image Primary Care Gateway (Link) Workers

Mental health and its management in community settings is complex. The key challenges include developing competence in assessment and risk assessment, in clarifying roles and services in the OOH/emergency contexts and drawing up clear and agreed guidelines and communication channels. Underpinning a number of these actions is the Mental Health Act.

The Mental Health Act

Patients who have a mental disorder requiring immediate treatment commonly consent to treatment. Only around 10% of those admitted to Mental Health Hospitals are there against their will under a ‘Section’ of the Mental Health Act (MHA).

In situations where a person is suffering from a ‘Mental Disorder’ and refuses intervention for that Mental Disorder, then the Authority for intervention may be the Mental Health Act (1983). Key to the understanding of the MHA are the definitions of mental disorder. The definitions are legal terms, but the diagnosis of a type of Mental Disorder is a matter for clinical judgement. Use of alcohol and other substances might sometimes cause a Mental Disorder which is within the scope of the Act, but use of these substances in itself is not within the scope of the Act.

Only a small number of professionals are involved in applying the Mental Health Act (MHA), principally Approved Social Workers (ASWs), GPs and doctors approved under Section 12 of the Act (either psychiatrists or others with experience in mental health who have been certified by the Department of Health). Each professional completing a recommendation for detention performs a detailed assessment of the patient’s mental state and circumstances. If any one of them feels there is insufficient evidence to recommend detention, the person cannot be kept in hospital. [Mental health law is currently under review, the draft Mental Health Bill is currently receiving detailed scrutiny (and engendering great debate) prior to enactment in due course. The MHA (1983) therefore is the current mental health legislative guidance.]

Definitions

Mental Disorder is defined as: ‘mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind’.

The four sub-categories of Mental Disorder are further defined.

1 Mental illness

There is no legal definition but there are many terms and definitions, see for example the JRCALC Clinical Practice Guidelines11 or the International Classification of Diseases, version 10.12 Mental illness may be defined as a number of conditions typically involving impairment of an individual’s normal cognitive (thinking), emotional, or behavioural functioning. It can be precipitated by biopsychosocial, biochemical, normal and traumatic life events, genetic or other factors, including infection or head injury.

The following are some of the potential characteristics of mental illness presentations:

image impairment of intellectual functions shown by a failure of memory, disorientation, difficulties in comprehension or learning capacity
image persistent alteration of mood affecting the patient’s daily life
image delusional beliefs
image abnormal perceptions (hallucinations) associated with delusional beliefs and thinking patterns
image disordered thinking (cognition) which prevents the patient exercising judgement and perceiving the consequence of their actions.

2 Severe mental impairment

‘A state of arrested or incomplete development of mind which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’

3 Mental impairment

‘A state of arrested or incomplete development of mind (not amounting to severe mental impairment) which includes significant impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’

4 Psychopathic disorder

‘A persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’

Treatment options

In an emergency situation the police have powers of arrest under section 136 of the MHA. Under section 136 the police may remove the patient to a place of safety for detention for up to 72 hours. The patient may be detained within that time period by anyone accepting custody from the police, and a place of safety can include an NHS hospital, police station, mental health nursing home, residential home for the mentally disordered, social services residential accommodation, or any other suitable place if the occupier is willing.

It is important to note that Section 136 does NOT include the power to impose treatment without consent. The patient has the right to consult a solicitor in private and to have a person of their choice present.

The presence of Mental Disorder does not in itself render the individual unable to give Valid Consent. Valid Consent is always ‘situation specific’. An individual who has a Mental Disorder may be able to give Valid Consent for some things, but not for others.

Use of the MHA is strictly defined (Fig. 15.1). ‘Informal’ patients are either:

image ‘admitted and treated with their valid consent’

image

Fig. 15.1 Use of the Mental Health Act.

or:

image ‘incapacitated and unable to give valid consent’, so:

admitted and treated under the Common Law doctrine of:

image ‘necessity’
image acting in the patient’s ‘best interests’
image under a ‘duty of care’.

If an incapacitated patient Dissents, and the Dissent is ‘persistent and purposeful’ – then an Assessment should be made for compulsory Treatment under the Mental Health Act.

A ruling by the European Court of Human Rights (October 5, 2004), regarding the ‘Bournewood’ case may have significant impact on the use of Common Law to admit and treat Incapacitated Adults. At the time of writing the UK Government is considering their position regarding this ruling.

Most importantly, unless the patient has been detained under a relevant section of the MHA (currently section 3), if they have capacity they may legally refuse treatment, even if they are suffering from a mental disorder. Even if detained under section 3, only treatment for the mental disorder can be legally imposed in a patient with capacity. Treatment for a physical disorder which is not associated with the mental illness cannot be imposed under these circumstances.

Assessment of valid consent

An underlying principle of medical care is that consent should always be sought before any intervention is commenced. Treatment without valid consent may lead to charges of assault, or battery or worse, but there are situations where it is necessary to treat a patient without consent. There is sometimes a difficult conflict between the patient’s right to determine their own treatment and the professional responsibility to act ‘in the patient’s best interests’. Failure to intervene and care for a patient who cannot give valid consent may lead to charges of negligence.

