Friday, 17 February 2012

Nature or Degree

The Mental Health Act attaches a lot of importance to the concept of “nature or degree” in relation to mental disorder. In fact, the MHA refers to “nature or degree” at least 18 times (I’ve counted).

For example, Sec.2(a) states:
“(2) An application for admission for assessment may be made in respect of a patient on the grounds that he is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period.”

The distinction between “nature” and “degree”, and its implications for practice, is a complex one. On a day to day basis, an AMHP tends to be more concerned with the “degree” of mental disorder present on assessment. For a patient not previously known to mental health services, the “nature” of their mental disorder may be unknown or unclear.

Someone who has taken amphetamines or a hallucinogen like LSD may present with symptoms difficult to distinguish from schizophrenia or bipolar affective disorder. It is only when the effects of the drugs have worn off that it might become clear that they do not have a mental disorder at all. Similarly, an older person with a urinary tract infection may present with symptoms very similar to dementia or other mental illness. It is only when there has been an opportunity to diagnose and treat the infection that it is apparent that they do not have a mental disorder.

I have detained many people presenting with acute indications of severe mental illness who have, following admission, been found to have taken drugs, or have some other organic cause for their presentation, which has quickly resolved with the passage of time or physical treatments. I recall the psychiatrist and I being convinced that someone being assessed at the CMHT had all the signs of bipolar disorder: pressure of speech, flight of ideas, sleeplessness, hyperactivity and irritability. However, on admission it was discovered that he had been drinking 10 or more cans of Red Bull daily prior to the assessment, and after a night in hospital he returned to normal.

Detention under Sec.2, then, might commonly occur when someone is presenting with symptoms of a “degree which warrants the detention of the patient in hospital for assessment”, but where the nature of their disorder may be far from clear.

“Nature” becomes more important when assessing someone under Sec.3, for treatment. Anyone being considered for detention under Sec.3 should have some sort of working diagnosis of mental disorder, and the psychiatrist should have a pretty clear idea of the sort of treatment that is required to treat that disorder. The patient must therefore have a mental disorder of a sufficient “nature” to warrant detention for treatment.

In fact, not only must the psychiatrist state on the medical recommendation that the patient has “a mental disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment in hospital”, but he or she also has to give an account of the symptoms that have led them to that conclusion, the sort of treatment the patient requires, and where that treatment is available.”

If someone is in hospital at the time of assessment, “degree” is also very important; the AMHP needs to be satisfied that the patient has active symptoms of mental illness or disorder that require treatment in the first place to alleviate them.

It can, however, become more complicated when someone in the community is being considered for detention under Sec.3. While normally, both nature and degree should be present in order to justify detention for treatment, there are circumstances in which it may be justifiable to detain someone who has a known diagnosis, for example, paranoid schizophrenia, and therefore has a mental disorder of a “nature”, but who is currently symptom free.

In Smirek v Williams [2000] MHLR38, it was noted:
“”Where there is a chronic condition, where there is evidence that it will soon deteriorate if medication is not taken, I find it impossible to accept that that is not a mental illness of a nature or degree which makes it appropriate for the patient to be liable to be detained in hospital for medical treatment if the evidence is that, without being detained in hospital, the patient will not take that treatment”.

Richard Jones (Mental Health Act Manual) makes the proviso that making a decision to detain in such a case should be based on an assessment of the risk to the patient or others if they are not treated.

(I once detained a patient under Sec.3 who had made an advance decision requesting that she be detained if she became unwell and no longer had the capacity to make an informed decision about admission. In the past, she frequently damaged and destroyed her property when unwell, and would be understandably very distressed about this when she recovered.)

The question of “nature or degree” invariably arises in Tribunal hearings. Here, if the Tribunal is not satisfied that a patient is, at the time of the Tribunal, suffering from “mental disorder of a nature or degree which warrants detention in hospital” for either assessment or treatment, then they have to discharge the patient. They will therefore be keen to establish from the psychiatrist whether mental illness of a nature or degree or both are present in the patient.

