11th Greek Australian Legal and Medical Conference
Crete, Greece 2007

Mental Health and the Legal System in the Management of Eating Disorders

Dr. Revindran Nair BHB, MBchB (NZ), FRANZCP

Introduction

The recognition of mental illness in the law dates back at least to Roman times. Over the years this relationship has become more complex and important, with ever more areas in which the practice of law and psychiatry meet. This paper will explore one such area: how Mental Health Act legislation can influence the management of anorexia nervosa. The first part of the paper describes the syndrome of anorexia nervosa, in particular why it is an important condition and what the management options are. Issues related to phenomenology and competence, are explored in greater detail, to illustrate the different emphasis given to these issues in Mental Health Act legislation. Changes to the New South Wales (NSW) Mental Health Act are explored to show the challenges to legislatures in what emphasis they give to the legislation. NSW uses a predominantly symptom based definition of mental illness in the Act and as a consequence the presence or absence of certain symptoms are given particular importance in decisions made about involuntary treatment. In Victoria by contrast the definition of mental illness is vaguer but more emphasis is given to the impact the illness has upon a person being competent and thus being able to give informed consent to a particular treatment. A table comparing Mental Health Act legislation in the different states of Australia is provided to further illustrate this point.

Anorexia Nervosa

Anorexia nervosa is a serious mental illness with a significant risk of morbidity and mortality. The key features of the disorder include a fear of gaining weight and the refusal to maintain a minimally normal weight, a disturbance in the perception of the shape or size of the body. Postmenarchael females with the disorder are amenorrheic.

There are 2 main subtypes of anorexia nervosa: the restricting subtype in which weight loss is accomplished primarily through dieting, fasting or excessive exercise and the binge-purge/purging subtype in which the use of purging, laxatives, diuretics or other weight loss inducing substances is used to control weight. It may be associated with binge eating but not always as purging may occur even with small meals.

Anorexia nervosa can be associated with other psychiatric co-morbidity which may be a consequence of weight loss but may also occur concurrently. These include major depressive disorder, obsessive compulsive disorder, social phobia and personality disorder.

Eating disorder not otherwise specified, or atypical eating disorder, is a category where the illness may be evolving, resolving, secondary to another psychiatric illness (e.g. depression, anxiety, hypochondriasis and schizophrenia) or describes a binge eating syndrome.

Issues related to classification

The use of strict diagnostic criteria has advantages and disadvantages. The DSM-IV-TR is the most widely used classification system for psychiatric disorders in Australia and provides a clear definition for anorexia nervosa that is both reliable and valid. This is particularly useful in research but in clinical practice can affect the ability of research findings being applied to the “real world”. An example of this is the consistent research finding that the most commonly diagnosed eating disorder using DSM-IV-TR criteria is eating disorder not otherwise specified. Given this category contains a mixture of conditions that has abnormal eating behaviour as their core feature but varies in how this manifests and presents including in terms of weight, complications, prognosis and treatment, it is difficult to design meaningful research in this group. In practice management is usually guided by research from those who do meet all the diagnostic criteria for a particular eating disorder e.g. anorexia nervosa, but the degree to which this can and should be generalised to those who do not meet all the criteria for a specific eating disorder remains controversial.

Another issue relates to recruitment into research given that, of those suffering from an eating disorder, the most common category is eating disorder not otherwise specified. There are relatively fewer patients available for research into specific conditions such as anorexia nervosa. This is particularly important in relatively low prevalence conditions such as anorexia nervosa. The number of individuals in a study plays a vital role in statistics used to establish the power of a particular study, for example in studying the effects of a particular intervention on a population group. Therefore recruitment remains one of the major hurdles to research but is also clearly affected by other factors including ethical considerations and the effect the illness process has on those asked to participate in research e.g. level of insight into the condition.

Psychopathology

Diagnostic criteria provide a framework to establish the presence of a disorder and are often used as a template for legal definitions of mental illness in relation to mental health law. In Australia, definitions of mental illness contained in mental health law relate most closely to the diagnostic criteria of the major psychotic and affective illnesses. This has led to some of the debate around the most appropriate legislation to be used for the involuntary treatment of eating disorders. The NSW Mental Health Act requires the presence of certain symptoms and signs as evidence of mental illness. The criteria most often cited in patients with eating disorders for the purposes of the Act is body image disturbance. The body image disturbance seen in anorexia nervosa can be difficult to define in phenomenological terms. Furthermore the disturbance of body image can vary between sufferers of the condition and may change over the natural history of the disorder.

