Psychosis and Bipolar Disorder: A Multisite Evaluation of the United Kingdom’s (UK’s) Section 136 of the Mental Health Act (1983) Detentions over a 4 Year Period ()
1. Background
Psychosis and bipolar disorder are associated with a significant risk of involuntary psychiatric hospital admission, often with police involvement [1]. A significant proportion of people with first episode psychosis (51% collectively; non-affective psychosis and affective psychosis 48% and 74% respectively) are admitted to hospital at the time of first episode presentation (especially where there is a shorter duration of untreated psychosis), and of these, 31% are admitted involuntarily [2]. In addition, there is a disparity between ethnic groups, with “Black African and Caribbean” and “Other White” (i.e., not “British White”) ethnicity people with psychosis more likely to have police and criminal justice system involvement in their admission compared to patients of “White British” ethnicity [3].
Section 136 (s136) of the Mental Health Act (1983) [4] is an emergency power that allows police to remove a person, believed to be “suffering from a mental disorder and in immediate need of care or control”, from a public place to a locally identified place of safety, usually a local mental health hospital, where a Mental Health Act assessment is then carried out.
Between 2010/11 and 2022/23, the number of s136 detentions in the United Kingdom (UK) had steadily increased from 14,111 to 34,685 [5] [6]. Despite various mental health transformations and initiatives, people with severe mental illness continue to face significant barriers to accessing appropriate care and treatment [7], and there is a lack of coordinated care [8]. Better understanding is needed in terms of local NHS Trust trends and outcomes of s136 detentions in relation to people with psychosis or bipolar disorder, in order to inform future effective service delivery and prevention efforts.
This evaluation was part of a larger overall multisite s136 detention evaluation over a 4-year period within Northamptonshire Healthcare NHS Foundation Trust (NHFT). For the purpose of the evaluation, year 1 was defined as August 2019 to July 2020, year 2 August 2020 to July 2021, year 3 August 2021 to July 2022, and year 4 August 2022 to July 2023.
The study aimed to identify the trend in yearly s136 detentions and repeat detentions in patients with severe mental illness (SMI), defined as those with psychosis or bipolar disorder, examine clinical and demographic characteristics, including first or repeated episode, and outcomes following s136 detention. There are no known studies to our knowledge of longer-term follow-up that examine trends and outcomes beyond 2020 (COVID-19 pandemic onwards), and also in particular focusing on SMI patients. Therefore, this is the first service evaluation review to do so.
2. Method
This was a retrospective case note review study of all s136 detentions, at two separate health-based “Places of Safety” (north and south in the county of Northamptonshire) between 1 August 2019 and 31 July 2023. A list of all s136 detentions during this time period was received from the Trust Mental Health Act Administration Office. Psychosis or bipolar disorder diagnoses were manually checked within clinical electronic patient notes. The diagnosis was defined by the International Classification of Diseases (ICD) 11th revision [9] (WHO, 2022): Schizophrenia (6A20), Schizoaffective Disorder (6A21), Acute and Transient Psychotic Disorders (6A23), Delusional Disorders (6A24), Schizotypal Disorder (6A22), Other specified primary psychotic disorder (6A2Y), Bipolar I Disorder (6A60), Bipolar II Disorder (6A61), and Cyclothymic Disorder (6A63). Patient self-reported ethnicity based on pre-defined categories. The data collected were anonymised. Data were analysed using descriptive statistics, including frequencies, percentages and means. The evaluation was agreed by the Trust Clinical Audit and Effectiveness Committee.
3. Results
Over the 4-year study period, there were a total of 1892 s136 detentions. A total of 383 patients (unique individuals) had a diagnosis of psychosis or bipolar disorder, representing 20% of the overall s136 detentions.
Of this cohort, 1 in 5 (20%) patients were first episode psychosis (ICD 11 6A23.0: Acute and transient psychotic disorder, first episode [9] [WHO, 2022]), and two-thirds (68%) of patients were repeated episode psychosis (6A20, 6A21 6A23, 6A24, 6A22, 6A2Y [9] [WHO 2022]). A smaller proportion of patients (18%) were bipolar patients (6A60, 6A61, 6A63 [WHO, 2022]). The trend in s136 detentions in this patient cohort appeared cyclical, with an upward trend in spring and reaching a peak in summer (See Figure 1). In contrast, during the early COVID-19 period, there appeared to be a flattening around summer following a spring peak.
Figure 1. S136 trends (psychosis or bipolar).
The number of patients with psychosis or bipolar diagnoses (and proportion of total) detained under s136 showed a consistently increasing trend over the 4-year study period (see Table 1).
