August 2007: Discussion Paper

“EXTENDED LEAVE, COMMUNITY TREATMENT ORDERS, AND CONTINUITY OF CARE”

The Right to Receive Treatment

Persons with severe mental illness have a fundamental right to treatment, even if at times the treatment may not be completely voluntary (1). Appropriate and humane community treatment-placement decisions, set as conditions for “extended leave” as defined in the B.C. Mental Health Act, can help address these concerns (2,3).

It is a fact that many people with schizophrenia, even when stabilized on medication, continue to lack insight and awareness about the importance of continuing treatment. Since there is now increasing evidence which shows that early diagnosis, stabilization, and continuing treatment for patients who are ill with schizophrenia considerably improves individual prognosis (4, 5), every effort should be made to see that successful treatment, once begun, is continued.

Reduction of Harmful Incidents

Research studies show that while receiving medication, people with schizophrenia are not ordinarily violent—in fact, they tend to be somewhat less violent than other people (6). Research and documentation also confirm:

• that there is a statistically significant relationship between violent behaviour and seriously mentally ill individuals who are discharged from hospital without adequate follow-up supervision, or who are untreated with medication (6)
• that suicide rates among people with mental illness are alarmingly high: 10 to 15% of people with schizophrenia will kill themselves, and 50% will attempt to commit suicide during the course of their illness (7)

Provisions for conditional release defined as “extended leave” in Sections 31-33 of the B.C. Mental Health Act could help to reduce the incidence of these tragedies.

Current Provisions in British Columbia

Extended leave as defined in the present Act provides a mechanism for the release of an inpatient from hospital to community care before the expiration of an existing committal order. It is available at the discretion of the director of the hospital psychiatric facility (8).

As such, extended leave provides for conditional release that can be tied to continued participation in a comprehensive treatment plan within the community. The present B.C. Act makes no provision for any other form of outpatient committal.

Current Practice in British Columbia

The type of conditional release defined as extended leave in the Act is not presently being used in most parts of British Columbia. Where it is being used (for example, in Victoria) it is successful. This is at least partially due to the fact that the hospital concerned has written policy regarding extended leave. The results of this policy are considered beneficial to both the patients and the immediate community.

It is not entirely clear why extended leave is not being similarly used in other jurisdictions throughout the province. Generally, it is thought to be due to perceived liability protections and weak enforcement mechanisms. These factors must be re-examined (9).

In addition, however, a written statement of hospital policy regarding extended leave is obviously a useful first step, in that it sets out conditions of professional responsibility under which hospital and community treatment physicians agree to cooperate in the best interests of the patient.

Treatment vs. Incarceration

In 1992, the BCSS voiced its concern over undue focus by the medical profession on the criterion of dangerousness in the Mental Health Act (10). Since that time, the ruling of Justice Ian Donald of the B.C. Supreme Court (June 17, 1993) in the McCorkell case has helped to change this focus, by making it clear that “unlike incarceration in the criminal justice system, involuntary committal is primarily directed to the benefit of the individual so that they will regain their health.”

Professional Responsibility

Strong emphasis must continue to be placed on the fact that previous liability concerns among medical professionals who are mandated to accept responsibility for treating patients are now unjustified. This is particularly important in the light of the growing evidence showing that early intervention, close follow-up, and continued stabilization on medication greatly improves the prognosis of the individual who is diagnosed with schizophrenia.

Enforcement Mechanisms

The perception of “weak enforcement mechanisms” with respect to extended leave as set out in the B.C. Mental Health Act is inaccurate. Enforcement mechanisms regarding extended leave are specific. Section 33 of the Act states that the release of a patient on leave does not impair authority for detention if the conditions for such release are not met. It also sets out procedures to be followed by all authorities.

Many British Columbia police officers are presently frustrated in their efforts to protect people with chronic mental illness who are in a state of mental deterioration. Without cooperation and direction from physicians and hospital authorities, it is difficult for the police to help such individuals.

If hospital policy includes provisions for extended leave that are clearly written and understood, there is no reason to anticipate enforcement difficulties.

Conclusions

While families remain the largest group caregivers in the community, this burden has not been accompanied by the support they need. Thus, they are in the position of having responsibility for their ill relatives, yet often have great difficulty gaining access to adequate services, policy input, decision making, or resources.

This situation must change. The extended leave provision of the present Mental Health Act can and should be used to provide specific and enforceable community treatment. In addition, the government should develop and introduce separate legislation for community treatment orders, similar to that instituted by the Province of Saskatchewan’s Bill 87 (11).

Good community treatment, combined with more cooperative and assertive case management – including quality community care (housing, rehabilitation and outreach services) – would help to alleviate much of the suffering of people with serious mental illness.

Proposed Recommendations and Comments

The Society urges that

• Present provisions of the Mental Health Act for extended leave be upheld and enforced;
• All provincial hospitals with psychiatric care facilities have clearly written policy regarding the administration of this responsibility; and
• The provincial government develop and enact additional legislation for community treatment orders.

Education about schizophrenia is necessary to gain understanding and support for the proposed policy position. State-of-the-art continuing education programs should be mandatory for all health care providers, especially psychiatrists (12). Consumer and family-member educators, as well as mental health practitioners, should be used to help deliver these programs. Certification in mental disorders education should also be required for all judges, lawyers and justice personnel who work with people with mental illness.

In order to improve the effectiveness of the present B.C. Mental Health Act and to facilitate future legislative changes, the B.C.S.S. should assume responsibility for a comprehensive and continuing study of additional forms of outpatient committal to community treatment, based on current research and practices in other jurisdictions within Canada, the United States, and Great Britain.

References

1. Lamb, HR, Mills, MJ: Needed changes in the law and procedure for the chronically ill. Hospital and Community Psychiatry 37:475-480, 1986

2. Lamb, HR: Deinstitutionalization at the crossroads. Hospital and Community Psychiatry 39:941-945, 1988 and Lessons learned from deinstitutionalization in the United States. British Journal of Psychiatry 162:587-592, 1993

3. Swartz, M, Burns, B, et al. New Directions in Research on Involuntary Outpatient Commitment, Psychiatric Services. Psychiatric Services 46:4: 381-385, 1995

4. Jones, BD. New Psychopharmacology in the Context of Positive and Negative Schizophrenia Symptoms. 1st Annual Schizophrenia Day Conference, June 7, 1995

5. McGorry, P. Early Psychosis Prevention and Intervention Centre. Australasian Psychiatry:1:1:31-34, 1993

6. Torrey, E F: In Reply, On Violence and Mental Illness. Psychiatric Services 46:4: 407, 408, 1995

7. Keefe, R, Harvey P: Understanding Schizophrenia: A Guide to the New Research on Causes and Treatment. Maxwell MacMillan, Toronto, 1994

8. British Columbia Mental Health Act, Part 3, sections 31 – 36

9. Kaplan, RJ: New Survey Assesses Outpatient Commitment. RJ Kaplan and E.Fuller Torrey. NAMI Advocate, 12, Jan/Feb 1995

10. B.C. Schizophrenia Society: Response to the B.C. Ministry of Health. Discussion Paper on Mental Health Legislation, September, 1992

11. Province of Saskatchewan: Bill 87, April, 1994

12. Packer, S, Prendergast, P, et al. Psychiatric Residents’ Attitudes Toward Patients With Chronic Mental Illness. Hospital and Community Psychiatry 45:11: 1117-1121, 1994