Clinically Significant Differences Among Canadian Mental Health Acts

Transcription

1 REVIEW PA PERS Clinically Significant Differences Among Canadian Mental Health Acts John E Gray, PhD 1, Richard L O Reilly, MB, FRCPC 2 Ob jec tives: First, to high light the ma jor dif fer ences among men tal health acts in dif fer ent Ca na dian ju ris dic tions as they re late to in vol un tary ad mis sion cri te ria, treat ment authori za tion, re view and ap peal pro ce dures, and con di tional leave and com mu nity treat ment or ders. Sec ond, to analyze the im pact of these dif fer ences on the care that indi vidu als with men tal ill ness re ceive. Method: We ex am ined the men tal health act pro vi sions of all Ca na dian ju ris dic tions to de ter mine how the clinical man age ment of a typical case would dif fer among ju ris dic tions. We used a state ment of prin ci ples for mental health leg is la tion en dorsed by the Ca na dian Psy chi at ric As so cia tion to guide the analy sis. We con firmed in ter pre ta tion of each act and its im ple men ta tion through key in for mant con tact in each prov ince and ter ri tory. Re sults: We found clini cally sig nifi cant dif fer ences among the prov inces and ter ri to ries on all ma jor com po nents of their men tal health acts. Con clu sion: Pro vi sions that pre vent pa tients re ceiv ing ap pro pri ate clini cal care can be found in some Ca na dian men tal health acts. Al ter nate pro vi sions that sup port ap pro pri ate clini cal care, that re spect the hu man rights and per sonal dig nity of patients, and that are con sis tent with the Ca na dian Char ter of Rights and Free doms can be found in the leg is la tion of other ju ris dic tions. (Can J Psy chia try 2001;46: ). Key Words: mental health act, committal criteria, community treatment orders Men tal health leg is la tion can be a criti cal fac tor in de ter - have sig nifi cantly broad ened their physi cal dan ger ous ness min ing whether a per son who is se verely af flicted by com mit tal cri te ria (6). Vari ous forms of out pa tient com mit tal men tal ill ness does or does not re ceive psy chi at ric treat ment have been in tro duced in more than one- half of the US states and whether this treat ment occurs in a timely fash ion. To in - (7), in Aus tra lia, and in New Zea land (8); they are also being form the de bate on men tal health law re form, it is help ful to con sid ered in the UK (9). This pa per uses a typi cal but fic - com pare pro vin cial and ter ri to rial mental health acts in Can - tional case to dis cuss the clini cal sig nifi cance for an in di vid - ada to de ter mine what dif fer ences ex ist and whether dif fer ent ual of dif fer ent Ca na dian mental health laws. pro vi sions help or hin der the treatment of peo ple with se ri ous men tal ill nesses, such as schizo phre nia and bi po lar dis or der. In recent years Sas katche wan (1), Mani toba (2), Brit ish Co - lum bia (3), and On tario (4) have made major amend ments to their mental health acts, and re views of mental health acts are oc cur ring in other ju ris dic tions. These changes, and the pol - icy im pli ca tions of vari ous op tions in Ca na dian mental health laws, have re cently been de scribed (5). In the US, many states Manuscript received February 2000, revised, and accepted March Manager, Policy and Systems Development, Adult Mental Health Division, Ministry of Health, British Columbia. 2 Associate Professor, Department of Psychiatry, University of Western On - tario, London, Ontario. Address for correspondence: Dr JE Gray, Manager, Pol icy and Systems De - velopment, Adult Mental Health, Ministry of Health, 1520 Blanshard Street, Victoria, BC V8W 3C8 john.gray@moh.hnet.bc.ca Method The pro vi sions of the pro vin cial and ter ri to rial men tal health acts that are the fo cus of this study were the ma jor top ics ad - dressed in a po si tion pa per on mental health leg is la tion pro - duced by the Ca na dian Psy chi at ric As so cia tion (10). We added the is sue of out pa tient com mit tal be cause of its rele - vance to cur rent law re form de bates. Thus, we have stud ied in vol un tary ad mis sion cri te ria, treat ment authori za tion, re - view and ap peal pro ce dures, and con di tional leave and com - mu nity treatment or ders. We ex am ined the pro vi sions in the 12 Ca na dian mental health acts (10 prov inces and 3 ter ri to - ries North west Ter ri to ries and Nuna vut use the same act). We have created a fic tional il lus tra tive case as a frame work in which to dis cuss the im pli ca tions of vari ous mental health act pro vi sions for ap pro pri ate and timely psy chi at ric treat ment. Can J Psychiatry, Vol 46, May

