Annex A
CURRENT GOVERNMENT DEFINITIONS AND CATEGORISATION
OF MENTAL ILLNESS
A1. There is no single set of definitions
or categorisations of mental illness. Rather, there have been—and
currently are—different definitions for different purposes
in different contexts and settings. This paper summarises three
approaches—through diagnostic coding, in the legislative
framework, and, more pragmatically, operational definitions for
service development and monitoring. It also includes a summary
of the types of mental health beds which are provided.
DIAGNOSTIC CODING
A2. It is Government policy to use the World
Health Organisation International Classification of Disease rather
than the USA Diagnostic and Statistical Manual.
A3. There are two main internationally recognised
systems for diagnosis of mental disorder: the WHO's International
Classification of Mental and Behavioural Disorders Tenth Revision
(ICD 10) and the American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).
These both cover disorders generally recognised as mental illness
as well as personality disorders and recent editions have provided
detailed criteria required for the assignment of each listed disorder.
The aim of such systems is to enhance the comparability of diagnoses
between clinicians, centres and countries for the purposes of
health care management, statistics and research. They are particularly
relevant in the classification of mental illness where unambiguous
diagnostic markers such as blood or x-ray examinations tests are
seldom available.
THE LEGISLATIVE
FRAMEWORK
Current definition of mental disorder in the Mental
Health Act 1983
A4. The current Mental Health Act is concerned
with mentally disordered patients. Mental disorder is defined
at section 1 as:
Mental illness, arrested or incomplete development
of mind, psychopathic disorder and any other disorder or disability
of mind.
A5. For many of the Act's purposes, a diagnosis
of mental disorder is not enough: a diagnosis of one of the four
specific categories of mental disorder is required. These are:
— mental illness, which is not defined
in the Act;
— severe mental impairment, defined
as:
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;
— mental impairment, defined as:
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;
NB: The qualification "abnormally
aggressive or seriously irresponsible conduct" is intended
to ensure that people with learning disabilities are not subject
to long-term compulsory powers unless their behaviour, which is
part of their condition in a particular case, justifies the use
of those powers.
— psychopathic disorder, defined as:
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.
Exclusions: Those suffering from the following
conditions alone are not covered by these definitions, promiscuity
or other immoral conduct, sexual deviancy or dependence on alcohol
or drugs.
Proposed definition of mental disorder in the
Green Paper
A6. The Richardson Committee, whose work
informed the Government's consultation paper Reform of the
Mental Health Act 1983, proposed that the detailed definition,
on the 1983 Act should be replaced by a broad definition of mental
disorder; namely:
Any disability or disorder of mind or brain,
whether permanent or temporary, which results in an impairment
or disturbance of mental functioning.
A7. This is consistent with the definition
of mental disability adopted by the Law Commission in their report
on Mental Incapacity. The Committee also recommended that disorders
of sexual preference and misuse of alcohol and drugs, where these
are the sole mental disorders, should be excluded from the definition.
Operational definitions for service development
and monitoring
A8. Severe mental illness has been referred
to in a variety of Government publications.
A9. The National Centre for Health Outcomes
Development defined severe mental illness as follows:
— there must be a mental disorder as
designated by a mental health professional (psychiatrist, mental
health nurse, clinical psychologist, occupational therapist or
mental health social worker) and either;
— there must have been a score of four
(severe/very problem) on at least one, or a score of three (moderately
severe problem) on at least two, of the Health of the Nation Outcome
Scales items1 to 10 (excluding item 5 "physical illness or
disability problems") during the previous six months; or
— there must have been a significant
level of service usage over the past five years as shown by:
— a total of six months in a psychiatric
ward or day hospital; or
— three admissions to hospital or day
hospital; or
— six months of psychiatric community
care involving more than one worker or the perceived need for
such care if unavailable or refused.
A disadvantage of this definition is its reliance
on a prolonged high level of service usage.