Legal definitions generally require a clear separation between normal and abnormal in relation to mental illness. This allows tribunals and magistrates to make decisions about who will meet criteria for the Mental Health Act and involuntary treatment. This is especially challenging in anorexia nervosa where there has been considerable debate about the phenomenology of the condition. Is the body image disturbance a delusion, overvalued idea or obsession?

JB a 15 year old girl in year 10 of her local high school is referred to a psychiatrist by her general practitioner for assessment of a possible eating disorder. Her BMI was 17. She described being teased at school by her class mates about her weight. She has become increasingly concerned about her weight and has started dieting and exercising regularly. She was concerned about her body and at times felt that she needed to lose more weight and this thought was associated with her feeling more anxious. When asked more closely about how she felt about her body, she was able to acknowledge that she had lost a significant amount of weight and her current weight was below the normal range. “I know I am probably too skinny but I can’t stop thinking that parts of me are too fat, even though I know it is silly and don’t want to think that way”.

In the case described above the patient recognises the thoughts about her weight and body as recurrent unwanted thoughts that she feels aren’t under her voluntary control and that she is trying to resist. Thus from a phenomenological view point it most closely fits the definition for an obsessional thought.

A 20 year university student is referred by the student health clinic for assessment of weight loss. Her BMI was 16 at the time of referral. She tells her general practitioner that she does not think that she is under weight and is not sure why she was referred. When challenged about her weight loss she protests “I know everyone else thinks I am too skinny but I feel fat and I am frightened of gaining weight. If I have to gain weight I do not know how I will survive, it’s just so important to me”.

The term ‘overvalued idea’ is much more ambiguous with some psychiatrists using it to refer to a delusional idea which falls short of being a full delusion because it is not held with utter conviction, while others use the term to refer to unusual false beliefs that are not idiocentric. David Veale’s suggestion, that overvalued ideas are associated with idealized values of such overriding importance that they totally define the ‘self’ or identity of the individual, has the greatest resonance for anorexia nervosa. In the example given above the patients beliefs about their weight are held rigidly and have come to assume a major role in their sense of identity, leading to them ignoring the consequences of acting on these values.

PB a 43 year old women is referred to the emergency department by a general practitioner who had seen her for the first time. She was taken there by concerned work colleagues after she complained of feeling unwell. Her BMI was 12. When assessed at the emergency department and informed of the seriousness of her condition, she replied “I can’t understand how this has happened, I love food and eat like a horse, I am a very healthy person and have never tried to lose weight in my life, and I must just have a very fast metabolism”.

A delusion may be defined as ‘a fixed belief incorrigible and impervious to logical argument, whose content is idiocentric’. The problem with this definition is that it is not how a patient with a delusion would describe the thought or experience it. As a result the phenomenological approach to the assessment of a delusion emphasises the basis of the thought and how it is held, not on its truth, falsity, reasonableness or irrationality.

The various forms of thought content disorder are not clearly distinct from each other, but pass almost imperceptibly from one to another. Whether a particular experience should be considered a delusion, an overvalued idea or an obsession is often a matter of argument, especially as all these abnormalities may be found simultaneously in the same patient and are not diagnostic of any particular psychiatric disorder. In the final appraisal of the mental health status of an anorexia nervosa patient, it is necessary to recognize that psychopathology, in a technical sense, may be present simultaneously or evolve through the natural history of the disorder. The challenge to the lawmakers is how to encompass the fluidity in their laws.

Epidemiology

Anorexia nervosa is most common in women with less that 10% of cases being male but there is some evidence to indicate it is becoming more common in males. The average age of onset is 17 but there are indications that anorexia nervosa is becoming more common in prepubertal children and older adults. Point prevalence for girls in the age group 15 to 19 is about 0.5% and in women 20-24 about 0.25%.

The mortality rate estimated in a number of follow up studies is about 20% at 20 years. The overall mortality rate for anorexia nervosa is 5 times that of the same aged population in general, with death from natural causes being 4 times greater, and deaths from unnatural causes being 11 times greater than expected. The risk of suicide is 32 times greater.