2 316 The Canadian Journal of Psychiatry Vol 46, No 4 Illustrative Case Vic to ria is a 25- year- old woman who, in her fi nal year of law school, un char ac ter is ti cally starts to miss some of her classes. Within a few weeks, it be comes clear that she is ex pe ri enc ing audi tory hal lu ci na tions and para noid de lu sions. She ex - presses a be lief that uni den ti fied in di vidu als are us ing the inter net to place thoughts di rectly into her brain. These psy - chotic symp toms re sult in a marked im pair ment in her ability to con cen trate and com plete course work. Con cerned family and friends try to per suade her to seek pro fes sional help, but she re fuses. Rather, she with draws from law school and sub - se quently spends sev eral weeks iso lated in her apart ment, only coming out to shop for gro cer ies. As her ill ness pro - gresses, she starts to shout in re sponse to the voices and pound on the walls of her apart ment, in sist ing that her neigh bors stop ma nipu lat ing her thoughts. She is evicted from her apart ment, and, re fus ing an offer to re turn to her par ents home, she spends nights in a shel ter for the home less and days wan der - ing the streets. One month af ter her evic tion, a friend ob serves Vic to ria shouting out side a res tau rant. De spite Vic to ria s ver - bal ob jec tions, the friend takes her to the lo cal hos pi tal emer - gency room. She is as sessed by the duty psy chia trist, who de ter mines that she is psy chotic and has no in sight but is not likely to be physi cally dan ger ous. The psy chia trist di ag no ses schizo phreni form dis or der and rec om mends a short hos pi tal ad mis sion to fa cili tate ini tia tion of treat ment with an atypi cal an tipsy chotic. Victoria re fuses to con sider ei ther admission to hos pi tal or treat ment. Given her ex cel lent pre mor bid func tion ing and the rapid on - set of her symptoms, Vic to ria would likely re cover fully from her psy chotic symp toms if treated with an tipsy chotic medi ca - tion, and she might well com plete her stud ies. With out treat - ment, or with sig nifi cantly de layed treat ment, she is likely to con tinue to suf fer from her hal lu ci na tions and de lu sions and to ex pe ri ence pro gres sive de te rio ra tion in men tal, so cial, and vo ca tional func tion ing. Admission Criteria Where Vic to ria lives in Can ada will de ter mine whether it will be pos si ble to ad mit her in vol un tar ily for treat ment. She can - not be ad mit ted in ju ris dic tions where ad mis sion cri te ria stipu late that she must be likely to cause serious physi cal harm to her self or oth ers. Con versely, she can be ad mit ted in ju ris dic tions with ad mis sion cri te ria that in clude non physi cal harms. To un der stand how a cli ni cian using a mental health act makes the in vol un tary ad mis sion de ci sion, it is necessary to ex am ine the spe cific ad mis sion cri te ria. These vary among ju ris dic tions and may stipu late that the person: 1. is not suitable as a vol un tary or in for mal pa tient (all ju ris dic tions), and 2. meets the defi ni tion of mental dis or der (all ju ris dic tions), and 3. meets the cri te ria for harm (all ju ris dic tions) or, as an al ter na tive, 3a) will likely suf fer sub stan tial men tal or physi cal de te rio ra tion (only in Brit ish Co lum bia, Sas katche wan, Mani toba and On tario), and 4. is in need of psy chi at ric treat ment (only in Brit ish Co lum bia, Sas katche wan and Mani toba), and 5. is not ca pa ble of treatment de ci sions (only in Sas katche wan). Ta ble 1 shows the cri te ria that must be met for in vol un tary ad - mis sion in the prov inces and ter ri to ries. The cri te rion of not be ing suit able as a vol un tary pa tient is not shown be cause it is stated or im plied in all acts. When we ex am ine each of these cri te ria and use Vic to ria s situa tion for il lus tra tion, the fol low ing sce nar ios emerge: Not Suit able as a Vol un tary or In for mal Pa tient (All Ju ris - dic tions) If a per son is willing and ca pa ble of con sent ing to the ad mis - sion and a vol un tary ad mis sion is ap pro pri ate (de spite the per son be ing physi cally dan ger ous), he or she cannot be ad - mit ted as an in vol un tary pa tient any where in Can ada. Vic to - ria does not con sent to be ad mit ted; she is there fore not suit able as a vol un tary pa tient. Meets the Defi ni tion of Men tal Dis or der (All Ju ris dic tions) Vic to ria, with a clearly de fined, se vere, and treat able mental ill ness, meets the mental dis or der defi ni tion in all ju ris dic - tions. By con trast, a per son with a non severe, nontreat able men tal disorder (for ex am ple mild mental handi cap or an ti so - cial per son al ity dis or der) would only meet the broad defi ni - tions of mental dis or der ( any dis ease or dis abil ity of the mind ) pres ent in the On tario (4, s.1), Nova Scotia (11), and New found land (12) acts. Ju ris dic tions with more spe cific defi ni tions of men tal dis or der stipu lat ing a need for treat ment would ex clude per sons with mild mental handicap and with no treatable psy chi at ric symp toms (for ex am ple, Brit ish Co - lum bia [3, s.1] and Sas katche wan [1, s.2.m]), but would in - clude Vic to ria. A per son with mild men tal handi cap also would not meet the se ver ity re quire ments of those ju ris dic - tions wherein the spe cific defi ni tions of men tal dis or der state that the per son must have a sub stan tial dis or der which grossly or se ri ously im pairs func tions (for ex am ple, Al - berta [13, s.1f], Sas katche wan [1, s.2m], Mani toba [2, s.1], New Bruns wick [14], Prince Ed ward Is land [15], the North - west Ter ri to ries [16], and Yukon Ter ri tory [17]). Rob ert son has sug gested that broad defi ni tions are vul ner able to a Char - ter chal lenge be cause they ap pear to be un jus ti fia bly vague and wide- ranging (18). Likely to Cause Harm (All Ju ris dic tions) Vic to ria is not likely to harm her self or oth ers physi cally. She can not there fore be ad mit ted un der the physi cal harm cri te ria in Ontario (4, s.20.5). (The On tario de te rio ra tion cri te rion is dis cussed in the next sec tion.) Simi larly, she can not be