The Mental Capacity Act13 gives clear guidance in this area. A good understanding of the principles of this legislation and its application to practice empowers not only the practitioner, but also the patients with whom we work.

In a large majority of cases the authority for examination and treatment is established by the patient giving their valid consent. Issues of consent in children are discussed in Chapter 5 (pages 87–89). The discussion in this section applies to adults. Valid consent comprises four components. The absence of any one component will render the consent invalid. For consent to be valid the patient should be able to:14

image understand relevant information about the decision to be made
image retain that information
image use the information as part of the decision-making process and understand the consequences of their decision
image communicate their decision.

We must give the patient adequate information so that they can make an informed choice. The law requires that we inform the patient of the ‘broad terms of the nature of the procedure’. In the time pressured environment of emergency care it is not possible to discuss every detail of management, but we should try to ensure the patient has adequate information on which to base a decision.

We must ensure that neither we, nor anyone else, put undue pressure on the patient to comply with our wishes to intervene.

Capacity

Does the patient have ‘capacity’ to consent? Assessment of a patient’s capacity to make a decision about their own health care is a matter of clinical judgement, guided by current professional practice and subject to the legal requirements of the Mental Capacity Act. It is the responsibility of any healthcare professional proposing treatment to determine the patient has capacity to give valid consent.

An individual is presumed to have capacity unless you have good grounds to suspect they lack capacity. If the patient appears not to have capacity to consent, then reasonable steps should be taken to help -the individual understand the situation. Capacity will be affected by common trauma situations such as, shock, pain or fear.

Box 15.11 The capacity test

image Is the person able to take in and retain information material to the decision, especially as to the likely consequences of having, or not having the treatment?

or:

image Is the patient unable to weigh the information in the balance, as part of the process of arriving at the decision?

Treatment without consent

There will be some instances where care or treatment is needed, but the patient is unable to give valid consent. At times it is obvious that you need to act without consent, for example the patient is unconscious. In other situations the decision might be less clear, for example in patients with dementia or a mental disorder. If there is time, it is advisable to ask for help and a second opinion but this is not always possible.

If an adult patient is unable to give valid consent then a healthcare professional can decide to treat the patient. We must be able to demonstrate that:

image our interventions are necessary to save life or prevent deterioration of the situation
image our interventions are in ‘the patient’s best interests’
image any action or treatment should be proportionate and necessary.

Even if a patient lacks capacity there is a fundamental need to ensure they are given an explanation of what is to happen.

Patients detained under the Mental Health Act can still retain capacity and that consent may still be required to provide certain forms of treatment.

Summary of principles13

image A person must be assumed to have capacity unless it is established that they lack capacity.
image A person should not be treated as lacking capacity unless all practicable steps to help them decide have been taken without success.
image A person is not to be treated as unable to make a decision merely because they make an unwise decision.
image A decision made on behalf of a person who lacks capacity must be made in their best interests.
image If a patient lacks capacity and you elect to treat the patient without their consent, plan a course of action that has least effect on the person’s rights and freedom of action.

References

1 Mental Health After Care Association. First national GP survey of mental health in primary care. London: MACA, 1999.

2 Department of Health. Modern standards and service models: mental health. London: NHSE, 1999.

3 National Institute for Health and Clinical Excellence. Depression: the management of depression in primary and secondary care, 2004. Available online http://www.nice.org.uk/ (5 Mar 2007)

4 Mynors-Wallis L, Moore M, Maguire J, Hollingbery T. Shared care in mental health. Oxford: Oxford University Press, 2002.

5 World Health Organization. WHO Guide to mental health in primary care. London: Royal Society of Medicine, 2000.

6 Evans J. Suicide, deliberate self-harm, and severe depressive illness. In: Elder A, Holmes J, editors. Mental health in primary care. Oxford: OUP, 2002.

7 Department of Health. National suicide prevention strategy for England. London: DoH, 2002.

8 Doy R. Women and deliberate self-harm. In: Boswell G, Poland F, editors. Women’s minds, women’s bodies: an interdisciplinary approach to women’s health. Basingstoke: Palgrave Macmillan, 2003.

9 Burstow B. Radical feminist therapy: working in the context of violence. London: Sage, 1992.

10 National Institute for Health and Clinical Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, 2004. Available online http://www.nice.org.uk (5 Mar 2007)

11 Joint Royal Colleges Ambulance Liaison Committee. Clinical practice guidelines version 3.0. University of Warwick/ASA/JRCALC, 2004. Available online http://www.nelh.nhs.uk/emergency (5 Mar 2007)

12 World Health Organization. ICD-10 Classification of mental and behavioural disorders. Geneva: WHO, 1992.

13 http://www.dca.gov.uk/menincap/legis.htm#reldocs.

14 http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/ jrcalc_2006/guidelines.

Further reading

BMA. Guidance for general practitioners: medical examinations and medical recommendations under the Act. London: BMA, 1999.

Department of Health. Reference guide to consent for examination or treatment. London: DoH, 2001.

Hatton C, Blackwood R. Examination of the mental state. Lecture notes on clinical skills, 4th edn. Blackwell Science, Oxford, 2003.

National Institute for Health and Clinical Excellence. The NICE website contains clinical guidelines for depression and anxiety, also for schizophrenia and self-harm. www.nice.org.uk. (5 Mar 2007)

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