Cardiac arrhythmias are a common cause of death in anorexia nervosa patients. Long term physical morbidity is also common and serious. Growth retardation is present in some patients with an early onset of the disease. Anovular infertility is common in some women who have only partially recovered. Osteopaenia leading to osteoporosis is a serious complication of the active disease but may also have long term consequences as bone mineralisation terminates with the menopause. This may result in fractures from minimal trauma and delayed healing or complications preventing repair. Renal and liver function are frequently permanently impaired by anorexia nervosa and a neurogenic bowel with subsequent rectal prolapse is common, sometimes but not always associated with laxative abuse.

Risk factors for developing anorexia nervosa include a positive family history for eating disorders, parental obesity, restrictive dieting and abnormal attitudes to eating, appearance, and weight in the family. In a particular individual; body dissatisfaction, restrictive eating, childhood obesity, early menarche, depression, substance abuse, obsessive compulsive disorder, social anxiety and adverse life events act as risk factors. Personality characteristics include perfectionistic or obsessional traits, alexithymia and low self esteem.

Anorexia nervosa has a chronic course in the majority, the average duration of illness being 5 years, even though an estimated 70% regain weight within 6 months of onset of treatment, 15-25% of these relapse, usually within 2 years. Follow up studies suggest that under one half have a good outcome as defined by a return to normal weight, eating and menses, a third intermediate and the reminder poor. Positive prognostic indicators generally suggest a less severe illness and include higher weight at presentation, absence of medical complications, motivation to change and good social support. Family cohesion and attitude to illness play a vital role when the disorder develops in children and adolescents, but may also be important in older age groups. Purging particularly associated with low weight is associated with poorer outcomes, as is onset in adulthood, other psychiatric co morbidity, disturbed family relationships and longer duration of illness.

The impact anorexia nervosa has upon families is a much harder thing to measure and has been complicated by a tendency to blame the family for the disorder developing in one of its members. This may manifest in unwarranted suspicions about abuse particularly sexual, which is actually less common than alleged. There is no doubt that studies indicate high rates of family dysfunction when a member has the disorder but it is difficult to establish what is caused by the disorder rather than the result of it. Family therapy, particularly in younger sufferers, plays an important role in management of the disorder.

The health care costs of anorexia nervosa are considerable, this is related to its chronic course in some resulting in frequent and prolonged admissions to hospital and the management of morbidity associated with the disorder such as osteoporosis. MBF, a major insurance provider in Australia, has published figures showing that anorexia nervosa patients are consistently among those making the highest claims. The lack of specialist services to treat the disorder is a world wide phenomenon; in America managed care funds are placing significant restrictions on treatment facilities for the disorder and in England the only inpatient treatment facilities are in London and Oxford. In Australia NSW there are 20 public beds available for specialised care of anorexia nervosa in a state where there are 2,000 sufferers of the disease at any one time and about 400 new cases every year.

Treatment

A detailed discussion of treatment is beyond the scope of this article but a brief outline of treatment options is important in understanding different options in the management of this condition and in particular the requirement for involuntary treatment.

The main aims of treatment are nutritional and weight restoration but the identification and effective management of medical complications and psychiatric co morbidity are particularly important, because as mentioned above these things significantly worsen prognosis. A multi discipline team often including a psychiatrist, physical medicine specialist (general practitioner, physician or paediatrician), dietician, nurse and other allied health specialists for example psychologist, occupational therapist, family therapist and physiotherapist is required for the optimal management of this condition.

The setting in which treatment occurs is more often dictated by service availability but ideally should be based upon the afflicted individual’s needs. In the less severe forms of the disorder management can occur in the community with regular outpatient reviews by members of the treating team and close monitoring. Day hospitals and community based day care centres can be useful when more support is required. Inpatient treatment is usually required in the severely ill; this is often associated with the patient denying they have an illness or refusing treatment. In these settings the use of involuntary treatment orders may be required. This poses a particular challenge as much of the management of the severely ill patient may be termed “medical” rather than “psychiatric”, for example nasogastric feeding which often occurs at the direction and under the supervision of a general medical team. The type of legislation used to enforce treatment has been the source of considerable controversy and will be explored in greater detail later in the article.

In the initial stages of treatment of the severely ill, close monitoring of physical parameters is required associated with gradual re feeding and correction of electrolyte abnormalities.