3 May 2001 Clinically Significant Differences Among Canadian Men tal Health Acts 317 ad mit ted in the Northwest Ter ri to ries (16, s.13) be cause of the se ri ous bod ily harm or im mi nent and se ri ous physi cal im pair ment re quire ment. It is proba bly not pos si ble to ad mit her in Al berta be - cause that prov ince (13, s.2) uses the term dan ger. This term can em brace more than physi cal dan ger, but it has been in ter - preted by a court to mean bod ily harm (19). Nova Sco tia s cri te rion of dan ger to safety (11, s.36) also ap pears to be in ter - preted as bod ily harm. Vic to ria could probably be ad mit ted in ju - ris dic tions where harms other than bod ily harm can also be con sid ered. For ex am - ple, Brit ish Co lum bia uses the term pro - tec tion (3, s.22.3), which has been in ter preted by the court to in clude a broad Jurisdiction range of serious harms that re late to the so cial, fam ily, vo ca - tional and fi nan cial life of the pa tient as well as the pa ti ent s physi cal con di tion (20). Sas katche wan uses the term harm (1, s.24.2), and Mani toba uses se ri ous harm (2, s.17.1) not oth er wise quali fied. Yukon Ter ri tory in cludes se ri ous men - tal or physi cal im pair ment among its cri te ria (17, s.13.1), and New Bruns wick in cludes im mi nent physi cal or psy cho - logi cal harm (14, s.8.1). While Que bec uses grave and im - me di ate dan ger to him self or oth ers (21), this appears in prac tice to in clude grave non bod ily harms. Prince Ed ward Is - land (15, s.13.1) and New found land (12, s.5.1) use hos pi tali - za tion for the per son s or oth ers safety. The Prince Ed ward Is land Court of Appeal has in ter preted safety to in clude the al le via tion of dis tress ing physi cal, men tal or psy chi at ric symp toms (22). It can be seen that most Ca na dian ju ris dic tions do not limit in - vol un tary ad mis sion only to per sons likely to cause se ri ous bod ily harm or physi cal im pair ment. The broader harm cri te - ria that in clude non bod ily harms have been found by courts to be in ac cord with the Char ter in Brit ish Co lum bia (20), Mani - toba (23), and Prince Ed ward Is land (22). Al ter na tive to the Harm Cri te rion: Likely to Suf fer Sub stan - tial Men tal or Physi cal De te rio ra tion (Brit ish Co lum bia, Sas katche wan, Mani toba, On tario) In 3 prov inces (Brit ish Co lum bia [3, s.22.3], Sas katche wan [1, s. 24,2], and Mani toba [2, s.17.1]) that in clude a men tal or physi cal de te rio ra tion cri te rion as an al ter na tive to the harm cri te rion, Vic to ria could probably be ad mit ted, given the like - li hood of fur ther de te rio ra tion. On tario also has a de te rio ra - tion cri te rion (4, s ); how ever, this only ap plies if the per son has pre vi ously re ceived treat ment for mental disor - der of an on go ing or re cur ring na ture, and a simi lar situation has re curred. This cri te rion would ex clude Vic to ria be cause she is ex pe ri enc ing her first treated epi sode, al though the pro - vi sion will apply if she is suc cess fully treated but later suf fers Table 1. Criteria for involuntary admission by jurisdiction Definition of mental disorder Harm criterion Deterioration as alternative to harm Need for treatment British Columbia Specific Broad Yes Yes No Alberta Specific Physical No No No Saskatchewan Specific Broad Yes Yes Yes Manitoba Specific Broad Yes Yes No Ontario Broad Physical Yes No for bodily harm. Yes for deterioration Quebec Broad? No No No Nova Scotia Broad? No Implied No New Brunswick Specific Broad No Implied No Prince Edward Island Specific Broad No Implied No Newfoundland Broad Broad No Implied No Yukon Specific Broad No No No Northwest Territories, Nunavut Specific Physical No No No? = It is not clear from the leg is la tion or court cases how to clas sify. a simi lar epi sode. The de te rio ra tion cri te rion has been tested in a Mani toba court and found to be con sti tu tional (23). In Need of Psy chi at ric Treat ment (Brit ish Co lum bia, Sas - katche wan, Mani toba) Vic to ria clearly needs psy chi at ric treat ment and thus would meet the need for treat ment cri te rion in Brit ish Co lum bia, Sas katche wan, and Mani toba, as well as in other ju ris dic tions where the cri te ria imply a need for psy chi at ric treat ment. It is im por tant to note that in nontreat ment ju ris dic tions it may be pos si ble to com mit a dan ger ous per son with a mental dis - or der (for ex am ple, an ti so cial per son al ity dis or der) for whom psy chi at ric treatment does not exist, so that the ad