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Reporting Treatment to the Chief Psychiatrist

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Electroconvulsive Therapy (ECT)

Under section 201 of the Mental Health Act 2014 (MHA 2014) the person in charge of a mental health service, where Electroconvulsive Therapy (ECT) is performed, needs to provide monthly statistics on the use of ECT to the Chief Psychiatrist. The head of service making the report must use the approved form – Form 13 – ECT Statistics.

These statistics must include:

  • The number of people in respect of whom a course of ECT therapy at the mental; health service was completed or discontinued during the month;
  • The number of those people who were children;
  • The number of those people who were voluntary patients;
  • The number of those voluntary patients who were children;
  • The number of those people who were involuntary patients;
  • The number of those involuntary patients who were children;
  • The number of those people who were mentally impaired accused (MIA) under the Criminal Law Act detained at an authorised hospital;
  • The number of those MIA who were children;
  • The number of treatments with ECT in each of those courses;
  • The number of those courses that were courses of Emergency ECT;
  • Details of any serious adverse event that occurred, or is suspected of having occurred, during or after any of those courses.

Serious adverse events include:

  • Premature consciousness during a treatment;
  • Anaesthetic complications (e.g. cardiac arrhythmia) during recovery from a treatment;
  • An acute and persistent confused state during recovery from a treatment;
  • Muscle tears or vertebral column damage;
  • Severe and persistent headaches;
  • Persistent memory deficit.

Emergency Psychiatric Treatment (EPT)

Under section 204 of the MHA 2014 the medical practitioner who provided Emergency Psychiatric Treatment must provide the Chief Psychiatrist with a copy of an approved Form 9A.

The following information must be provided:

  • The name of the person provided with the treatment;
  • The name and qualification of the practitioner who provided the treatment;
  • The names of any other people involved in providing the treatment;
  • The date, time and place the treatment was provided;
  • Particulars of the circumstances in which the treatment was provided;
  • Particulars of the treatment provided.

Urgent Non-Psychiatric Treatment

Under section 242 of the MHA 2014 the person in charge of the Authorised Hospital must report the provision of Urgent Non-Psychiatric treatment to the Chief Psychiatrist through submission of the approved Form 9B.

The form must contain the following information:

  • The name of the person provided with the treatment;
  • The name and qualification of the practitioner who provided the treatment;
  • The names of any other people involved in providing the treatment;
  • The date, time and place the treatment was provided;
  • Particulars of the circumstances in which the treatment was provided;
  • Particulars of the treatment provided.

Treatment decision different to the Advance Health Directive (AHD) of Involuntary patients

Under section 179 of the MHA 2014 the patient’s psychiatrist must ensure that a medical practitioner, in deciding what treatment will be provided to the patient, has regard to the patient’s wishes in relation to the provision of treatment, to the extent that it is practicable to ascertain those wishes.

If the treatment decision made by the medical practitioner is inconsistent with a treatment decision in the patient’s Advance Health Directive, or a term of an enduring power of guardianship, made by the patient, who is involuntary, than the reason the decision was made needs to be recorded.

Services must report a treatment decision different to the Advance Health Directive of involuntary patients on the approved form:

The patient’s psychiatrist must ensure that a copy of this form is provided to:

  • the patient;
  • if the patient has an enduring guardian or guardian — the enduring guardian or guardian;
  • if the patient has a nominated person — the nominated person unless the nominated person is not entitled, for the reason referred to in section 269(1), to be given a copy;
  • if the patient has a carer — the carer unless the carer is not entitled, for the reason referred to in section 288(2) or 292(1), to be given a copy;
  • if the patient has a close family member — the close family member unless the close family member is not entitled, for the reason referred to in section 288(2) or 292(1), to be given a copy;
  • the Chief Psychiatrist;
  • the Chief Mental Health Advocate.

If the treatment decision that was made is the same as an earlier treatment decision and the people listed 1-7 above were given a copy of that earlier decision the patient’s psychiatrist does not need to provide additional copies of the treatment decision.

Refusal of further opinion request by psychiatrist

Under section 183 of the MHA 2014 a request for an additional opinion may be refused.

This applies if —
(a) a further opinion about the treatment being provided to a patient has been obtained under section 182; and
(b) a person in relation to whom that provision applies requests that the patient’s psychiatrist or the Chief Psychiatrist obtain an additional opinion under that provision about the treatment being provided to the patient.

The patient’s psychiatrist or the Chief Psychiatrist may refuse to comply with the request if satisfied that, having regard to the guidelines published under section 547(1)(d) of the MHA 2014 for that purpose, the additional opinion is not warranted.

Services must report the refusal of a further opinion request by psychiatrist on the approved form:

If the patient’s psychiatrist decides not to comply with the request for an additional opinion they must:

  • file a record of the decision and reasons for it; and
  • give a copy to the patient; and
  • if the opinion was requested by a person other than the patient, give that person a copy; and
  • give a copy to the Chief Psychiatrist.

Segregation of children from adult inpatients

Segregation of children from adults, under the Mental Health Act 2014 (Part 2 Division 1 Section 4), a child is defined as a person who is under 18 years of age.

