This article is from Community Care, 1st August 1991
Controversy over the use of sedatives to control the behaviours of young people in psychiatric care is gathering pace. Mark Ivory reports.
Pin-down caused a furore because young people were put in solitary confinement for long periods in what was described by Allan Levy, who helped investigate the regime, as a ‘fundamental abuse of human rights’.
Since then, other young people have alleged similar treatment, mostly in psychiatric rather than local authority care.
In addition to ‘exclusion’, or solitary confinement, psychiatry has an even more powerful method at its disposal – sedation.
Hill End adolescent psychiatric unit in St Albans, Hertfordshire, has recently been accused of excessive use of sedatives, following similar allegations against Langton House, a mental nursing home for children in Dorset, and St Charles Youth Treatment Centre in Essex (News, 13, 27 June and 25 July).
All of these institutions took referrals from local authorities unable to look after the young people in council care homes because they were too disturbed or too troublesome. Some were suicidal, others violent.
According to Mary Moss, spokeswoman for the National Association of Young People in Care, the care system has failed these young people. Psychiatric care has, she says, become the ‘dumping ground’ for society’s most abused children.
She claims that four-fifths of adolescents sent to psychiatric units would be better off in local authority children’s homes if only they were properly resourced and supported by trained staff.
‘The way sedatives are used in psychiatric units is completely out of order,’ Moss says. ‘They literally dose up young people to keep them under control.’
Langton House was earmarked for closure soon after Community Care revealed the allegations and St Charles YTC is being shaken up by the DoH, but Moss says the use of sedatives as a means of restraint remains widespread.
Elaine Murphy, vice-chairwoman of the Mental Health Act Commission, believes the use of drugs like Largactil and Haloperidol – both anti-psychotic drugs with a sedative effect – to control behaviour in non-psychotic patients is an ‘extremely dubious’ practice.
‘I can’t imagine prescribing something of that potency to control impulsive behaviour’ said Murphy, who is a consultant psychiatrist at Guy’s Hospital in London.
The crucial question arises over how often these drugs are administered without consent. No consent is needed if the young person has been sectioned under the Mental Health Act. But many of those referred by local authorities are in psychiatric care voluntarily and consent is normally required.
There are two principal exceptions to this rule: when the life of the patient or a member of staff is in danger and when the patient is deemed mentally incompetent to give consent. Concern is growing that some consultant psychiatrists may be using these escape clauses too readily.
Bill McIntyre, priority services manager in charge of Hill End, says there are strict procedures for the use of sedation and exclusion. ‘The unit makes it very clear to the parents and the referring local authority that exclusion or sedation can be used if that’s the only way the situation can be managed,’ McIntyre says. ‘Sedation is used for behaviour control if it’s required as a last resort.’
McIntyre, who describes Hill End as a ‘breath of fresh air’ in psychiatric care, says the unit seeks verbal consent for these measures before the young person arrives.
‘When a child goes crazy and kicks a nurse, doctors can’t ask them permission to give a sedative injection,’ he says. However, the alleged over-use of sedatives to control behaviour, rather than as part of a structured treatment programme, has led the father o a 15-year-old-boy to contemplate legal action against Hill End and Bedfordshire SSD, the referring authority.
The boy’s allegations, which included prolonged exclusion, are being investigated by the Health Advisory Service.
Bedfordshire social services director, Tim Hulbert, is concerned about allegations that sedatives are used for restraint.
‘It might be legitimate in some circumstances but our anxiety is what safeguards there are’ he says.
Hilbert denied that Hill End had given him full information about administration of sedatives, saying that he had agreed to their use for treatment and not restraint.
Both Hulbert and Murphy say there should be a clearer framework of regulations and inspection to govern psychiatric units which look after children.
There are indications that some establishments, and even the courts, are giving short shrift to the Mental Health Act code of practice.
The code spells out the rules governing consent but the ready use of escape clauses by some psychiatric units appeared to win support from a decision last month by the Court of Appeal.
Subject to dramatic mood swings, a 15-year-old girl in an adolescent unit had refused sedative drugs during one of her lucid and rational periods.
Despite the code’s unequivocal assertion that an individual’s capacity to give consent can vary over time, the Appeal Court clearly took a different view.
It would be dangerous, said Lord Justice Farquharson, for the court to refuse to authorise medication on the basis that a patient was lucid on a particular day.
Mental health charity MIND accused the judges of moving the goalposts.
MIND solicitor Adina Halpern said: ‘It now appears that even though a young person is capable of giving consent, it’s still possible that a court can decide against his or her wishes to order treatment.’
As the judges appear to back the view of some psychiatrists, young people look increasingly beleaguered. Their only hope may be regulations with sharper teeth than a mere code of practice.