A10. The Mental Health Information Strategy
will incorporate a new, person based framework for mental health
information. The Mental Health Minimum Data Set defines its coverage
as individuals receiving assessment and/or care from specialist
mental health services. Diagnostic categorisation on the problems
of individuals in the data set is undertaken using the International
Classification of Diseases. For patients not seen by doctors,
the broader Primary Health Care groupings of the International
Classification of Disease are recommended. It is anticipated that
it will accommodate the data requirements for most routine definitions
of severe mental illness and mental health care case mix assignments.
A11. Classification of the range and severity
of patients' problems in the data set is undertaken using the
Health of the Nation Outcome Scale. This is a 12 item inventory,
developed for the Department by a wide consortium of British mental
health specialists, led by Professor John Wing of the Research
Unit of the Royal College of Psychiatrists. It provides a standardised
profile of the range and severity of problems arising from mental
illness. Each of the following items is rated on a scale from
0 (no problem) to 4 (severe):
(i) overactive, aggressive, disruptive or agitated
behaviour;
(ii) non-accidental self-injury;
(iii) problem-drinking or drug-taking;
(v) physical illness or disability problems;
(vi) problems associated with hallucinations and
delusions;
(vii) problems with depressed mood;
(viii) other medical and behavioural problems;
(ix) problems with relationships;
(x) problems with activities of daily living;
(xi) problems with living conditions; and
(xii) problems with occupation and activities.
A12. The External Reference Group which
advised on the development of the National Service Framework defined
severe mental illness as follows:
There must be a mental disorder as designated
by a mental health professional (psychiatrist, mental health nurse,
clinical psychologist, occupational therapist or mental health
social worker) and either:
— there must have been a score of four
(very severe problem) on at least one, or a score of three (moderately
severe problem) on at least two of the Health of the Nation Outcome
Scales items one to 10 (excluding item five "physical illness
or disability problems") during the previous six months;
or
— there must have been a significant
level of service usage over the past five years as shown by:
— a total of six months in a psychiatric
ward or day hospital; or
— three admissions to hospital or day
hospital; or
— six months of psychiatric community
care involving more than one worker or the perceived need for
such care if unavailable or refused.
A13. This developed the approach set out
in Building Bridges: A Guide to Arrangements for Inter-Agency
Working for the Care and Protection of Severely Mentally Ill People
(1995) which identified "the dimensions of a definition of
severe mental illness, the key elements of which were disability,
diagnosis, duration, safety and informal and formal care".
A14. Building Bridges described the
characteristics of people suffering from severe mental illness
as being individuals who:
— are diagnosed as suffering from some
sort of mental illness (typically people suffering from schizophrenia
or a severe affective disorder, but including dementia);
— suffer substantial disability as
a result of their illness, such as an inability to care for themselves
independently, to sustain relationships or to work;
— are currently displaying florid symptoms;
or
— are suffering from a chronic, enduring
condition;
— have suffered recurring crises leading
to frequent admissions/interventions;
— occasion significant risk to their
own safety or that of others.
A15. Not all these conditions had to be
met for a person to be regarded as severely mentally ill. For
example:
— a person who had a chronic illness
but who had not been in regular contact with services would still
be regarded as a severely mentally ill person;
— an individual who presented for the
first time with florid symptoms would also be regarded as suffering
from a severe mental illness;
— a person with a very serious phobic
disorder which was not necessarily chronic, but resulted in a
very considerable disabilities would also fall within this remit;
and
— a person can be severely mentally
ill without occasioning significant risk to their own safety or
that of others.
Child and adolescent mental health
A16. In Epidemiologically based needs
assessment: Child and adolescent mental health (1995), Wallace,
Crown, Cox and Berger provided detail on the prevalence of child
and adolescent mental health problems and disorders. They defined
a problem as "a disturbance of function in one area of relationships,
mood, behaviour or development of sufficient severity to require
professional intervention". A disorder is defined "either
as a severe problem (commonly persistent), or the co-occurrence
of a number of problems, usually in the presence of several risk
factors".
DEFINITIONS OF
MENTAL HEALTH
BEDS
A17. The number of NHS mental health beds
have reduced dramatically. The numbers of short stay acute beds
have continued to drop from 17,390 in 1987 to 14,500 in 1997.