With weight restoration and correction of physical complications, support and psychological strategies have a greater role. This may occur in the form of “supported meals” and monitoring of behaviour including activity levels. Education plays an important role for the individual and the family. Psychological support, an empathetic therapeutic relationship and cognitive behavioural strategies are important throughout treatment.

Effective treatment of co morbidity is also vital and has a significant impact on prognosis, but once again can be complicated by the difficulty of establishing what may be the result of the disorder. For example depressive symptoms can be a consequence of weight loss and improve when weight is restored without further intervention as opposed to things that may have resulted in an increase risk of developing the disorder and complicate its course, such as the trauma associated with child sexual abuse. Long term treatment is usually required for chronic forms of the illness. The use of a ‘rehabilitation’ model may be required where there has been significant impairment in social functioning, work/study and activities of daily living.

Competence

Can be defined as “the ability to do something well or to a required standard”. In relation to mental health competence often refers to the ability of a person to reach a rational decision regarding their health and well being. Strictly speaking there is no such thing as general competence. Competence is related to a specific task, decision or procedure that the person is being asked to consider. For example a person may be incompetent to make a decision about the treatment of a psychiatric disorder but may be competent to make decisions about other aspects of their health. In the foundations of clinical psychiatry, Russel Pargiter and John Coverdale suggested 5 steps, each dependant on completion of the previous step, to assess the decision making process and by extension the competence of an individual to make a decision.

  1. The person is able to register the information provided.
  2. The person can absorb, retain and recall the information provided.
  3. The person appreciates the relevance of the information provided.
  4. The consequence of the decision is appraised on the basis of the person’s values and beliefs.
  5. The person is able to communicate both cognitive and evaluative understanding and a decision based on it.

Issues of competence arise most frequently in relation to giving consent to treatment, release of information, management of finances, management of affairs, testamentary capacity and durable power of attorney. The final decision is made by a statuary body; often the courts and therefore clinicians provide advice and information.

Tan et al in an article in the International Law and Psychiatry Journal titled “Competence to refuse treatment in anorexia nervosa” compared the MacCAT-T test (Macarthur competency assessment tool) of competence (a structured interviewer rated interview in which a previously prepared script giving patient information on anorexia nervosa as well as a choice of treatment options in a standardised way) with a semi structured interview focusing on a broad range of issues that could be relevant to competence in accordance with grounded theory. They concluded that the standard concept of capacity to consent to treatment, as being one of understanding and reasoning which is well captured by the MacCAT-T, may not be relevant to the difficulties that patients with anorexia nervosa may have with decision making. In particular, they identified three areas in which standard tests of competency fail to identify impairment, the first being attitudes to death and disability. Patients with anorexia nervosa may not wish to die but rather death and disability are relatively unimportant when compared to anorexia nervosa. It is this relative unimportance that can lead to treatment refusal. This is not related to co morbidity such as depression or picked up as an impairment of competence on the MacCAT-T. The second area is the importance that anorexia nervosa has to the sufferer’s sense of identity and the associated reluctance to receive treatment. This is particularly important in adolescents who may have no clear sense of identity. Finally, ambivalence to treatment that may be related to the following: an advantage that having anorexia nervosa may give to the patient; that the patient may feel that changing behaviour may not be a choice that they can make even if they wanted to; or the patient may wish to be coerced before they can comply with treatment. These are also poorly captured on standard tests of competence. As a result current concepts of competence may not identify key reasons for treatment refusal in patients suffering from anorexia nervosa. This is particularly important in jurisdictions where competence to make treatment decisions plays a key role in decisions regarding involuntary treatment.

Webster et al in an article published in the psychiatric bulletin titled “Reforming the Mental Health Act: implications of the government’s white paper for the management of patients with eating disorders”, in which they discussed the implications of reforming the Mental Health Act in the United Kingdom and noted that feeding someone against their will under the Mental Health Act was only clarified in 1997 despite the Mental Health Act legislation being law since 1983. Furthermore they noted that given the average age of presentation of anorexia nervosa which was quoted as 16 in the paper, the management and legal status of children requiring treatment poses a special challenge. Reforms to the Mental Health Act in the United Kingdom have made the first step of the assessment procedure relatively straight forward by broadening the definition of a mental disorder; however, the recommendation of an assessment of competence remains an area of controversy. This relates to the reforms failing to provide a formalised competence assessment and the subsequent difficulty in establishing if competence is impaired. This has lead to considerable variation in practices across the United Kingdom in the use of inpatient admission and compulsory treatment in cases of anorexia nervosa.