mis sion to hos pi tal is for pre ven ta tive de ten tion pur poses only. This has been found to be in ac cord with the Char ter in On tario (24). Need- for- treatment cri te ria that ex clude the ad mis sion of a per son with an un treat able an ti so cial per son al ity dis or der have been found to be in ac cord with the Char ter in British Co lum bia (20) and Mani toba (23). Not Ca pa ble of Mak ing a Treat ment De ci sion (Sas katche - wan Alone) If Victoria had been ca pa ble of mak ing treatment decisions, she could not have been ad mit ted in Sas katche wan, de spite meet ing all the other cri te ria (1, s.24.2.a.ii). This pro vi sion en sures that a ca pa ble per son will not be in vol un tar ily ad mit - ted and then ref use the treat ment nec es sary for dis charge from de ten tion. It does not, how ever, ad dress the prob lem en - coun tered in some ju ris dic tions where a pre vi ously compe - tent and ap pli ca ble wish by Vic to ria not to be treated must be hon oured (for ex am ple, On tario). Treatment Authorization and Refusal Not capable of treatment decision Let us as sume that, in those ju ris dic tions in which Vic to ria is not able to be ad mit ted, further de te rio ra tion leads her to as - sault a shelter vol un teer whom she ac cuses of in ter fer ing with her thoughts. This vio lent act now makes it le gally pos si ble to No

4 318 The Canadian Journal of Psychiatry Vol 46, No 4 ad mit Vic to ria as an in vol un tary pa tient in all ju ris dic tions. (It should also be noted that Victoria has now bro ken the law be - cause she has not been ap pro pri ately treated. She could be charged with as sault and en ter the crimi nal jus tice sys tem and the fo ren sic psy chi at ric sys tem, in cur ring treatment de lays and stigma that may af fect her future ca reer as a law yer.) Once ad mit ted, Vic to ria states that she does not want the medi ca tion rec om mended by the at tend ing psy chia trist. Vic - to ria be lieves that medi ca tion will make it eas ier for her per - se cu tors to in ter fere with her thoughts. Be cause of her in abil ity either to rec og nize that she has a mental ill ness or to ap pre ci ate the con se quences of re ceiv ing or re fus ing an tipsy - chotic medi ca tion, Vic to ria would be re garded as in ca pa ble of making a de ci sion to take or ref use medi ca tion in all Cana - dian ju ris dic tions. Whether Vic to ria re ceives treat ment and how quickly this is com menced de pends, once again, on where in Canada she lives. Some ju ris dic tions do not al low treat ment re fusal. Other ju ris dic tions al low a re fusal, but it can be over ruled in the per son s best in ter ests. Oth ers honour a pre vi ously ex pressed, ap pli ca ble, and ca pa ble re fusal, even if that pro longs de ten tion and suf fer ing. These op tions are based in part on the ju ris dic tion s pol icy choice on 3 vari - ables: state or pri vate authori za tion of treat ment, best in ter - ests or ca pa ble wishes as the cri te rion for sub sti tute de ci sion mak ing, and the type of re view and ap peal pro ce dures. Treat ment Authori za tion (State or Pri vate) State Authori za tion. Five prov inces use an ap pointee of the state to author ize treat ment. In Sas katche wan, where only pa - tients in ca pa ble of mak ing a treat ment de ci sion are ad mit ted, the at tend ing phy si cian author izes treat ment af ter discussing the op tions with the pa tient (1, s.25.2). In New found land (12, s.5) the at tend ing phy si cian also authorizes the treat ment. In Brit ish Co lum bia, the di rec tor of the psy chi at ric unit con sents if the pa tient is in ca pa ble or re fuses to con sent (3, s.8). New Bruns wick uses a tri bu nal (dis tinct from the re view board) to author ize gen er ally rec og nized and ac cept able psy chi at ric treat ment both for men tally in com pe tent pa tients and for com pe tent pa tients who ref use (14, s ). Que bec uses the court to author ize treat ment, which, for in ca pa ble people who do not have a sub sti tute de ci sion maker, can in clude antici - pated treat ment when the pa tient leaves the hos pi tal (25). These state mecha nisms for author iz ing treatment re sult in mini mal or no de lay in its ini tia tion. Pri vate Authori za tion. In all other ju ris dic tions in Can ada, pri vate sub sti tute de ci sion mak ers pro vide con sent in a man - ner simi lar to that for a vol un tary medi cal pa tient who is not ca pa ble of con sent ing. Con sent is sought from a per son ap - pointed by the pa tient when com pe tent, or from a guard ian or rela tive. If these are un avail able, the Public Trus tee makes the de ci sion. In ju ris dic tions that use rela tives to con sent, there can be sig - nifi cant de lays in ob tain ing treat ment. If Vic to ria lives in On - tario, Prince Ed ward Is land, or prov inces and ter ri to ries with simi lar pro vi sions, the doc tor may have trou ble lo cat ing a rela tive, or rela tives may de cline or not be quali fied. Fi nally, the Public Trus tee may have to be ap proached. Including week ends, it is not dif fi cult to en vi sion de lays of 5 to 7 days be fore a sub sti tute con sent is ob