Select Committee on Health Fourth Report



24. The Department of Health highlighted the fact that there is currently no single set of definitions or categorisations of mental disorder, with various definitions being used for different purposes.[28] Firstly, the World Health Organisation International Classification of Disease (ICD 10) and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) definitions are used for diagnostic purposes. Secondly, section 1 of the Mental Health Act 1983 sets out definitions of "mental disorder" (of which "mental illness" is an undefined sub-classification) which are used to determine whether a patient is liable for detention under the Act. Thirdly, operational definitions are used to determine access to services. The Department drew our attention to the definition of "severe mental illness" developed by the National Centre for Health Outcomes Development, which includes a diagnostic criterion, evidence of high use of services, and evidence of significant problems with everyday living.[29] This definition was also used by the External Reference Group which advised on the development of the National Service Framework.[30]

25. The Law Society developed this point further in written evidence to us, arguing that the purpose for which a definition is being used is a crucial factor in deciding whether or not it is appropriate. In the case of the definition of mental disorder to be used in any new legislation, the Society argued that:

    "If it is intended that the legislation should have a broad focus, encompassing entitlement to health care and service provision, the Law Society supported use of a correspondingly broad definition of mental disorder, to ensure that all people affected by mental disability could benefit from the Act's provisions. However, if legislation is concerned only with powers of compulsion, to force people with mental health problems to undergo assessment and treatment which they will not accept or comply with voluntarily, the definitions and diagnostic criteria must be narrowly drawn to ensure that compulsion, which deprives people of their liberty, is only used where it can be justified, as a last resort and in restricted circumstances."[31]

We agree with the Law Society that the appropriateness of any definition of mental disorder will depend on the purpose for which it is being used. We also agree that any criteria used for determining access to services should be far wider than those used to define the circumstances when compulsion may be permitted.

26. We will look at two major areas where definitions are currently the subject of debate, the definition of mental disorder to be used in the forthcoming mental health legislation and the definition "dangerous people with severe personality disorder" which forms the basis of the Home Office/Department of Health proposals on preventative detention, later on in this Report when we consider these areas of policy in more detail. However, there are a number of more general observations which we would like to make here on the implications of the way definitions may be used.

27. A number of witnesses, including the British Psychological Society, Breakthrough, and the Manic Depression Fellowship, expressed concerns about the tendency to divide mental illness into categories such as "mild", "acute" and "severe and enduring".[32] They argued that by its nature mental illness may be intermittent and episodic, and that it is not helpful to attempt to place individuals in fixed categories. Mr. Tony Russell from Breakthrough, for example, told us:

    "I think it is a dangerous road to go down if we start labelling people as severely mentally ill or just the worried-well, because I have been both, and I have been both on the same day."[33]

The Manic Depression Fellowship similarly suggested that the category "severe and enduring mental illness" was "arbitrary" and "divisive", only serving to "demonise and exclude service users".[34]

   28. While we appreciate that stretched services need to set boundaries in order to be able to care for the patients on their case-load, we believe that, from the patient perspective, inflexible labelling is both unhelpful and often stigmatising. Given the fluctuating nature of mental illness, concepts such as "severe and enduring", while useful for targeting resources, must not be used inflexibly to restrict access. We recommend that when individuals are discharged from specialist services, such as those provided by community mental health teams, they should receive clear information on how they can easily re-access these services if their situation deteriorates.

29. We also received a considerable amount of evidence on the problems experienced by those

with a "dual diagnosis", either of learning disability and mental disorder,[35] or substance misuse and mental disorder.[36] While the difficulties experienced by these two quite disparate groups of patients may often be different, it was made clear to us that both face the common problem of "pass the parcel", with services keen to regard the patient as the "problem" of another statutory service. We were told by Young Minds, for example, that "the division between drug and alcohol services and mental health services creates widespread problems throughout the mental health system"[37] while the father of a young autistic man who died in an incident in a care home made very similar points in relation to the divisions between learning disability and mental health services."[38] Paul Farmer of the National Schizophrenia Fellowship expressed the dilemma of patients with mental illness and substance misuse problems succinctly: "they are deemed too 'mad' to go into an alcohol or drugs unit or too 'high' to go into a mental health service."[39] The charity Turning Point, which provides services to people with alcohol, drug and mental health problems, highlighted concerns that such patients may also find it difficult to access primary care services, and hence may experience additional difficulty in having their physical health needs addressed.[40]

30. Two further points were made to us in relation specifically to dual diagnosis of mental illness and substance abuse. The first was that such patients, when they are admitted to in-patient mental health services, can be highly disruptive in a way that is very difficult for other patients. Lionel Joyce, the chief executive of Newcastle City Health NHS Trust, painted a vivid picture for us:

    "A big problem for us (and you) is drugs. Most of our patients have dual diagnosis ... on a general ward that is really very difficult where you have other people with other conditions who do not want young men out of their heads on wards."[41]

The second point, which appeared to us of particular concern, was that substance misuse is very often implicated in acts of violence (both homicide and suicide) committed by individuals suffering from mental disorder. The Centre for Mental Health Services Development at King's College London argued that dual diagnosis of substance misuse and mental disorder is "the major public safety issue", and cited figures from homicide inquiries showing that in three quarters of homicides by mentally ill individuals, the perpetrator had a significant substance abuse problem.[42] A number of other witnesses highlighted the link that the recent report Safer Services[43] (which summarised the findings of the National Confidential Enquiries into homicide and suicide) made between suicides and homicides by individuals who have been in touch with mental health services, and drug or alcohol abuse.[44]

