Commentary: A Comparative Review of Involuntary Admission of People with Mental Illness in China and Barbados

Criteria for Involuntary Admission of the Mentally Ill

We note a potentially problematic element in the National Act. If a person poses significant risk to self and there is no family member willing or able to initiate medical protective admission, the processes to facilitate protective custody appear unspecified. Risk to self is not a basis for emergency admission; therefore, persons at risk to self but without identifiable family members cannot be admitted involuntarily.

In Barbados, both risk to self and risk to others constitute a legal basis for involuntary admission under two distinct pathways: medical recommendation (MR) and hospital order (HO).⁶

Medical recommendation involves an application, signed by a parent or guardian of the patient, requesting psychiatric evaluation for involuntary admission. Subsequently, two medical doctors (not necessarily psychiatrists) must independently evaluate the patient. The application contains the facts on which the doctors have based their opinion and a statement to the effect that the person has a mental disorder and is likely to benefit by temporary treatment.

A hospital order allows a court to order an accused person who appears to have a mental disorder to be admitted to a mental hospital. A second category of HO allows a ministry-appointed mental health officer (MHO) to recommend that a senior member of the police take a person into custody without warrant on the basis of behavior or appearance evidencing mental disorder. The Minister of Health can designate any person employed by the Psychiatric Hospital as an MHO: mainly community psychiatric nurses and a few consultant psychiatrists.

Although Barbadian legislation provides a mechanism of hospitalization for persons at risk of self-harm, with or without the involvement of family, in practice, there are some barriers to admission. No MHO is employed at the Queen Elizabeth Hospital (QEH), the sole public general hospital, which provides voluntary inpatient and outpatient psychiatric services. This means that if a person thought to be at risk to self or others is evaluated at the QEH and the relative is unwilling to sign the request for evaluation, that person cannot be admitted involuntarily. Instead, the patient is discharged to the care of relatives if the family is so willing.

However, in other situations, relatives may be unwilling to initiate a request for evaluation because of fear of retaliation by the patient resulting in physical or emotional risk; these are legitimate concerns, particularly in instances in which emergency responses may be delayed. We have long opined that relatives should not determine risk and the need for admission. Instead, a mental health professional should request evaluation for involuntary admission. The present system all too often requires relatives to function as (untrained) clinicians or to expose themselves to avoidable risk.

Procedures of Initial Assessment and Decision-Making

Shao and Xie note the stipulation that a registered psychiatrist conduct the initial assessment, and in some jurisdictions, specific experience is required. Barbadian law requires two medical practitioners for the evaluation who must not bear any affinity to the patient or to each other. There is no requirement regarding the specialty or years of experience. In practice, one practitioner is usually a psychiatrist or psychiatrist in training.

Physicians with postgraduate training in psychiatry are best qualified to make accurate diagnoses and develop treatment plans. Particularly in the case of MR admission, specialized training is important to protect patient rights because the periods of commitment legally (though not commonly in practice) could last up to six months without review.

Notably, China's National Act allows “affiliated units, neighborhood committees or villagers' committees where the patient resides” to make decisions on admission, with the police having a limited role in that process. This further underscores the concern expressed above regarding the use of lay people, who in this circumstance may know even less about the patient than a relative, to make clinical decisions. From our perspective, this raises serious questions about the level of training and potential conflict of interest of these groups.

Periods of Detention

As the authors point out, the local regulations “lack effective oversight … review mechanisms … clear time limitations, and specific discharge procedures” (Ref. 1, p 36). Clear periods of detention or review should be included in the National Act. The National Act must become the gold standard for China as legislation and the treatment of persons with mental disorders change to meet international standards.

In the Barbadian context, the case of an MR patient must be reviewed at least once every six months and the medical certification is valid for 12 months. In addition, the senior consultant psychiatrist may change the status of an MR patient to that of a voluntary patient. A patient on HO may be admitted for up to 72 hours (or up to 8 weeks if sent via court).

Discharge and Complaint Procedures

Cultural norms in China may put the distinction made between procedures for discharge or complaint of a person at risk to self versus risk to others in a different context than that in which we have trained and worked. We nonetheless wish to express concern that legal protections for those at risk for self-harm appear to be less stringent than those for persons who pose risk to others.