tained. Treat ment can then start, pro vid ing the per son does not re quest a review- board hear ing. In private- consent- model ju ris dic tions, reviewboard hear ings can re sult in a fur ther treat ment de lay. Typi - cally, the de lay can be at least a week, and it can be more. Treat ment can be fur ther de layed for months if the re view board s or der for treat ment is ap pealed to the courts (see be - low). Cri te ria to Guide Sub sti tute De ci sion Mak ing The sub sti tute de ci sion maker is guided by dif fer ent cri te ria in dif fer ent ju ris dic tions. Three types of cri te ria can be dis - cerned with pro found ef fects on whether a pa tient is pro - vided with timely treat ment. Best In ter ests. Three ju ris dic tions that use a state ap pointee to make the treatment de ci sion (Brit ish Co lum bia, Sas katche - wan, New found land) use best- interests tests. Al berta also re - quires the sub sti tute de ci sion maker to make the de ci sion in the per son s best in ter ests (13, s.28.3), which are care fully de - fined. Best interests would pre suma bly take the wishes of the pa tient into ac count, and that is made ex plicit in Sas katche - wan, where the phy si cian who authorizes treat ment must dis - cuss the treat ment op tions with the pa tient (1, s.25.3). In Que bec, the court that makes treat ment de ci sions is also bound to ob tain the opin ion of the per son con cerned un less that is im pos si ble, and to re spect his re fusal un less the care is re quired by his state of health (26). Thus, the pa ti ent s capa - ble wishes are con sid ered by the cli ni cian (as they should be for good clini cal prac tice) and by the de ci sion maker, but the pa ti ent s best in ter ests are de ter mi na tive. Ca pa ble Wishes. A wish ap pli ca ble to the cir cum stances that the in ca pa ble per son ex pressed while ca pa ble, cannot be over rid den in some ju ris dic tions (for ex am ple On tario [27] and the North west Ter ri to ries [16, s ]). If the pa tient or the sub sti tute de ci sion maker re fuses the treatment necessary for the pa ti ent s re lease, the pa tient must re main de tained un - til he or she re cov ers without treat ment or dies, which ever comes first. As Mr Michael Bay, the chair of the On tario Con - sent and Ca pac ity Board, has writ ten about On tario leg is la - tion, The law con tains al most no lati tude for dealing with treat ment of per sons who, in the past, ex pressed a ca pa ble wish not to re ceive treat ment (28). The clini cal con se quence of leg is la tion that binds the sub sti tute de ci sion maker to pre - vi ously ex pressed, valid, com pe tent wishes not to be treated can be very sig nifi cant for the pa tient. For ex am ple, Mr. Sevels, suf fer ing from treatable schizo phre nia, was de scribed by an On tario court as being caged and ware housed in

5 May 2001 Clinically Significant Differences Among Canadian Men tal Health Acts 319 se clu sion for 404 days (29). Al though the court found that the man could be eas ily treated and re leased from se clu sion, the court could not over rule the treat ment re fusal be cause of a prior de ci sion (see Fleming v Reid [30]) that struck down the abil ity of the re view board to overrule a re fusal on the best in ter ests test then used by the board un der the Mental Health Act. Modi fied Best In ter ests Cri te rion for Author iz ing Treat ment. Mani toba has in tro duced a modi fied best in ter ests test for con sent ing to treatment that ad dresses the is sue of con sid er - ing pre vi ous wishes raised in Fleming v Reid. The pa ti ent s pre vi ous ca pa ble wishes are or di nar ily fol lowed. If, how ever, fol low ing the pa ti ent s ex pressed wishes would en dan ger the physi cal or men tal health or safety of the pa tient or an - other per son, the de ci sion is to be made in ac cor dance with what the per son be lieves to be the pa ti ent s best in ter ests (2, s 28.4). Simi larly, in New Bruns wick the re view board can over rule a re fusal on a best in ter ests ba sis but must con sider pre vi ous re fus als (14, s ). The Que bec law, cited above, could also be clas si fied as modified best in ter ests (26). Review and Appeal Procedures All ju ris dic tions pro vide for a board or panel to re view the va - lid ity of in vol un tary hos pi tali za tion, al though none dis charge the pa tient while the mat ter is un der re view. If in ca pa bil ity is ap pealed, how ever, treat ment cannot be started un til the mat - ter, in clud ing any court ap peals, is re solved. In privatetreatment authori za tion ju ris dic tions, and in New Bruns wick, a re view of the de ter mi na tion of treatment in ca pa bil ity or other treatment- related is sues is avail able. If Vic to ria lives in Ontario and, prior to com menc ing treat - ment, in di cates that she intends to con test the de ter mi na tion of in ca pac ity, treat ment must be with held. Once she ap plies for a review- board hear ing, 7 days may elapse, with an other day to ren der the de ci sion. If those maxi mum times are ex er - cised, to gether with a delay of 3 days to ob tain the sub sti tute de ci sion maker s con sent, Vic to ria will