The case of R (Smith) v MHRT South Thames Region (1998) EWHC Admin 832 very usefully examined the issue of “nature and degree”, especially in connection with Tribunals. This case related to a patient with a diagnosis of paranoid schizophrenia who appealed against his detention. A Tribunal considered that he had a mental illness of a nature but not a degree which warranted his detention in hospital. He challenged the legality of this decision.

The judge concluded: “It is quite clear that the illness was not of a degree which of itself made it appropriate for him to be liable to be detained. The reason for that was because he has a chronic condition which was static. However, the nature of the condition was that it might cease to be static so that the interpretation that nature is in some way unchanging in one view may be right, but the effect of the condition is that because of its very nature it may not remain static. It seems to me that if the facts upon which the Tribunal rely have shown that it may not be static, that goes to the nature of the condition. The degree in the instant case, in relation to his condition, was not relevant because it was static and stable.”

He went on to state: “If one had simply to look at the degree it would have been right for the discharge to take place, but the nature of the condition was such that it was clear that he should not be discharged.”

This decision was widely quoted in both the Reference Guide and the Code of Practice and has become  the primary legal definition. C4.3 of the COP unequivocally states: “Nature refers to the particular mental disorder from which the patient is suffering, its chronicity, its prognosis, and the patient’s previous response to receiving treatment for the disorder. Degree refers to the current manifestation of the patient’s disorder.”

Whether you are presenting a social circumstances report or a medical report to a Tribunal, it is vital to understand this distinction. I have seen solicitors in Tribunals tearing inexperienced psychiatrists to pieces when they have sensed that they are unclear about the importance of establishing “nature and/or degree” and the difference between the two.

It’s not a pretty sight.


  1. Did I really understand well? It looks like once a patient is diagnosed with a chronic condition such as schizophrenia, he or she can be detained at any time under that pretext even if the illness itself has minimal symptoms or no symptoms at all at that particular time, since there is no way to prove that the illness is gone for good or won't get worse later. That's so scary! Mental health professionals may not necessarily detain currently asymptomatic or nearly asymptomatic patients, and in fact I understand you AMHPs are usually called when there are reports of odd behaviour, not just rounding up diagnosed individuals from their own homes on a whim. However, it looks like once diagnosed, patients are never safe and merely being normal or even defending their freedom in court won't save them from arbitrary detention unless mental health professionals simply do not wish to detain them.

    1. Monica - you have misunderstood the Mental Health Act

      The legal requirements for detention also require detention to be necessary (i.e. not just desireable to the medics) for the health of the patient, their safety or the safety of others. Not to be confused with a chronic mental illness that persists but does not endanger someone so they can live in the community and do not need to come into hospital, let alone need to be detained. The Act also says people should be treated in the least restrictive way that is effective and possible, i.e. by crisis teams/ crisis houses/ informal admission etc.

      Detention is only for those that need it and only for as long as it is needed.

  2. While in theory you are correct Monica, in practice doctors and AMHP's do try to act solely in the best interests of the patient. We don't go "rounding up" the usual suspects just to fill beds. It would be a very rare situation to detain someone from the community who was not displaying any symptoms. Such situations would concern patients who had stopped taking medication and who had a serious and well established history of dangerousness in relapse. A decision to detain would be taken on the basis of likely serious risk to the patient and the wider community if no action were taken.

  3. What if the diagnosis was wrong in the first place? It's not me who would tell a psychiatrist that my parents were scientists, my grandmother's family were Eastern European nobles and a distant relative of mine (who may not even be aware of my existence and is not in touch with me) is a politician in a foreign country from that area. I may get some diagnosis for supposedly being delusional even though those things are perfectly true. Other patients may have other slightly implausible facts that a psychiatrist won't believe, or may have had a supposedly psychotic episode triggered by an organic cause that was not detected at the time. And medication could be harmful or have terrible side effects. Are you saying that a patient just can't quit medication, ever? There should be a way to escape the clutches of the mental health system and the obligation to take medication, but you seem to suggest that there is none, at least not for people who do not wish to move far away and hide.

