Managing Clients with Psychiatric Disorders

Tony Glynn & Ian Curtis

Queensland Law Society

Soft Skills Series

Thursday 7 April 2005

Disclaimer

Criminal activity no more likely within mentally ill populations than in the general population.

Mental illness in a person does not predispose to crimes against persons or property.

There are occasions of causal relationship between mental illness and some unlawful acts.

Psychosocial

Every crime occurs in a psychosocial context.

It may be important for the Court, within the limits presumably of what is more probable than not, to know of the psychosocial context and the relevance of the person’s life course to a particular criminal or accidental event.

Explanation or excuse? (P Shea, 1993)

Workplace Injuries

The same issues can be raised about the psychosocial backdrop to an accident in the workplace.

Often more complex. Factors within the life course of the employing

entity are relevant as well as complainant factors.

It requires two people to make a mistake at the same time for an accident to occur.

Mental Health Gatekeepers

Mental health gatekeepers include police, clergy, and legal professionals amongst others because these groups all have training in observation and substantial contact with people.

So we could rename this presentation: Mental Health Awareness/Gatekeeping.

Presentations of People with Mental Health Harms

Threat towards the self (suicide/parasuicide) or towards another.

Covert (masked) illness. The swapping of types of suffering (eg depression/

alcohol). Major assault on one or more people. Colleagues in trouble with their mental health. Are

we sufficiently aware and active? Doctors are not!

Principles for Handling Overt Aggression

The non-reciprocal approach to threat of violence to minimise harms.

A violent man is a frightened man and how this helps you in confronting threat.

Office architecture. Office crisis plans. Self-defence, bearing in mind that the best self-

defence ever invented was running away.

Health and Safety Responsibilities to Support Staff

The healthy workplace. Safety of staff. Issues:

Duress alarms Procedures for warning neighbouring staff and other

offices of hazardous behaviours Evacuation plans to deal not just with fire but also to

deal with behavioural dangers and violence

Health & Safety Comments

If no crisis plan exists at the subject time, a crisis is not the time to be inventing the plan.

The colleague next to you must have an idea what you are likely to do.

If there is a plan in place, there is at least some chance that some people will keep to it.

Legal Professional Management

All have your own preferred methods for assessing clients.

We all have different practices depending largely on how we self-select client base.

This means that we all have differing experiences of professional practice, even within professions.

National Mental Health Survey

This 1997 work was a detailed overview of the prevalence of mental and substance-use disorders for Australia.

In line with the 1990 United States national comorbidity survey.

In line with the 1993 United Kingdom survey of psychiatric morbidity.

National Mental Health Survey Questions

How many adults in private households suffered from mental disorders?

How disabled were they by their psychiatric impairment?

What health services did they use and want?

Disability

People with mental disorders reported 14 million disability days each month.

Mental disorders account for 20% of the total burden of disease in Australia.

Expenditure on mental health is only 5% of the total health budget.

Half the disability associated with mental disorders is generated by two related disorders – the anxiety and affective (mood) disorders

10% is generated by one disorder – schizophrenia.

Australian Mental Health 1997

23% of adults reported having at least one psychiatric disorder in the previous 12 months.

14% were suffering from a disorder when interviewed.

35% had actually consulted about it. 50% of those disabled or having multiple

comorbidities had consulted. The total prevalence in the year was 22.7%

using the ICD-10 and 20.3% using the DSM-IV.

Other Aspects

Women had higher rates of mood and anxiety disorders and lower rates of substance use disorders in contrast to men.

The elderly had lower rates for all disorders except cognitive impairment.

The young had much higher rates of substance use disorders.

Currently married had lower rates for all disorders.

Other Aspects (cont’d)

Disorders frequent with less education. Those employed had lower rates. About 4% of people admitted to suffering from

2 or 3 or more diagnoses at the same time (comorbidity).

Prevalence of Disorders in Men

7.10%

4.20%

11.10%

Anxiety

Depression

Substance Use

Prevalence of Disorders in Women

7.40%

12.00%

4.50%

Anxiety

Depression

Substance Use

Suicide

Suicide is the leading cause of death amongst adult offenders in custodial settings. Inmates are up to ten times more likely to die from suicide than their counterparts in the general population. Custody-related deaths may account for up to three-quarters of all deaths amongst custodial clients who have not yet gone to trial and up to one-third of all deaths amongst sentenced prisoners.

Last 100 Consecutive Medicolegal Cases of Ian Curtis

0

43

2 2

0 0

2

54

3

10 0

5

13

19

9

5

2 23

1

7

3 32

00

2

4

6

8

10

12

14

16

18

20

'10-19 20-29 30-39 40-49 50-59 60-69 70-79Age in Years

Female-Criminal Female-Compensation Male-Criminal Male-Compensation

Last 100 Cases – By Type

3%

1%

55%

5%

1%

1%

34%

Bail Application

Parole Application

Criminal Case

Fitness for Trial

Children's Court

Family Court

Compensation

Last 100 Cases – By Gender

55

11

1915

0

10

20

30

40

50

60

Male Female

Criminal Compensation

Last 100 Cases – By Age

5

17

22

11

7

2 2

56

11

64

20

0

5

10

15

20

25

'10-19 20-29 30-39 40-49 50-59 60-69 70-79

Age in Years Criminal Compensation

Last 100 Cases – By Global Assessment of Functioning Scale*

1

3

14

38

16

16

8

1

3

0 5 10 15 20 25 30 35 40

21-30

31-40

41-50

51-60

61-70

71-80

81-90

unknown

not given

* DSM-IV Scale of Personal Functionality

Medical-Psychiatric Interventionat Legal Practice Level

Early detection is better. Substantiation of expert opinion is of importance to the

Court. The commissioning letter is vital. The commissioning

letter must pose clearly the questions that you require to be answered.

The question of professional fees. A personal and family history together with a plea for

mercy in the last paragraph is not a medicolegal report.

References

Andrews G, Henderson S, and Hall W (2001) ‘Prevalence, Comorbidity, Disability, and Service Utilisation: Overview of the Australian National Mental Health Survey’ British Journal of Psychiatry, 178, pp145-153.

Henderson S, Andrews G, and Hall W (2000) ‘Australia’s mental health: an overview of the general population survey’ Australian and New Zealand Journal of Psychiatry, 34, pp197-205.

Shea P (1993) Psychiatry in Cour,t Sydney: The Institute of Criminology.

Stuart H (PhD) (2004) ‘Suicide in Custody’ in Fast Facts – Psychiatry Highlights 2003-04 Malcolm Lader (ed), Oxford: Health Press Limited.

Treatment Protocol Protocol (2000) Management of Mental Disorders (3rd Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.