spend 11 days in de - ten tion, un treated. Let us sup pose that in Vic to ria s case, the board up holds the find ing of in ca pac ity. Fol low ing dis cus - sions with a rights ad vi sor, Vic to ria ap peals the de ci sion to the courts. Even if the de ter mi na tion of in ca pac ity is up held by a lower court, she may ap peal all the way to the Su preme Court of Can ada. O Reilly re ported such a case, which re - sulted in a man con tinu ing to suffer from para noid de lu sions while being de tained, un treated, for nearly 2 years (31). Conditional Leave and Community Treatment Orders Let us as sume that Vic to ria s hal lu ci na tions and de lu sions fully re mit when she finally re ceives treat ment. She does not, how ever, re gain full in sight. She in sists that she does not have a mental ill ness, and she re fuses to take medi ca tion to pre vent re lapses. As of ten hap pens when main te nance medi ca tion is dis con tin ued, Vic to ria s symp toms re turn. Over the year fol - low ing her first dis charge, Vic to ria has 3 fur ther involuntary ad mis sions, each pre cipi tated by a physi cal as sault. Vic to ria has de vel oped a classic revolving- door pattern of ad mis sions. What, if any thing, can be done to as sist Vic to ria? As sisted com mu nity treat ment pro vi sions in the form of con di tional leave from hos pi tal or com mu nity treat ment or ders are avail - able in most Ca na dian mental health acts. In ad di tion, leg is la - tion that al lows for sub sti tute de ci sions may be used to fa cili tate psy chi at ric treatment where the pa tient is not capa - ble of mak ing a treatment de ci sion. Ba si cally, as sisted com - mu nity treat ment pro vi sions re quire pa tients to ad here to such con di tions as taking medi ca tion and at tend ing a clinic. Fail - ing this, they may be hos pi tal ized. Con di tional Leave from Hos pi tal As an ex am ple, the Brit ish Co lum bia leave pro vi sion states: If the di rec tor con sid ers leave would benefit a patient de tained in a designated fa cil ity, the di rec tor may release the patient on leave from the designated fa cil ity pro vid ing ap pro pri ate sup port exists in the community to meet the con di tions of the leave (3, s 37). Fol low ing Vic to ria s ad mis sion and good re sponse to medi - ca tion in hos pi tal, she could be returned on con di tional leave to the com mu nity in Brit ish Co lum bia (3, s.37), Al berta (13, s.20), Mani toba (2, s.46), On tario, (4, s.27), Prince Ed ward Is land (15, s.25), and the Yukon (17, s.26) if she con tin ues to meet the ad mis sion cri te rion and with a stipulation that she take her medi ca tion and meet weekly with the psy chi at ric nurse. If she does not com ply, the treating phy si cian could re - turn her to hos pi tal, if war ranted. In On tario, she could be on leave for a maxi mum of 3 months (4, s.27). In Mani toba, con - di tional leave only ap plies after 3 ad mis sions or 60 days in hos pi tal in the pre vi ous 2 years (2, s.46.2). In Brit ish Colum - bia and Mani toba, she could not be placed on leave with out a guar an tee that the services required to sup port the con di tions of her leave were avail able. Be cause the cri te ria for in vol un - tary ad mis sion in Brit ish Co lum bia, Mani toba, and Ontario in clude the pre ven tion of sub stan tial physi cal or mental de te - rio ra tion and be cause Victoria has an es tab lished pattern of stop ping medi ca tion with a re sul tant pre dict able de te rio ra - tion, the leave could be re newed until she gains in sight and takes her medi ca tions. The Al berta and Yukon leave cri te ria are bod ily harm cri te ria that are proba bly more dif fi cult to meet in the com mu nity than is a de te rio ra tion criterion. Com mu nity Treat ment Or der (Sas katche wan, On tario) Vic to ria would also now qualify for a com mu nity treat ment or der in On tario and in Sas katche wan. She has had 3 ad mis - sions in the past year and there fore quali fies in On tario (2 ad - mis sions or 30 cu mu la tive in pa tient days in the pre vi ous 3 years [4, s.33.1]) and in Sas katche wan (3 or more involuntary ad mis sions or 60 cu mu la tive in vol un tary in pa tient days in a 2- year pe riod [1, s 24.3]). The dif fer ence be tween con di tional leave and a com mu nity treatment or der is that the person does not have to ac tu ally be in hos pi tal when put on the com mu nity