A third of patients (35%) had more than one s136 detention during the evaluation period, and of those, 15% had 3 or more detentions.
Table 1. Yearly number of patients detained under s136 with SMI diagnosis.
|
SMI (N) |
SMI (%) |
Overall (N) |
Year 1 |
65 |
15% |
449 |
Year 2 |
93 |
19% |
493 |
Year 3 |
102 |
20% |
504 |
Year 4 |
123 |
28% |
446 |
TOTAL |
383 |
20% |
1892 |
3.1. Age and Gender
The mean age was 39 years (range 17 - 76 years), with the majority of patients (69%) male.
3.2. Ethnicity
Over half of patients were of “White British” ethnicity (58%), with “other White ethnicity” 16%, “Black African” 10%, “Black Caribbean” 5%, and Asian 6%, Compared to Northamptonshire population statistics, there is an over-representation of “other White” ethnic group (16% compared to 4.7%), combined “Black” ethnic group (15% v 4%; ) and “Asian” group (6% v 4.5%). A breakdown in ranking of the two largest ethnic minority groups can be seen in Table 2 & Table 3.
Table 2. Black African group (ranking from highest to lowest).
Rating from the top higher to lower percentage |
1 |
Ghana |
37% |
2 |
Nigeria |
21% |
3 |
Somalia |
16% |
4 |
Zimbabwe |
13% |
5 |
Liberia |
5% |
6 |
Unknown |
5% |
7 |
Kenya |
3% |
Table 3. Other white group (ranking from highest to lowest).
Rating from the top higher to lower percentage |
1 |
Romania |
26% |
2 |
Poland |
16% |
3 |
Moldova |
13% |
4 |
Latvia |
8% |
5 |
Portugal, USA |
5% each |
6 |
Lithuania, Hungary, Bulgaria, Italy, South Africa |
3% each |
7 |
Albania, Germany, Cyprus, Greece, Afghanistan, Türkiye, New Zealand |
1.6% each |
3.3. Main Risk Profile
Main risk profile included that of aggression (49%), followed by vulnerability (40%), suicidality (8%), actual/attempted or threat of arson (2%) and sexual disinhibition/indecent exposure/assault (1%). Documented use of, or in possession of weapons at the time of s136 detention, were found in 10% of patients.
3.4. Outcomes
All percentages reported are based on 383 patient group. 92% (n = 353) of patients were admitted to hospital following the s136 detention, of these, 88% (n = 311) detained. Of note is also that although this group of patients represented only 20% of the overall s136 detentions during the evaluation period, the group made up 52% of all admissions following s136 detention.
40% of patients detained under s136, were under the care of mental health services. Over a third (36%) of patients with repeated psychosis (of this group, the main diagnoses were schizophrenia and schizoaffective disorder) were not under mental health services, thus had had previous contact but been discharged from services, and were returning to services via s136 detention.
Although the majority of patients were repeated episode (thus known to services previous or current, with established mental health diagnoses), only 7% of patients detained were under section 3 of the MHA (1983), 93% of detention outcomes were under section 2 of the MHA (1983).
4. Discussion
Although representing only 20% of all Section 136 detentions, this cohort accounted for 52% of admissions following detention, with an increasing trend in the number of SMI patients detained each year. Various initiatives within the local NHS Trust between 2014 and 2023 had been established to enable improved access to care and alternatives to divert from s136 admission. These included the establishment of the mental health street triage with police service (entitled Op Alloy), liaison and diversion teams in police custody centres, the establishment of two mental health crisis recovery houses in the county (north and south), and mental health crisis cafes in the larger urban towns. The NHS Trust also has an established early intervention in psychosis service (EIP). Community mental health teams (CMHTs) in the local NHS Trust underwent a transformation from 2023 following publication of the UK government’s “NHS Long Term Plan” which may have had an impact.
From the evaluation, a notable proportion of patients with repeated episode were detained under s136 whilst under the care of a community mental health team (CMHT). There is a need to prevent mental illness from developing into a mental health crisis. This requires a coordinated, consistent, assertive approach aimed at reducing risk factors and promoting and building on protective factors. Non-adherence to medication (on a spectrum that includes overt/covert and complete or partial) is one of the main preventable triggers for relapse, with up to 2.5 - 5.0 fold increased risk in this context [10] [11]. Factors that enhance and enable continuous adherence to treatment include good illness insight (psychological and psychoeducational work to address and support this), a positive therapeutic alliance with clinicians (thus a need for relationship building and engagement), family support (family therapy and education) and treatment related such as few side effects (physical health and side effect monitoring), efficacy of treatment (less symptoms experienced; regular review), support to address substance misuse, and the use of long-acting injectable (LAI) or “depot” antipsychotic medication [12], as well as earlier appropriate use of clozapine in treatment-refractory illness (this remains underutilised) [13].