  4. I'll give you a real, recent example of a man I detained under Sec.3 a few days ago. He hears voices. They tell him to do things he doesn't want to do, like to shoot himself or hang himself. He believes that a ghost inhabits his body from time to time, and when it is in control, he has no control over his actions. He believes that external forces are controlling his breathing and heartbeat. He does not think he is mentally ill, and does not see the point of taking medication. The inpatient mental health team, and I as an AMHP, are quite clear that he has a serious mental illness, namely schizophrenia. If he is not detained for treatment he will leave hospital, not take medication, and could endanger his life, or even the lives of others. We are confident that we can treat these symptoms with antipsychotic medication, but they will not cure him. He may become go into remissison and become free of symptoms with appropriate treatment, but he will still have schizophrenia. The mental health services have a responsibility towards him, to try to protect him from the consequences of his illness. If we manage to keep him well, then he and his family will be able to have a more fulfilled life. If we allow him to become seriously ill again, we will have failed him -- and his family, who are begging us for help. Similarly, there is no cure for diabetes, but the symptoms, and the long term harm to health, can be treated and mitigated with the use of medication. That medication will have to be taken for the rest of that person's life.

  5. What about a woman who did not hear voices but whose mother was deaf? Because she said that she was hearing her noisy neighbours and the psychiatrist asked "does your mother hear them?" and the patient said "no", the psychiatrist immediately assumed that the patient must be hearing voices and wouldn't even listen to the patient when she tried to explain. I'm sure many of you mental health professionals are not like that, and your example is pretty good unless responding well to some kind of alternative treatments or having really long periods of remission without medication or side effects of medication that are even worse than the symptoms or life-threatening or some other factors make even this example questionable in some particular cases. The problem is that if a mistake is made, such as in the example of the woman whose mother was deaf, that could amount to a life sentence for the unlucky patient and there is no appeal. It's not that you tend to abuse your power or make many mistakes. It's just that should that ever happen, the patient has no recourse.

    1. Why Nature or Degree? Why not just Nature? In other words is there ever a case when a person can be detained when they suffer a mental disorder of sufficient degree to warrant detention, but not of a nature to warrant detention? I don't think so.

  6. From another very experienced AMHP!
    Firstly I find your choice of pseudonym a bit weird and inappropriate! This is a serious business,AMHP work,and Monica raised a relevant point which you dodge in a defensive way. I've many times come across examples of misinterpretation of comments, scenarios etc by psychiatrists, who are trained to look for pathology. We know that diagnosing is a bit hit and miss, with psychiatrists disagreeing. Diagnoses should be open to review, particularly as side effects of much of the antipsychotic medication are pretty bad. I do agree that risk factors have to be considered but there can be more creative approaches, including a willingness by psychiatrists to change or reduce medication and sometimes to agree to a trial without, with close monitoring. With Bipolar, self management of mood swings together with a lesser amount of chemical treatment can be tried. And,yes,to be willing to not just see pathology as they may be guilty of missing reality and doing an injustice. We're all supposed to be listening to people,working alongside them. AMHPs have to work within a medical model but should be able to challenge it too - given the lack of scientific evidence about the accuracy of psychiatry.
    It's sad to see and hear AMHPs proudly spouting with confidence about what people must do, ie take medication for life or risk being detained!

  7. I was once at a s2 tribunal which began with the panel asking the standard statutory questions, including 'is the patient (today) suffering from a mental illness'. The RC replied 'no', but before the legal representative could ask for the detention to be cancelled immediately, the tribunal medical member asked the rc to clarify a few points and the hearing continued. Incidently the patient was discharged after the author of the scr, when asked about the views of the nr, reported the patient's wife as saying 'He's just been a bit of a naughty boy'.

    Tribunals can be rather effective sometimes.