6 320 The Canadian Journal of Psychiatry Vol 46, No 4 treat ment or der. In ad di tion, un like leave, the per son may not have to meet the same in vol un tary cri te rion as an in pa tient. Sub sti tute Decision- Making Legislation While not much used in Canada at pres ent, guardi an ship and other sub sti tute decision- making leg is la tion can of fer a mecha nism for pro vid ing as sisted com mu nity treat ment for per sons with a mental ill ness who are in ca pa ble of making a treat ment de ci sion (5). These mecha nisms are used in a number of US states (7,32). Discussion The dif fer ences in men tal health leg is la tion identified in this study have pro found ef fects on pa tients, who may be de nied treat ment. They can also cre ate sig nifi cant ethi cal di lem mas for psy chia trists. It is clear that psy chi at ric man age ment of pa tients like Vic to ria will differ greatly de pend ing on where they live. In some ju ris dic tions, Vic to ria will be ad mit ted to hos pi tal sev eral weeks af ter drop ping out of law school, and treat ment will start at once. As a re sult, there will be a good chance of her re turn ing to uni ver sity to com plete her law de - gree. In other ju ris dic tions, years may elapse be fore her men - tal con di tion de te rio rates to the point where she is deemed to be at risk of in flict ing serious bod ily harm on her self or on oth ers, suf fi cient to war rant in vol un tary hos pi tali za tion. Even when hos pi tal ized, treat ment may be de layed for months or even years in ju ris dic tions that ei ther pre vent its ini tia tion while an ap peal is out stand ing or are bound by a pre vi ous, ca pa ble, ap pli ca ble wish not to be treated. It is of con sid er able con cern that such dis pari ties of prac tice ex ist among Ca na dian prov inces and ter ri to ries. There is an in creas ing body of evi dence that the du ra tion of un treated psy cho sis is cor re lated with a poor prog no sis (33 35) and that early in ter ven tion may pre vent pro gres sion of the un der ly ing dis ease pro cess (36). Moreo ver, it is also clear that psy cho sis oc cur ring at a young age can in ter fere with the com ple tion of such im por tant de vel op men tal tasks as school ing, vo ca tional train ing, and psy cho so cial de vel op ment. Thus, in Vic to ria s case, early treat ment may en able her to re turn to uni ver sity, com plete her de gree, and en gage in a suc cess ful ca reer. Even if Vic to ria does not have a full re turn of in sight, her per - sonal safety and qual ity of life will likely be bet ter in those ju - ris dic tions that pro vide as sisted treatment in the com mu nity. There is evi dence, for ex am ple, that higher rates of home less - ness, vio lence, vic timi za tion, and crimi nali za tion oc cur when peo ple with a mental ill ness are not treated than when they are treated (6). Con di tional leave and com mu nity treat ment or der meas ures are now com mon in Ca na dian ju ris dic tions and are be com ing wide spread in other coun tries (7,8). They have been shown to ef fec tively re duce re hos pi tali za tion (37 44) and to fa cili tate treat ment ad her ence (38,39,43). Clinical Im pli ca tions Differences among mental health acts can have significant impact on whether seriously mentally ill patients receive timely treatment. Limi ta tions The conclusions drawn here are considered informed opinions, not scientific facts. Physi cal dan ger ous ness cer ti fi ca tion cri te ria raise ethi cal is - sues for psy chia trists, who may see a pa tient who is ex tremely dis tressed be cause of a psy chotic ill ness but who is not likely to be dan ger ous. While psy chia trists know that treat ment would be quickly ef fec tive and re lieve suf fer ing, they can nei - ther hos pi tal ize nor treat. There is evi dence in some ju ris dic - tions, how ever, that phy si cians bend the law to help such pa tients (45). An On tario study, for ex am ple, found that 93% of cer tifi cates did not meet the strict physi cal harm criterion (46). Simi lar ethi cal con cerns can be raised when psy chia - trists must re strain or de tain pa tients be cause the law does not al low psy chotic pa tients to be ap pro pri ately and humanely treated. For ex am ple, de spite his psy chia trist s rec om men da - tion that Mr Sevels be treated in the ap pro pri ate pro fes sional man ner (that is, with an tipsy chotic medi ca tion), be cause the law al lowed treat ment re fusal, his psy chia trist was forced to treat him with over 404 days of se clu sion (29). We note that many pro vi sions in dif fer ent Ca na dian mental health acts ad dress the treat ment, dig nity, and hu man rights needs of se verely men tally ill pa tients in a man ner con sis tent with the po si tion of the Ca na dian Psy chi at ric As so cia tion (10). We hope that, as prov inces and ter ri to ries re view their leg is la tion, this analy sis of clini cally sig nifi cant dif fer ences will in form the de bate about what type of mental health act should be avail able to their citi zens. Ul ti mately, it is our hope that a per son like Vic to ria, suf fer ing a first epi sode of a po ten - tially fatal and of ten chronic dis abling men tal ill ness, will re - ceive timely psy chi at ric treat ment sup ported by ap pro pri ate laws and serv ices, wher ever she lives in Can ada. Acknowledgements People who reviewed the pa per with knowl edge of a province s or ter ri to ry s leg is la tion in cluded Philip Beck, John Bib er dorf, Alan Gor don, Eric Hood, David Keegan, Ni zar Ladha, Grainne Neilson, Richard Pol ley, Jamie Smith, and Bill Twad dle. References 1. Men tal Health Serv ices Act, SS , c. M-13.1 as am. 2. Mental Health and Con se quen tial Amend ments Act, RSM c. 36, as am. (pro - claimed 31 Oc to ber, 1999). 3. Men tal Health Act, RSBC 1996, c. 288 as am. (pro claimed 15 No vem ber 1999). 4. Men tal Health Act, RSO 1990, c. M. 7 as am. By Bill 68 Bri an s Law (pro claimed De cem ber 1, 2000). 5. Gray, JE, Shone, MA, and Lid dle, PF. Ca na dian mental health law and pol icy. To - ronto: But ter worths; Tor rey EF. Out of the shad ows: con front ing Ameri ca s mental ill ness cri sis. To - ronto: John Wiley and Sons; p Tor rey EF, Kaplan RJ. A na tional sur vey of the use of out pa tient com mit ment. Psy - chi at ric Serv 1995;46:

