Can Finland have statutory mental health incarceration rates nearly 20 times higher than Italy? (Zinkler and Priebke 2002) Is it just the law or the context in which the law takes place? And how can we even begin to compare frames?

These are all questions that have been lurking for some time; they concerned the Independent Review of the Mental Health Act 1983 (Rains et al. 2019), and they are equally applicable when comparing regimes established for detention under mental capacity legislation (Serial 2022).

In a new paper (Davidson et al, 2024), Gavin Davidson and colleagues from Northern Ireland, the Republic of Ireland, Scotland and Australia use the example of the island of Ireland to begin to answer these questions. They do this by using previous work designed to address three key questions:

1. What information is currently available to examine and compare the law, policy and practice relating to mental health and mental capacity law on the island of Ireland?
2. What should be included in outcome frameworks that will ensure regular presentation and comparison of key variables related to mental health and intellectual capacity law?
3. What specific data should be collected on the use of mental health and intellectual capacity law on both sides of the border to enable comparison and collaborative learning?

Mental health incarceration rates vary widely across countries, but why?

Methods

The first question above is addressed through a Working Paper (Farrell et al, 2022), including an analysis of the wider contemporary policy and practice landscape, as well as potential implications for future research.

The second was addressed through a three-part rapid analysis (not available online): current international approaches; what should the results framework cover; and matters to be implemented.

The third question was addressed through a careful narrative review (Greenhalgh et al, 2018) that identified and analyzed some of the previous attempts to collect and present comparable international data specifically on the use of mental health law. The present paper consolidates the results of the previous work.

Results

Health and social care structures are similar in both the Republic of Ireland and Northern Ireland. The authors also identify similarities between the two legal frameworks at play:

1. Mental health is specifically defined in the Republic of Ireland as both the Mental Health Act 2001 and the Mental Health (Northern Ireland) Order 1986. “traditional 'mental disorder' and 'risk'-based legal frameworks that define the procedures by which people can be detained in inpatient settings.”

2. More broadly, the Assisted Decision-Making Act 2015 (ADMCA) and the Mental Capacity Act (Northern Ireland) 2016 (MCANI) are broadly similar by the authors in their guiding principles and functional approach to action. assessment of ability.

The authors note that the intention is that in due course the MCANI should replace the Mental Health (Northern Ireland) Order 1986 for everyone aged 16 and over.

The three conclusions that follow from the above are defined as:

1. The need for an agreed mental health dataset to facilitate comparison of service need, service delivery and outcomes for service users and carers.
2. An opportunity to develop an agreed approach to evaluating the implementation of relatively new capacity-based laws.
3. Potential benefits of developing a broader collaborative research agenda that can address a number of key priorities:
   “(i) legislative framework and services for children and youth;
   (ii) implementation and effectiveness of new capacity-based laws;
   (iii) the development and effectiveness of approaches to support autonomy and reduce the need for coercive intervention;
   (iv) providing specialist services and facilities for all island cooperation.

In terms of what a comprehensive approach to a mental health outcomes framework entails, the authors identify six key areas:

• social determinants of mental health;
• population needs;
• resources and inputs;
• activities and processes (eg number of therapy sessions provided, length of inpatient admissions and regularity of Tribunal hearings);
• professional report results; and
• service user and carer perspectives on outcomes.

The authors point out that data on the use of mental health and mental capacity law tend to focus on quantifying the use of powers rather than an approach that allows direct comparison of these indicators and other related data. context and “What matters is the experiences and outcomes for service users and carers when these powers are implemented and their impact over time.”

The authors of the study claim that “an inclusive strategy to develop a comprehensive, integrated and harmonized approach to data collection and analysis will be useful for citizens, policy makers and professionals”.

Results

The authors suggest that recent developments in mental health and mental capacity law and policy on the island of Ireland provide an opportunity for an integrated and harmonized approach to data collection and analysis on the island of Ireland. They further suggest the identified potential benefit of data matching on the island of Ireland:

increases opportunities to seek a broader international consensus on a core, common data set that will allow for further comparison and study of the use of mental health and mental capacity law among other countries. This type of cross-border collaboration and comparison also has the potential to demonstrate the benefits of data harmonization for law, policy and other areas of practice.