31. The Department told us that the National Service Framework on mental health, the Government's Drugs Strategy and the forthcoming Alcohol Strategy would together encourage individual services to plan for, and meet, the needs of patients with a dual diagnosis of mental illness and substance abuse.[45] The Department also highlighted two projects they have assisted through the Drug and Alcohol Specific Grant: a "dual diagnosis development programme" supporting service development and evaluation in the voluntary sector specialist drug services; and a "mapping exercise" looking at multi-agency, multi-disciplinary work between local authorities and the voluntary sector.[46] Other witnesses were less impressed by the emphasis given to dual diagnosis services in the National Service Framework (NSF): the National Homeless Alliance felt that, although the NSF acknowledged the problems of co-morbidity of substance misuse and mental disorder, it provided little guidance,[47] while the Centre for Mental Health Services Development at King's College London described dual diagnosis as a "serious omission in the National Service Framework."[48]

32. The Centre for Mental Health Services Development also provided us with some estimates of the prevalence of dual diagnosis. A study by the Maudsley had found that 40% of alcohol dependent patients had some form of mental illness, while a recent study in Lambeth, Southwark and Lewisham Health Authority suggested that 58% of people accessing mental health services had a dual diagnosis of substance misuse.[49]

33. Given the high incidence of co-morbidity of mental disorder and substance misuse, and the link between substance misuse, mental disorder and violence, we believe it is crucial that greater priority be given to this group of patients. We welcome the fact that the Department has been funding service development in this area, and intends to disseminate any lessons learned. We would also endorse the "practical steps" suggested by the Centre for Mental Health Services Development at King's College London, namely that the Department should:

  • require joint working and coordination between mental health and substance misuse agencies, to address the complex social and clinical needs of this client group;
  • require mental health services to take the lead for those people on enhanced CPA [Care Programme Approach] with a dual diagnosis;
  • include working with people with a dual diagnosis as a requirement within the remit of assertive outreach services.[50]

The Centre also argued that the Department should extend the duty of partnership imposed on the NHS and local authorities by section 27 of the Health Act 1999 to include substance misuse and housing services. Section 27 requires NHS bodies and local authorities to "co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales". We would understand this to include local authority responsibilities for housing and substance misuse provision, as both have a clear input into the "health and welfare" of local residents. We recommend that the Department should issue guidance, clarifying this position.

34. We would also draw to the Department's attention the difficulties being experienced by some patients with a dual diagnosis of learning disability and mental disorder. While this group of patients may not be as visible as those with the dual diagnosis of substance misuse and mental disorder, it is clear that services are far from adequate. We recommend that the Department should issue guidance highlighting the needs of this group of individuals and encouraging mental health and learning disability services to work much more closely and co-operatively together.

35. The final observation we want to make on the question of definitions is the effect that a diagnosis of personality disorder or psychopathic disorder (the term used in the 1983 Act) may have on an individual's access to services. The term "psychopathic disorder" is now generally regarded as redundant and stigmatising, with the term "personality disorder" being seen as clinically more meaningful. The sub-classifications "anti-social" or "dissocial" personality disorder are used to characterise personality disorders associated with violent and disruptive behaviour.[51] There are also longstanding disagreements between psychiatrists as to whether "psychopaths" are treatable, which resulted in the inclusion of the "treatability" criterion in the Mental Health Act 1983.[52] This criterion prevents patients classified as suffering from psychopathic disorder from being detained under the Act unless the treatment they are to be offered "is likely to alleviate or prevent a deterioration of his condition".[53] We discuss the question of treatability at length later in our Report (see below paragraphs 136-139 and 157-160), but would like to highlight in this section the evidence we received that a diagnosis of personality disorder or psychopathic disorder may be used as a way of excluding patients from services. The organisation INQUEST, for example, argued that "far too often diagnosis of personality disorder has meant that clearly distressed individuals have not had access to support,"[54] while the Children's Society told us that personality disorder is often used as a "dust-bin" category for children deemed too difficult to help.[55] We discuss later the importance of ensuring that the "treatability" criterion is not simply used as a cover for inadequate services (see below paragraph 159).

28   Ev., p15. Back

29   Ev., p16. Back

30   Ev., p16. Back

31   Ev., p314. Back

32   Ev., p148; Q200; Ev., p72. Back

33   Q200. Back

34   Ev., p72. Back

35   eg Ev., p235; Ev., p265. Back

36   Ev., p53; Ev., p153; Ev., p248; Ev., p251; Ev., pp292-294. Back

37   Ev., p71. Back

38   Ev., pp235-236. Back

39   Q150. Back

40   Ev., p310. Back

41   Q342. Back

42   Ev., pp293-294. Back

43   Department of Health, Safer services: National Confidential Inquiry into suicide and homicide by people with mental illness report, 1999. Back

44   eg Ev., p53; Ev., p251. Back

45   Ev., p205. Back

46   Ibid. Back

47   Ev., p248. Back

48   Ev., p293. Back

49   Ev., p293. Back

50   Ev,. p294. Back

51   Report of the Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital, Cm 4194-II, part 6.2. Back

52   Ibid, part 6.6. Back

53   section 3 of the Mental Health Act 1983Back

54   Ev., p312. Back

55   Ev., p327. Back

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