7 May 2001 Clinically Significant Differences Among Canadian Men tal Health Acts McIvor R. The com mu nity treatment or der: clini cal and ethi cal is sues. Aust N Z J Psy chia try 1998;32: Re port of the expert com mit tee: re view of the men tal health act London: De - part ment of Health; Pank ratz WJ. The po si tion of the Ca na dian Psy chi at ric As so cia tion on mental health leg is la tion. Can J Psy chia try 1988;33: Hos pi tals Act, SNS 1989, c.208, as am, (s. 2 [q]). 12. Men tal Health Act, RSN 1990, c. M-9 as am, (s. 2 [g]) 13. Men tal Health Act, SA 1988, c. M-13.1 as am. 14. Men tal Health Act, RSNB 1973, c. M-10 as am, (s. 1). 15. Men tal Health Act, SPEI 1994, c. 39 as am, (s. 1 [k]). 16. Men tal Health Act, RSNWT 1988, c. M-10 as am, (s. 1). 17. Men tal Health Act, SYT , c. 28 as am, (s. 1). 18. Rob ert son GH. Men tal dis abil ity and the law in Can ada. 2nd ed. To ronto: Car swell; p M v Al berta (1985), 63 AR 14 at 27 (QB). 20. McCorkell v Riv er view Hos pi tal (1993), 81 BCLR (2d) 273, 8 WWR 169, at p An Act re spect ing the pro tec tion of per sons whose mental state pres ents a dan ger to them selves or others. Bill 39:1977, Chapter 75, as am, CCQ. 22. Ref er ence re Men tal Health Act (1984), 5 DRL (4th) 577 (PEICA). 23. Bob bie v Health Sci ences Cen tre (1988), [1989] 2 WWR 153, 56 Man R (2d) 208, 49 CRR 376 (QB). 24. Star na man v Pene tan guish ene Men tal Health Cen tre (1994), OJ 1958 (QL) (Gen Div), affd (1995), 24 OR (3d) OAC 95, 100 CCC (3d) 190 (CA). 25. Certain Per son al ity Rights 1991, CCQ 1991, c. 64, art Certain Per son al ity Rights 1991, CCQ 1991, c. 64, art Health Care Con sent Act, 1996, SO c. 2 (s. 21 [1]). 28. Bay M. The On tario mental health act. Health Law in Can ada 1997;17: Sevels v Cam eron (1994), OJ 2123 (Sep tem ber 15, 1994), Doc. Bar rie G11872, Eber hard J (Ont Gen Div). 30. Fleming v Reid (1991), 4 OR (3d) 74 CA. 31. O Reilly RL. 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Im pact of in vol un tary out pa tient com mit ment on the revolving- door syn drome in North Caro lina. Hospital and Com mu nity Psy chia try 1990; 41: Mu netz MR, Grande T, Kleist J, Pe ter son GA. The ef fec tive ness of out pa tient civil com mit ment. Psy chi atr Serv 1996;47: O Keefe C, Po tenza DP, Mue ser KT. Treat ment out comes for se verely men tally ill pa tients on con di tional dis charge to community- based treat ment. J Nerv Ment Dis 1997;185: Swartz M, Swan son JW, Wagner HR, Burns BJ, Hi day VA, Bo rum R. Can in vol un - tary out pa tient com mit ment re duce hospital re cidi vism?: Find ings from a ran dom - ized trial with se verely men tally ill in di vidu als. Am J Psy chia try 1999; 156: Van Put ten RA, San ti ago JM, Berren MR. In vol un tary out pa tient com mit ment in Ari zona: a ret ro spec tive study. Hos pi tal and Com mu nity Psy chia try 1988; 39: Zanni G, de Veau L. In pa tient stays be fore and af ter out pa tient com mit ment. 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Résumé Différences cliniquement significatives parmi les lois canadiennes sur la santé mentale Ob jec tifs : Pre mière ment, pré senter les diffé rences im por tan tes parmi les lois sur la santé men tale des diffé rents ter ri toires cana - di ens, en ce qui a trait aux critères d hos pi tali sa tion in vo lon taire, à l au to ri sa tion de traite ment, aux procédures de révi sion et d ap pel, aux con gés con di tion nels et aux or dres de traite ment com munautaire. Deuxième ment, ana lyser l effet de ces diffé rences sur les soins que reçoivent les per son nes souf frant de maladie men tale. Méth ode : Nous avons ex aminé les dis po si tions des lois sur la santé men tale de tous les ter ri toires ca na di ens pour dé ter mi ner com ment la ges tion clin ique d un cas typique différe rait entre ter ri toires. Nous avons util isé un énoncé de prin cipe re latif aux lois sur la santé men tale et ap puyé par l As so cia tion des psy chia tres du Can ada pour ori en ter l ana lyse. L in ter préta tion de chaque loi et de sa mise en oeu vre a été con firmée par des personnes- ressources de chaque prov ince et ter ri toire. Résul tats : Des diffé rences clin ique ment sig ni fi ca tives ont été con statées entre les prov inces et ter ri toires dans toutes les prin ci - pales com po san tes de leurs lois sur la santé men tale. Con clu sion : On trouve des dis po si tions empêchant les pa tients de re cevoir des soins clin iques appropriés dans cer taines lois ca - na di ennes sur la santé men tale. On trouve égale ment d autres dis po si tions qui ap pui ent les soins clin iques ap pro priés, qui re - spec tent les droits de la per sonne et la dig nité des pa tients, et qui sont con for mes à la Charte ca na di enne des droits et libertés, dans les lois d autres ter ri toires.