In our evaluation, over a third (36%) of patients with repeated episode psychosis were not under the care of mental health services at the time of their section 136 detention. This suggests potential gaps in continuity of care and highlights the need to review discharge pathway policy, where disengagement is a common phenomenon [14] [15]. Disengagement has consistently been associated with younger age, male and from ethnic minority background, and people with early onset psychosis, poor medication adherence, and substance misuse are at particular risk of disengagement [16] [17]. For first episode psychosis, EIP services already provide early access to treatment (national standard of two weeks referral to access time) [18]; however, there is still more to be done, including targeted psychoeducation, reducing stigma to enable earlier help-seeking and recognition of early warning signs, and review of local NHS Trust single point of access (easier navigation and training of staff to recognise and identify early psychosis or bipolar disorder).
People from ethnic minority backgrounds are at increased risk of psychosis, and are at disproportionate increased risk of coercive entry into mental health care (and police involvement), less primary care intervention, and increased rates of involuntary admission to hospital [19]-[22]. Our evaluation showed an over-representation of people from ethnic minority groups detained under section 136 as a pathway into inpatient care. This disparity is likely due to a complex interplay of multiple variables, including stigma, systemic bias (which includes inequity in access and adverse pathways of care), cultural and other health related factors [20] [23] [24], and therefore a multifaceted approach is needed to address these, in order to improve earlier help-seeking and access to care, and support services to deliver culturally informed and competent care and treatment.
Seasonal patterns in schizophrenia admissions have been shown to have a summer peak, with some studies also reporting a winter peak, and schizoaffective disorder admission seasonal patterns showing higher rates in the autumn/fall months [25]-[27]. Bipolar disorder and manic episode admissions show a spring/summer peak [27] [28]. The seasonal trend in s136 detentions seen in this evaluation is similar to the seasonal admission trends in SMI (main peak for SMI overall is spring/summer), and likely a reflection of the coercive entry pathway into inpatient services for this patient cohort. Seasonal changes have been postulated as a risk factor for relapse and acute exacerbation of symptoms in patients with SMI [29]. Seasonal patterns of admission (and from our descriptive observation evaluation s136 detentions) have a predictive value for healthcare planning. This creates the opportunity for mental health services to adjust with early coordinated operational planning, such as increasing efforts for community proactive and assertive prevention of relapse, adjusting staff capacity, and inpatient bed capacity and flow (similar to emergency department core winter pressure strategies).
The evaluation period precedes the implementation of the “Right Care, Right Person” national partnership framework [30] in Northamptonshire (introducing a threshold to assist police, health and social care staff in making the decision when to attend incidents). Little is known about the impact locally in terms of outcomes for s136 detentions following its implementation, although early reports suggest police are still being called out to mental health crisis incidents; however, less likely to agree to respond. Further evaluation is needed to understand the impact (including any change in demand on other NHS services such as emergency departments), and in particular in patients with psychosis or bipolar disorder.
5. Limitations
Northamptonshire’s general population ethnic composition is different from other UK counties (all UK counties have their own specific ethnic compositions), reducing generalisability. However, results are in line with other studies in terms of disproportionately increased risk in coercive entry and compulsory admission to hospital in psychosis or bipolar disorder and those from ethnic minority backgrounds.
This was a large multi-site service evaluation over a 4-year period, and a real-world representation of s136 detentions in a typical NHS Trust. Results of descriptive characteristics need to be interpreted with caution, given no control group and therefore no assumption of causality to be made, and the potential for reporting bias with information based on police and healthcare staff reports within the electronic clinical note system. Factors influencing outcomes from s136 detention are likely to be multifactorial in nature. Factors such as substance misuse, housing instability, prior admissions, or illness severity were not extracted from the case notes and may affect detention outcomes.
6. Conclusion
People with psychosis or bipolar disorder, although a small proportion of overall s136 detentions, represent the majority of admission outcomes. There is a need for NHS Trusts and commissioning groups to focus on culturally informed service provision and better proactive care and treatment, and address gaps in community access and service provision in order to reduce crisis-driven care and resultant coercive entry pathways into care. Further evaluation will be needed to examine the impact of the UK government’s Right Care Right Person national initiative.