Strengths and limitations

A particular strength of the article (and the work it draws on) is that it brings a multidisciplinary and multinational perspective to examining the situation on the island of Ireland. Perhaps for historical reasons, work that directly compares the two jurisdictions is relatively rare, especially research conducted by those based in the two jurisdictions as opposed to purely foreign scholars. Research conducted not only by those interested in black letter law, but also by those interested in how this law affects and is affected by social and cultural conditions is also very useful. The authors are also aware of the limitations of the specific comparative exercise they have undertaken with regard to Ireland and the extent to which it is possible to generalize from such an exercise to consider the implications for other jurisdictions. don't try to torture the data to get results they can't produce.

A limitation is that the study group did not include anyone who clearly identified as having experience of being subject to mental health or mental capacity frameworks in any of the jurisdictions. Given the important focus on the involvement of such individuals in developing the type of metrics the authors propose in the paper, the absence of such a voice was unfortunate. An example of such a study that can be used to develop tools that allow this to be explored “relatively neglected but key aspect” (to use the authors' own words) is a paper in which Davidson himself contributed (Webb et al, 2020).

The main limitation of this study is the lack of co-production with experienced people.

Implications for practice

Two jurisdictions on the island of Ireland are engaged in different forms of legal reform in parallel in a relatively small geographical area. Although they are currently on parallel tracks, they will begin to diverge significantly, at least in formal legal terms, once MCANI becomes fully effective. At this time, Northern Ireland will have no separate mental health legislation for those aged 16 and over. Conversely, the long-running cycle of legal reform in the Republic of Ireland will, for example, create new capacity legislation that is closer to the UN Convention on the Rights of Persons with Disabilities than MCANI, without having a 'diagnostic' element. testing his ability and trying to reflect his will and preferences rather than basing decision-making on his best interests. But this legislation will stand alongside ADMCA (currently in force for about a year), legislation aimed at assessing, treating and, where necessary, detaining people with mental health conditions in the Republic of Ireland.

In principle, give the potential for quite radical disagreement, so this is a particularly opportune moment to publish the research that led to the current article. If its recommendations are followed, it will provide an important opportunity to determine whether and to what extent current and proposed legal changes are delivering real change (and to ask what real change looks like).

Furthermore, despite the modest nature of the authors' claims for implications for practice beyond the island of Ireland, the suggestions they provide are equally useful for those seeking to conduct research and develop policy proposals in other countries. As a start, developing and applying the frameworks they identify would be a very enlightening exercise to implement more widely in the UK.

Video chat

Watch Alex Ruck-Kine talk to Gavin Davidson about how to compare mental health and intellectual capacity frameworks across countries

Gavin and Alex from Rook Kin about Vimeo.

Statement of interest

I know several of the researchers (Davidson, Donnelly, Farrell and Kelly) and have discussed issues of comparative mental health and ability with them in the context of my own research.

Connections

Primary paper

Davidson, G, Agnew, E, Brophy, L, Campbell, J, Donnelly, M, Farrell, AM, Forbes, T, Frowde, R, Kelly, B, & McCartan, C (2024). Comparing mental health and mental capacity law data across borders: Challenges and opportunities. International Journal of Law and Psychiatry, 92101949.

Other references

Farrell, AM, Davidson, G, Donnelly, M, Agnew, E, Forbes, T, & Frowde, R (2022). Mental health policy and legislation on the island of Ireland. Edinburgh Law School Research Paper(2022/07).

Greenhalgh, T, Thorne, S, & Malterud, K (2018). Is it time to challenge the systematic false hierarchy over narrative reviews?. European Journal of Clinical Research, 48(6).

Rains, S, Zenina, T, Dias, M, Jones, R, Jeffreys, S, Branthonne-Foster, S, Lloyd-Evans, B & Johnson, S (2019). Changes in involuntary hospitalization patterns and legal frameworks: An international comparative study. Lancet Psychiatry6(5), 403-417.

Series, L (2022) Deprivation of liberty in the shadow of the institution (Bristol University Press).

Webb, P, Davidson, Rosalie Edge, David Falls, Fionnuala Keenan, Bernie Kelly, Aisling McLaughlin et al. “Service users' experiences and views of decision support.” Health and social care in the community 28, no. 4 (2020): 1282-1291.

Zinkler, M and Priebe, S (2002). Detention of the mentally ill in Europe – an overview. Acta Psychiatrica Scandinavica106(1), 3-8.