The biggest decline has been in the number of long stay NHS beds
from 21,390 in 1987 to 5,410 in 1997. There have been corresponding
increases in staffed residential home places, particularly in
the private sector, although patients at these homes will not
be so severely ill as to require care in a secure environment.
A18. Before the allocation of specific funds
from the Modernisation Fund in 1999-2000 for the development of
additional secure NHS places, approximately a third of medium
security places and 10 per cent of low security places were provided
by the private sector. One of the objectives of the allocation
of specific funds for additional secure places in 1999-2000 was
to release resources from independent sector placements to be
reinvested in local NHS places.
The following types of beds are provided:
— rehabilitation/24 hour nursed care;
ACUTE
A19. Acute beds are intended for people
in acute crisis who cannot be managed safely in the community
and who usually require short term intervention and treatment.
The length of stay is usually below five weeks. Around 10 per
cent of all admissions nationally are compulsory admissions under
a section of the Mental Health Act. In inner cities this figure
may be 50 per cent or higher. These wards are not locked.
REHABILITATION/24
HOUR NURSED
CARE
A20. Rehabilitation facilities include non-acute
beds and are either hospital or community based providing 24 hour
staffed care to people with severe and enduring mental illness.
The focus is on enabling people over longer lengths of time to
achieve their optimum level of health and social functioning prior
to discharge into a community facility. There will be a proportion
of people, however, who cannot be discharged into non-NHS facilities;
some will remain on a section of the Mental Health Act and may
require intensive support over several years. These people require
24 hour nursed care either on the hospital site or in the community.
INTENSIVE CARE
A21. Intensive care beds are intended for
those people who cannot be managed safely on an open acute ward.
They usually cater for two types of patients. First, those with
an acute psychotic episode who need time in a locked environment
to receive the treatment that they require. Patients can stay
from a few days to a few weeks. Second, a group of patients who
require a longer length of stay in a secure environment, although
would not be expected to stay more than a few months. However,
some patients do require longer lengths of stay and, if no other
facility is available locally, may remain longer, denying access
to other patients. This in turn creates further pressure on acute
wards which are unable to transfer patients into locked environments
when needed.
LOW SECURE
A22. Low secure or high dependency services
are geared towards the client group who require long lengths of
stay in a locked environment usually in excess of six months and
many will require help and support for several years. Such facilities
need to be lockable and focus on quality of life issues due to
patients' long lengths of stay. A number of patients will have
been admitted via the courts, often under a section of the Mental
Health Act with restrictions, although it is deemed they do not
need the higher levels of security offered in medium or high secure
units.
MEDIUM SECURE
A23. Medium secure units or regional secure
units are mainly geared towards forensic mental health, and although
they will take patients who cannot be managed safely in local
environments, they also take patients from prisons and other facilities.
Medium secure facilities are intended as intensive rehabilitation
units and generally therefore restrict admissions to patients
who would not require a length of stay more than 18 months. They
will also take people referred from the high secure hospitals,
although many of these patients are assessed to require much longer
lengths of stay. Many therefore remain for much longer periods
than they need to in a high secure environment.
HIGH SECURE
A24. High security hospitals are intended
to provide a high secure and safe environment for people regarded
as a grave and immediate danger to the public. In physical security
terms, the high security hospitals currently broadly equate to
Category C prison standards. The average length of stay is in
the region of seven to eight years, although some patients will
require treatment in a high security environment for most, if
not all, of their lives. Because so many patients require what
are called "step down" facilities, it can be very difficult
to find a suitable placement. There are over 400 patients, representing
roughly a third of the resident population, currently within the
high security hospitals transfer/discharge system. This includes
patients at various stages in the transfer/discharge process,
from those just identified by their Clinical Teams as no longer
requiring high security care and treatment, to those for whom
suitable alternative placements have been identified, and Home
Office consent (where restricted patients are concerned) to a
move obtained, but vacancies in the receiving facility are awaited.
Around 60 patients currently come into this latter group. The
new Regional arrangements for commissioning high security services
should help to ease the problems.
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