Whenever a child is admitted to any mental health service (including MHOAs or MHOA equivalents) where adults are also admitted, MHA 2014 s.303 must be applied. This includes when a child is admitted to a youth inpatient mental health service and applies whether the child is admitted as a voluntary or involuntary inpatient.

When considering and applying MHA 2014 s.303, the person in charge of the mental health service must first be satisfied that:

  • the mental health service can provide the child with treatment, care and support that is appropriate having regard to the child’s age, maturity, gender, culture and spiritual beliefs; and
  • the treatment, care and support can be provided to the child in a part of the mental health service that is separate from any part of the mental health service in which adults are provided with treatment and care if, having regard to the child’s age and maturity, it would be appropriate to do so.

A report to the Chief Psychiatrist must be completed at admission on one of the following forms:

The person in charge of the mental health service, when a child is being admitted as an inpatient, must give to the child’s parent or guardian a copy of the form or written report setting out:

  • the reasons why the person in charge is satisfied of the matters referred to above (section 303 2(a) and (b));
  • and the measures that the mental health service will take to ensure that, while the child is admitted as an inpatient, the child is protected and the child’s individual needs in relation to treatment and care are met.

This report must also be filed in the patients medical record and a copy provided to the Chief Psychiatrist.

See also – MHA 2014 FAQ: Segregation of children from adult inpatients (MHA s.303)

Off-label prescription to a child who is an involuntary patient

Under section 304 of the MHA 2014 the provision of off-label treatment to any child who is an involuntary patient must be reported to the Chief Psychiatrist.

 

Services must report off-label prescription to a child on the approved form:

The report needs to contain:

  • the decision to provide the off-label treatment, including a description of the off-label treatment; and
  • the reasons for the decision.

Approved product information: for registered therapeutic goods, means the product information approved under the Therapeutic Goods Act 1989 (Commonwealth) in relation to the registered therapeutic goods;

Off-label treatment: means the use of registered therapeutic goods other than in accordance with the approved product information for the registered therapeutic goods;

Product information: has the meaning given in the Therapeutic Goods Act 1989 (Commonwealth) section 3(1);

Registered therapeutic goods: means registered goods as defined in the Therapeutic Goods Act 1989 (Commonwealth) section 3(1).

A copy of the form should also be filed in the patients records.

Further Information from the Child & Adolescent Mental Health Service

There is increasing scrutiny around the prescription of “off label” psychotropic medications for children and adolescents. The Council of Australian Therapeutic Advisory Groups (CATAG) report “Rethinking medicines decision making in Australia: Guiding Principles for the quality use of off-label medications” in November 2013 reflected this.  It provided guiding principles and specific recommendations for paediatric population. There was also a study released in June 2014 from the University of Sydney, and Drug Utilisation Subcommittee of PBAC that tracked the  marked increase in use of off label psychotropic medication in children and adolescents and expressed significant concerns about this trend and lack of monitoring.  Perhaps as a result, a late amendment to the Mental Health Act 2014 included a clause that a record must be made of off-label prescribing in involuntary paediatric inpatients and that the Chief Psychiatrist must be notified.

Off-label treatment simply means the use of registered therapeutic goods other than in accordance with the approved product information for the registered therapeutic good. If the medication is being used outside of the age group, dose, indication or route as mandated by TGA registration and/or official manufacturers Product Information (PI) then it constitutes off-label prescribing. Most pharmaceutical companies have not gone through the process of registering psychotropic medications for children and adolescents, hence they are off label. This does not in itself indicate whether there is an evidence base to support prescription.

To assist CAMHS clinicians to make informed decisions about prescribing off label, and to create a platform to obtain informed consent the following resources have been developed and will be placed in the CAMHS Medication Safety Toolbox.

  1. Off-Label Psychotropic Prescribing Guide for CAMHS Clinicians: This guideline is a quick-reference guide to determine the licensed age, indication and dosage for psychotropic medication used in paediatric patients. This guide also contains a very brief description of the level of evidence for use of the psychotropic medication in major international clinical guidelines. This guide is not intended to be used as a primary reference for medication dosages. The guideline should also be used in conjunction with Appendix 1 – Responsibilities of CAMHS Clinicians, and Appendix 2 – Flowchart for assessing appropriateness of off-label medicines use.
  2. Consent for Off-Label Medication Use form: CAMHS clinicians are required to attain consent for the use of off-label medication from the parent when prescribing off-label treatments. A completed signed consent form should be included in the patient’s permanent record.

Please ensure you use both resources. This is an important medico-legal and medication safety initiative.

Inpatient treatment order in general hospital (attachment to Form 6B)

When a person is in a general hospital under a Form 6B – Inpatient treatment order in a general hospital, at the end of every 7 days the treating psychiatrist must report to the Chief Psychiatrist using the Form 6B attachment.

Definition of treatment: the provision of a psychiatric, medical, psychological or psychosocial intervention intended (whether alone or in combination with one or more other therapeutic interventions) to alleviate or prevent the deterioration of a mental illness or a condition that is a consequence of a mental illness, and does not include bodily restraint, seclusion or sterilisation (s4).

See also the Process and Instruments of Delegation.

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