Informed consent

Informed consent emphasises the need for the patient to participate in treatment decisions. The doctrine of informed consent evolved partly in response to two major failings of medical practice, excessive paternalism and nonparticipation of patients’ in decisions about their own bodies and their own health care. The aim is to establish a collaborative approach between doctor and patient toward decision about their health. It has also taken on increasing importance in medical negligence and malpractice litigation. There are three main components: information, consent and competence. In the Victorian Mental Health Act of 1986 one of the criteria for involuntary admission is that “the person has refused or is unable to consent to the necessary treatment for the mental illness.” The emphasis given to issues related to competence and informed consent were strengthened by amendments made to the Victorian Mental Health Act in 1996.

Involuntary commitment

The legal justification for involuntary commitment has centred on two principles. The first, parens patriae, refers to the concept that the king is the parent to his country and, as such, has a parental responsibility for subjects who are unable to care for themselves. Therefore in relation to involuntary commitment it offers a rationale for a protective mechanism for citizens in need of protection, a mechanism that at best is parental and at worst paternalistic. The second principle is that of police powers which relates to the state’s responsibility for maintaining control and order among its subjects. The police powers principle casts the state as the protector of other citizens from patients. Therefore the emphasis is on the protection of society at large rather than the individual.

These principles are related to the competing moral framework of utilitarianism, which is that actions should be guided by the principle of the greatest good for the greatest number as against deontological ideas, that there is a universal applicability of certain irreversible moral judgements. Therefore utilitarianism argues that decisions about involuntary commitment should be based on what is best for society as a whole and therefore the subversion of certain individual rights may be justified. On the other hand arguing from a deontological stand point, that there are fundamental rights processed by every human being that should not be violated, decisions regarding involuntary detention should be based upon these fundamental rights. Related concepts include autonomy which literally means self governing as against paternalism. The ethics of involuntary treatment are complex and controversial, given the process by definition will impair the individual’s autonomy, for example the right to consent to treatment. As a result of this most Mental Health Act legislation provides for checks and balances in involuntary commitment laws. In America there is close judicial oversight of involuntary treatment with many jurisdictions requiring judicial reviews prior to commencing treatment. This may be accompanied by full legal representations and argument. This is further complicated by varying judicial approaches to defining the right to refuse treatment.

The NSW Mental Health Act of 1958 had no clear definition for mental illness and therefore offered no assistance in deciding what did and what did not constitute it as an entity. This allowed for flexibility in interpreting the law and may even have been thought to have rendered it permeable to lay understandings of mental illness, had the courts not interpreted it in more specialized terms in order to limit excursions on personal liberties. As a result, the Mental Health Act of 1990 as amended in 1997, proposed a clear definition for mental illness, with certain psychological symptoms being seen as sine-qua-non for its presence. This can be characterised as a psychopathological approach to definition with an emphasis on the disorder of function that occurs as part of the process. While this provides a relatively clear definition for magistrates to make decisions regarding involuntary commitment, it also leads to considerable debate regarding psychiatric illnesses that do not fit neatly into this definition, anorexia nervosa being one such example. The other problem is that the definition does not provide the degree of precision hoped. It shifts the definition from that of mental illness to that of symptom presentation. The assumption is that symptom definition is precise, when many psychiatrists will attest to the difficulty in describing psychopathology in fixed and constant terms. Unfortunately the courts have failed to appreciate this difference and have tended to rely on this strict definition when asked to make findings regarding the presence of mental illness.

The changes made to the mental health act legislation in NSW has lead to more consistent findings regarding the involuntary treatment of anorexia nervosa, as illustrated by the following case.

In the NSW supreme court ruling in the case of JAH versus the medial superintendent of Rozelle Hospital (S.14, 4 March 1986), Justice Powell referred to sections 4,12 and 18 of the then current Mental Health Act 1958 (NSW).

