Improving human rights in mental health takes more than just changing the law: An audit of medical assessments in regional community patients in Queensland.

OBJECTIVE: To evaluate the medical assessments of involuntary community patients in a regional mental health service, determine the compliance with requirements under Queensland's Mental Health Act 2016 (the Act) to regularly review orders and assess patients' mental capacity. METHOD: We audited 183 patient records on community treatment authorities (CTAs) to determine whether medical assessments undertaken under the Act included consideration of the person's capacity, and regular reviews by an authorised doctor as required1s205. RESULTS: The audit revealed that 51% of the CTA patients did not comply with legal requirements either to complete a capacity assessment and/or be medically assessed within three months of the last review. CONCLUSIONS: Over 50% of medical assessments did not comply with the legislative requirements to record capacity assessments and review involuntary treatment on at least a three-month basis. However, when the treatment criteria were met, it did not appear to be a basis for CTA revocation. Further research may help determine whether the Mental Health Review Tribunal (Tribunal) could play a greater role in overseeing compliance with the new legislative requirements or if other clinical oversight mechanisms would be appropriate to improve the assessment process.

New laws that prohibit conversion therapy pose no material risk to evidence-based and clinically appropriate practice.

OBJECTIVE: To examine the extent to which the Sexuality and Gender Identity Conversion Practices Act 2020 (ACT) and Change or Suppression (Conversion) Practices Prohibition Act 2021 (Vic) might pose a risk to evidence-based and clinically appropriate practice. METHOD: Using a recent publication by Parkinson and Morris as a starting point, the provisions of the new legislation are carefully examined. RESULTS: The ACT and Victorian laws do not imperil psychiatrists undertaking evidence-based and clinically appropriate practice. CONCLUSIONS: While it may be wise for psychiatrists to abandon this area of practice if they hold strong personal beliefs that the failure to identify with one's natal gender is morally wrong, nothing in the new laws should deter psychiatrists from providing people with gender dysphoria with evidence-based and clinically appropriate care.

Reducing Internet Gambling Harms Using Behavioral Science: A Stakeholder Framework.

Internet gambling provides a unique environment with design mechanics and data-driven opportunities that can impact gambling-related harms. Some elements of Internet gambling including isolation, lack of interruption, and constant, easy access have been argued to pose specific risks. However, identifiable player accounts enable identification of behavioral risk markers and personalized private interfaces to push customized messages and interventions. The structural design of the Internet gambling environment (website or app) can have a strong influence on individual behavior. However, unlike land-based venues, Internet gambling has few specific policies outlining acceptable and unacceptable design practices. Harm minimization including responsible gambling frameworks typically include roles and responsibilities for multiple stakeholders including individual users, industry operators, government regulators, and community organizations. This paper presents a framework for how behavioral science principles can inform appropriate stakeholder actions to minimize Internet gambling-related harms. A customer journey through internet gambling demonstrates how a multidisciplinary nexus of collaborative effort may facilitate a reduction in harms associated with Internet gambling for consumers at all stages of risk. Collaborative efforts between stakeholders could result in the implementation of appropriate design strategies to assist individuals to make decisions and engage in healthy, sustainable behaviors.

We need to treat pregnant women as adults: Women should be consented for an attempt at normal vaginal birth as for operative delivery, with risks and potential complications explained.

Since the mid-90s, Australian law has required doctors to disclose material risks of proposed treatment. Medical practitioners have had two decades to adapt, and, by and large, patient autonomy is acknowledged and respected by obtaining 'informed consent'. While problems with obtaining consent do surface in medico-legal litigation, practitioners are generally aware of the need to do so and usually comply with requirements. However, not in obstetrics. Here, even if material risk of a serious adverse event in an attempt at vaginal birth in a given case is over 50% (as it would be in the case of a 35-year-old primigravida at 41 + 3) obtaining informed consent is the exception rather than the rule. This degree of paternalism is not just unethical and immoral. It is illegal - and it needs to change.

An algorithm for managing adults who refuse medical treatment in New South Wales.

OBJECTIVES: The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient's decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia. METHODS: We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals. RESULTS: We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person's status under the Mental Health Act 2007 (NSW). CONCLUSIONS: The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW.

Community treatment orders: towards a new research agenda.

OBJECTIVES: The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research. METHODS: The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects. RESULTS: Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified. CONCLUSIONS: The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.

The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act.

OBJECTIVES: The Mental Health Act 2007 (NSW) ( MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice. CONCLUSIONS: The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients' decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.

The importance of least restrictive care: the clinical implications of a recent High Court decision on negligence.

OBJECTIVE: This paper aims to explain the meaning and implications for practice of the High Court of Australia's finding in the negligence case, Hunter and New England Local Health District v McKenna [2014] HCA 44. METHOD: The facts of the case and the law of negligence are reviewed before reporting the Court's decision. RESULTS: The High Court found that the obligation upon doctors to provide the least restrictive option for care that was imposed by the, then applicable, Mental Health Act 1990 (NSW) was inconsistent with an obligation that might otherwise be imposed by a common law duty to have regard to the interests of those with whom a psychiatric patient may come into contact if not detained. CONCLUSIONS: The Court's finding underlines the importance of clinicians documenting their clinical reasoning around why their negotiated management plan was the option least restrictive of the patient's freedom and most protective of his or her human rights.

The capacity to refuse psychiatric treatment: a guide to the law for clinicians and tribunal members.

OBJECTIVE: In some Australian states clinicians and mental health tribunal members are already required to assess a person's decision-making capacity before involuntary treatment can be applied. Professionals in other jurisdictions will likely soon be required to do the same as mental health law reform in most Australian jurisdictions makes the assessment of decision-making capacity a central component of the process of providing unconsented psychiatric treatment. We provide a guide to the legal issues around the capacity to refuse psychiatric treatment to assist with this task. METHOD: We review the legislation in the four Australian states most advanced in the mental health law reform process and use examples from clinical practice and the common law to describe how decision-making capacity should be assessed by these statutory standards. RESULTS: Clinicians and tribunal members will primarily be required to judge whether a person with mental illness can understand the information relevant to the treatment decision and whether he or she can use or weigh that information to come to a decision. A person with a mental illness is presumed to have capacity, but that presumption can be rebutted. Capacity is specific to the decision at hand and cannot be determined by the nature of the decision made. CONCLUSIONS: The information provided should assist clinicians and tribunal members to make determinations of decision-making capacity around treatment refusal in the context of mental illness.

Risk of suicide is insufficient warrant for coercive treatment for mental illness.

Mental health laws in many jurisdictions currently permit coercive treatment for persons with mental illness who are thought to be at risk of harm to themselves or others. These laws are often used to provide involuntary treatment to persons who are thought to be at risk of suicide. In this article we argue that legislated coercive psychiatric treatment should not be triggered by an assessment of the likelihood of harm, including a likelihood of suicide, but should be available only where a person is found to lack capacity to make their own decisions about their own health risks, after appropriate support has been given. We suggest that current opposition to this approach may find its origin in factors including uncertainties about the idea of vulnerability and its relationship to capacity as well as tendency to minimise the real costs of psychiatric treatment and coercion against the aim of suicide prevention. Given the limits of suicide risk assessment, we argue that a public policy that allows involuntary preventative detention of competent persons thought to be at risk of suicide, places too great a burden on all persons living with mental illness to be justified. We suggest that we are better placed to serve the interests and respect the human rights of people with mental illness if we respect and support the right of persons to make decisions, rather than focussing on perceived vulnerabilities and calculations of suicide risk.