The Mental Health Act (1983)
Summary
The Mental Health Act (MHA) 1983 (amended 2007) is the primary legislation in England and Wales allowing for the compulsory admission and treatment of persons with a "mental disorder". It balances the rights of the patient (autonomy) with the need to protect the patient or others from harm (beneficence/non-maleficence). Most hospital admissions are Informal (Voluntary). The MHA is used only when a patient refuses voluntary admission and meets strict criteria. [1,2]
Clinical Pearls
MHA vs MCA: This is the key exam distinction.
- Mental Capacity Act (MCA): Used for physical illness (e.g., confused patient refusing antibiotics for pneumonia) or general decision making.
- Mental Health Act (MHA): Used only for the assessment/treatment of Mental Disorder (e.g., Schizophrenia) where the patient refuses admission. You cannot use the MHA to treat a broken leg.
One S12 Approved: For Section 2 or 3, you need 2 doctors. According to the Act, only one needs to be "Section 12 Approved" (a specialist in psychiatry). The other can be ANY registered medical practitioner (e.g., the GP). However, in practice, usually two psychiatrists attend.
Section 5(2) is for Inpatients ONLY: You cannot use Section 5(2) (Doctor's holding power) in A&E. An A&E department is considered a "public place" for triage purposes, or a place of safety, but not an "inpatient ward" legally until admission. In A&E, use Common Law / MCA or call Police for S136 (complex).
Statistics
- Use: ~50,000 detentions per year in England.
- Trend: Increasing year on year.
- Demographics: Higher rates of detention in Black and Minority Ethnic (BAME) groups (a subject of the ongoing Wessely Review).
Criteria for Detention
- Mental Disorder: The patient must be suffering from a mental disorder of nature/degree that warrants hospitalisation.
- Risk: Detention is necessary for the health/safety of the patient OR the protection of others.
- Refusal: Appropriate treatment cannot be provided informally (patient refuses or lacks capacity to consent).
| Situation | Legal Framework |
|---|---|
| Psychosis + Refusing Antipsychotics | Mental Health Act |
| Dementia + Wandering (No resistance) | DoLS (Deprivation of Liberty Safeguards) |
| Delirium + Pulling out drip | Mental Capacity Act |
| Unconscious + Head Injury | Common Law / MCA |
Civil Sections (Community -> Hospital)
| Section | Purpose | Duration | Doctors Needed | Application by | Renewable? | Treatment? |
|---|---|---|---|---|---|---|
| S2 | Assessment | 28 Days | 2 | AMHP | No | Yes |
| S3 | Treatment | 6 Months | 2 | AMHP | Yes | Yes |
| S4 | Emergency | 72 Hours | 1 | AMHP | No | No* |
*Section 4 is rarely used now. It allows emergency admission with only 1 doctor if waiting for a 2nd would cause dangerous delay. Must convert to S2 within 72h.
Holding Powers (Already In Hospital)
| Section | Person | Duration | Purpose |
|---|---|---|---|
| S5(2) | Doctor (Consultant/Deputy) | 72 Hours | Stop inpatient leaving until assessment. |
| S5(4) | Nurse (RMN) | 6 Hours | Immediate stop until Doctor arrives. |
Police Powers
| Section | Place | Duration | Purpose |
|---|---|---|---|
| S135 | Private Property | 24 Hours | Police + Doctor + AMHP enter home to remove patient. |
| S136 | Public Place | 24 Hours | Police remove person "in need of care/control" to Place of Safety. |
The Mental Health Act Assessment
- Who: 2 Doctors (usually 1 Psych, 1 GP/Independent) + 1 AMHP (Approved Mental Health Professional - usually a Social Worker).
- Process: They interview the patient (together or separately).
- Outcome: They agree criteria are met -> AMHP completes paperwork -> Patient transported to hospital.
Roles
- AMHP: The applicant. They decide if the section happens (Doctors just provide medical recommendations). They look at social context and alternatives.
- Nearest Relative (NR): A legal hierarchy (Spouse > Child > Parent). The NR can object to a Section 3 (stopping it), but not a Section 2. They can also request discharge (can be barred by Responsible Clinician).
Rights
- Appeal: Patients on S2 have 14 days to appeal to Tribunal. S3 can appeal once per period.
- IMHA: Independent Mental Health Advocate. Every detained patient is entitled to one.
Treatment
- Consent: For the first 3 months of detention (S3), medication can be given against will (T3 form).
- Second Opinion: After 3 months, if patient still refuses, a SOAD (Second Opinion Appointed Doctor) from CQC must authorise the plan.
- Institutionalisation: Long stays.
- Trauma: Being sectioned is distressing. Use least restrictive practice.
- Police Involvement: Transport often involves police/ambulance.
- Section 2 -> 3: Many patients convert from assessment to treatment.
- Section 2 -> Discharge: Some recover or agree to stay voluntarily (Informal).
- CTO (Community Treatment Order): After S3 discharge, patients can be placed on a CTO (Section 17A) - conditions to stay well in community (recall to hospital if breached).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Code of Practice | DoH (2015) | The "Bible" of MHA application. Must be followed. |
| Wessely Review | Govt (2018) | Recommendations to modernise act (esp regarding Autism/LD and BAME detention). |
Landmark Evidence
1. Bournewood Case (HL v UK)
- Led to the introduction of DoLS (Deprivation of Liberty Safeguards). A patient with autism compliant with admission was deemed "detained" without legal process. Closed the "Bournewood Gap".
What does "Being Sectioned" mean?
It means you are kept in hospital under the Mental Health Act, even if you want to leave. This only happens if a team of professionals believes you are too unwell to make safe decisions and you need urgent treatment.
Who decides?
Usually three people: two independent doctors and an "AMHP" (a specialist social worker). They all have to agree.
How long will I be there?
- Section 2: Up to 28 days. Used for diagnosis and initial treatment.
- Section 3: Up to 6 months. Used for established treatment.
Can I appeal?
Yes. You have the right to a free lawyer and an appeal to a Tribunal (a specialist court) to prove you are well enough to leave.
Primary Sources
- Department of Health. Mental Health Act 1983: Code of Practice. 2015.
- Jones R. Mental Health Act Manual. (The standard legal textbook).
- The Mental Capacity Act 2005.
Common Exam Questions
- Emergency: "Patient on med ward trying to leave?"
- Answer: Section 5(2) (Consultant/Deputy holding power).
- Police: "Police find madman in street?"
- Answer: Section 136 (Remove to Place of Safety).
- Roles: "Who applies for the section?"
- Answer: The AMHP (Supported by 2 medical recommendations).
- Duration: "How long is Section 2?"
- Answer: 28 days.
Viva Points
- Section 135 vs 136: 135 is Private premise (needs Magistrate Warrant). 136 is Public place (Police judgement).
- Treatability Test: Abolished in 2007. Now just need "appropriate medical treatment available".
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.