“Powell, JL the condition from which the Plaintiff suffers, and for which, on a number of occasions over the last four years, she has, because of her intractable attitudes, required treatment, is that commonly known as anorexia nervosa. Since it deals with the matter in such a clear and succinct way, it is convenient to set out some of the evidence of professor B. It is as follows:

‘Anorexia nervosa is a diagnostic term applied to a condition of self-induced under nutrition usually seen in adolescent girls and young women. Its cause is unclear and it does not arise from any discernible pathological change to the brain or other organ of the body. Therefore it is not a disease (which in medical parlance implies structural or chemical change), but rather an illness, that is an experience of ill-health. In these respects it is similar to most psychiatric diagnostic terms which refer to conditions of unknown causation, without discernible pathological changes.

All such illnesses are defined in terms of a syndrome, that is an association of symptoms and signs which are consistently associated with each other, which point to a common course of illness, and (preferably) which respond to a common form of treatment. As a syndrome, anorexia nervosa is as well established as any other psychiatric illness.

The patient must fulfil specified operational criteria if the diagnosis of a syndrome is to be made. The diagnostic criteria for anorexia nervosa, as given in the [ICD-9 or DSM-III] are basically unaltered from... the original descriptions of the illness more than 100 years ago.

Essentially these criteria are:

  1. A significant state of under nutrition, together with its physical consequences
  2. Brought about deliberately by the patient using a variety of weight losing behaviours
  3. Associated with a fear of being fat and an overvalued idea about the desirability of being thin
  4. In the absence of other physical or psychiatric illnesses that might account for the patient’s symptoms. It is criterion (c) which is of crucial importance. In its absence, the subject’s condition is not necessarily seen as being an illness. For instance, someone who goes on a hunger strike for political purposes, or on a long period of fasting for religious reasons, is not considered to have anorexia nervosa although he fulfils criteria (a) (b) and (d).

Although it is a serious mental condition and may be life-threatening, anorexia nervosa is not a psychotic illness. The term psychosis is defined in the Comprehensive Textbook of Psychiatry, 3rd edition (Kaplan, Freedman and Sadock) as ‘a mental disorder in which a person’s thoughts, affective response, ability to recognize reality, and ability to communicate and relate to others is sufficiently impaired to grossly interfere with his capacity to deal with reality. The classical characteristics of psychosis are: impaired reality testing, hallucinations, delusions, and illusions. Confusion arises when the term psychotic is used to indicate a level of severity of mental illness. Its proper use is to refer to specific kinds of mental illnesses, not to their level of severity.’

Powell, J continued: In the light of this evidence, and the views which I have expressed as to the meaning to be attributed to the phrase ‘mental illness’ for the purposes of the Act, it is, in my view, inescapable that I should hold that the Plaintiff is not suffering from a ‘mental illness’, and that, accordingly, she is not a ‘mentally ill person’, for the purposes of the Act.

This decision was reversed after the new Mental Health Act was introduced in 1990 in NSW, but there continues to be debate regarding the involuntary treatment of anorexia nervosa and the most appropriate legislation to use.

Why involuntary treatment is necessary

Involuntary treatment is often required in the more severe forms of anorexia nervosa. This may be due to a range of different factors that result in increased risk of harm or death for the sufferer.

Griffiths et al in a paper in the Australian and New Zealand journal of psychiatry titled “The use of guardianship legislation for anorexia nervosa: a case report of 15 cases”, noted that more severely ill patients were managed under guardianship law and the length of stay in hospital was significantly longer as compared to voluntary patients and to those managed under the Mental Health Act.

Watson et al in a paper published in the American journal of psychiatry titled “Involuntary treatment of eating disorders” examined 397 patients admitted to an inpatient treatment program over 7 years. They concluded that a substantial minority of patients with severe eating disorders will not seek treatment unless legally committed to a program, furthermore their involuntary status did not affect response to treatment as measured by weight gain or attitude toward the treating team or the treatment offered with most later acknowledging that treatment was necessary.

The reason some patients with anorexia nervosa do not voluntarily accept treatment may relate to an impaired drive for health. There are many theoretical models in health psychology, which explain an individual’s drive for health. Many take a dimensional approach to health seeking behaviour with the sick role and hypochondriasis at one end and stoicism and self destructive behaviour at the other end. The common factors in these models are that health promoting behaviour occurs if a person has:

  1. Positive intention or predisposition.
  2. A minimum of environmental barriers.
  3. The requisite skills.
  4. The belief that positive outcomes or reinforcement will follow.
  5. The belief that there is normative pressure to achieve health and none sanctioning it.
  6. The belief that health is consistent with the persons self image.
  7. A positive affect regarding health.
  8. Cues or enablers to act or engage in the behaviour at an appropriate time and place.

When this model is applied to criteria for anorexia nervosa it is likely that people suffering from the condition would fail to endorse 1,4,6,7 and possibly 3. Blake et al used the transtheoretical model of change of Prochaska and Declemente to show that most patients presenting for treatment at a specialized clinic for anorexia nervosa were found to be in precontemplation or contemplation rather than action.

The Greek experience

The Greek psychiatric reforms began in the early 1980’s with the support of the then European community and the introduction of the national health system. The adoption of the European human rights charter added further impetus to the reforms. As a result de-institutionalization of patients from psychiatric hospitals has almost been achieved. Associated with this have been the introduction of laws that strengthen community based care and statutory review of involuntary commitment. This has resulted in psychiatric hospital beds being reduced, psychiatric units in general hospitals being developed and a substantial number of community mental health centres being established. The standard of care is gradually improving but there remain gaps particularly in service provision.

The involuntary commitment of severe cases of anorexia nervosa is consistent with the Greek mental health act and there has been less controversy in its application in these cases, when compared to NSW.

Conclusion

Mental Health Act legislation continues to evolve around the world. The increasing importance given to individual rights has been the driving force for the introduction of reforms that have resulted in greater scrutiny of involuntary treatment. The challenge to law makers is to come up with a balance between effective treatment and management of serious psychiatric illnesses which are often complicated by impaired insight and judgement and protection of fundamental human rights including the right to make decisions regarding treatment. This has been approached in different ways with NSW enshrining close legal oversight of involuntary commitment and a definition of mental illness in its mental health act as compared to Victoria which has adopted a more pragmatic approach with involuntary commitment being overseen by a mental health review board.

JURISDICTION VIC NSW QLD WA SA TAS ACT NT
LEGISLATION MHA 1986 MHA 1990 MHA 2000 MHA 1996 MHA 1993 MHA 1996 MHA 1994 MHA 1998
PRIMARY CATEGORY Mental illness. Mental illness. Mental illness. Mental illness. Mental illness. Mental illness. Mental dysfunction. Mental illness.
DEFINITION (Primary category) Presence of disorder. Emphasis on symptoms. Presence of disorder. Presence of disorder. Presence of disorder Emphasis on symptoms. Presence of disorder Emphasis on symptoms.
EXCLUSIONS Intellectual disability, antisocial personality. Developmental disability of mind. Intellectual disability. Intellectual disability. Nil. Intellectual disability. Nil. Intellectual disability, personality, habit, impulse disorders, acquired brain damage, mental disturbance.
TREATMENT Defined. Not defined. Defined. Defined. Not defined. Not defined. Not defined. Defined.
SECONDARY CATEGORY Mental disorder. Mental disorder. N/A N/A N/A N/A N/A Mental disturbance.
NATURE/ CONSTITUTION OF REVIEW BODY MHRB. Magistrate initially then MHRB. MHRB. MHRB. Guardianship board. MHRB. MHRB. MHRB.
SECONDARY REVIEWS VCAT/ Supreme court. Supreme Court – re-hearing Mental Health Court Supreme Court. District Court – re-hearing Supreme Court – re-hearing. Supreme Court – re-hearing. Mental Health Tribunal.
POWERS Broad-ranging Broad-ranging Broad-ranging Broad-ranging Broad-ranging Broad-ranging Broad-ranging Supreme Court – re-hearing.
MANDATORY REVIEW Within 8 weeks and thereafter every 12 months. As soon as practicable and thereafter 3-6 months. Within 6 weeks and thereafter every 6 months. Within 8 weeks and thereafter 3-6 months. Up to 45 days and thereafter 12 monthly. 28 days and thereafter 6-12 months. 3-6 months. Broad-ranging
PATIENT APPEALS Yes- at any time. Yes- at any time. Yes- at any time. Yes- provided 28 days have elapsed since last review. Yes- at any time. Yes- heard within 21 days, provided 90 days have elapsed since last review. Yes- at any time. No later than 7 days and thereafter every 3-6months.
FORENSIC No Yes Yes Yes Yes No Yes Yes

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