Psychiatry: assessment, treatment and the law

• Assessment: The Psychiatric History | Mental State Examination | Risk Assessment | Physical Causes of Psychiatric Symptoms | Classification and Formulation
• Treatment and services: Mental Health Services | Psychological Therapies | ECT and Other Physical Treatments | Physical Health in Severe Mental Illness
• Law and ethics: The Mental Health Act 1983 | Mental Health Act Sections | Treatment, Leave and Aftercare Under the MHA | The Mental Health Act 2025 | The Mental Capacity Act 2005 | Deprivation of Liberty | MHA or MCA? | Confidentiality, Driving and Firearms
• Revision: Drug and Treatment Reference Table | Spot the Answer | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🧠 Psychiatric assessment, treatment and the law — about 1 in 4 adults has a mental health problem each year, and every doctor sees them: in the emergency department, on the medical wards and in general practice. The core skills are a good history, a structured mental state examination, a needs-based risk assessment, ruling out physical causes, and knowing when to use the Mental Health Act or the Mental Capacity Act.
Your four questions for every patient: What is the main problem (mood, anxiety, psychosis, cognition, substance use)? Could there be a physical cause? Is the person safe — to themselves, from others, and to others? Do they have capacity to make this decision, and do they need the protection of mental health law?

The Psychiatric History

• Setting — a private, safe room; know the exits; tell staff where you are; read the notes and risk history first; use an interpreter (not family) when needed.
• Presenting complaint — in the patient's own words; why now?
• History of presenting complaint — onset, duration, course, triggers; key screening questions:
  • Mood — low mood, loss of interest, sleep, appetite, energy, concentration, guilt, hopelessness; elevated mood, reduced need for sleep.
  • Anxiety — worry, panic attacks, avoidance, obsessions and compulsions, flashbacks.
  • Psychosis — hearing voices, feeling watched or followed, special messages, thoughts being interfered with.
  • Self-harm and suicidal thoughts — always ask directly.
  • Thoughts of harming others.
• Past psychiatric history — diagnoses, admissions (and under which section), treatments and response, self-harm, contact with services.
• Medical history and medication — including over-the-counter and herbal drugs, adherence, side effects; allergies.
• Drugs and alcohol — type, amount, pattern, dependence features (AUDIT for alcohol); smoking and vaping; gambling.
• Family history — mental illness, suicide, substance misuse, dementia.
• Personal history — birth and development, childhood (adversity, abuse, care), education, work, relationships, sexual history, children, forensic history (offences, violence, prison).
• Social circumstances — housing, finances, benefits, debts, carers, dependants (children — safeguarding), social support, daily activities.
• Premorbid personality — how they were before, how they cope with stress.
• Collateral history — from family, GP, carers or police (with consent where possible; necessary in some cases without it).

Mental State Examination

• First-rank symptoms (Schneider) — suggest schizophrenia (but not diagnostic):
  • Auditory hallucinations — third-person voices discussing the patient, running commentary, thought echo.
  • Thought alienation — thought insertion, withdrawal, broadcasting.
  • Passivity phenomena — feelings, actions or impulses controlled by an outside force.
  • Delusional perception — a normal perception given a sudden delusional meaning.

Risk Assessment

• Areas of risk:
  • To self — suicide, self-harm, self-neglect (not eating or drinking), accidental harm (e.g. when manic or confused).
  • To others — violence, threats, specific named victims, children (safeguarding).
  • From others — exploitation (financial, sexual), abuse, domestic violence.
• NICE (NG225) — don't use risk assessment tools or scales (e.g. SAD PERSONS) to predict future suicide or self-harm, or to decide who gets treatment or discharge. They perform poorly; most suicides happen in people judged "low risk".
• Instead — a needs-based psychosocial assessment: understand what has happened, current thoughts and plans, the person's circumstances, strengths and what would help.
• Factors to explore (to understand, not to score):
  • Suicidal thinking — frequency, intent, plans, preparations (notes, saving tablets, settling affairs), access to means, rehearsal.
  • Recent self-harm — what happened, how lethal they believed it was, planning, precautions against being found, regret at survival.
  • History — previous attempts (the strongest predictor), mental illness, substance misuse, impulsivity, violence.
  • Current state — hopelessness, severe depression, psychosis (command hallucinations), agitation, intoxication.
  • Circumstances — recent loss (relationship, job, bereavement), debt, legal problems, social isolation, chronic pain or illness, recent discharge from psychiatric hospital (high-risk period).
  • Groups — men, middle age, people who are unemployed or socially isolated, LGBTQ+ people, people in prison, farmers, doctors, veterinary surgeons and nurses.
  • Protective factors — family (especially children), reasons for living, faith, engagement with help, future plans.
• Risk to others — previous violence (the best predictor), substance misuse, paranoid delusions about a specific person, command hallucinations, poor adherence, anger, access to weapons.
• Management — a collaborative safety plan, means restriction, increased contact (crisis or home treatment team), admission (informal or under the MHA) if needed, involvement of family (with consent), safeguarding referrals; document the reasoning.

💡 Clinical Pearl: Ask directly: "Have you had thoughts of ending your life?" Asking does not plant the idea — it is the only way to find out, and most people are relieved to be asked.

Physical Causes of Psychiatric Symptoms

• Think "organic" if — new symptoms in older age, sudden onset, fluctuating consciousness or confusion, visual hallucinations, abnormal neurological signs, no previous psychiatric history, recent head injury, physical illness, new medication.
• Causes:
  • Delirium — infection, drugs, metabolic disturbance (the commonest "psychiatric" presentation on medical wards).
  • Endocrine — thyroid (hyper — anxiety, mania; hypo — depression, "myxoedema madness"), Cushing's (depression, psychosis), Addison's, hyperparathyroidism (hypercalcaemia — depression), hypoglycaemia (insulinoma), phaeochromocytoma (panic).
  • Neurological — dementia, brain tumour (frontal — personality change), stroke (post-stroke depression), epilepsy (temporal lobe — psychosis, déjà vu), Parkinson's disease (depression, psychosis with medication), MS, Huntington's, head injury, autoimmune encephalitis (anti-NMDA receptor — young women with psychosis, seizures, movement disorder).
  • Infections — HIV, syphilis (general paralysis of the insane), encephalitis, Lyme disease.
  • Deficiencies — B12, folate, thiamine (Wernicke's), niacin (pellagra).
  • Drugs — steroids (mania, psychosis, depression), levodopa, isotretinoin, interferon, mefloquine, efavirenz, anabolic steroids, beta-blockers; alcohol and illicit drugs (intoxication and withdrawal).
  • Other — SLE (neuropsychiatric lupus), Wilson's disease (young people with psychiatric symptoms and liver disease), porphyria.
• Baseline tests — FBC, U&E, LFTs, TFTs, calcium, glucose and HbA1c, B12 and folate, CRP, lipids; urine drug screen; consider HIV and syphilis serology, ECG (before antipsychotics), CT or MRI brain, EEG, autoimmune antibodies.

Classification and Formulation

• Classification systems — ICD-11 (WHO — used in the NHS) and DSM-5-TR (American Psychiatric Association — used in research).
• Main groups:
  • Neurodevelopmental (ADHD, autism, learning disability).
  • Schizophrenia and other psychotic disorders.
  • Mood disorders (depression, bipolar).
  • Anxiety and fear-related disorders; OCD and related disorders.
  • Disorders associated with stress (PTSD, adjustment disorder, prolonged grief disorder).
  • Dissociative disorders; bodily distress and functional disorders.
  • Feeding and eating disorders.
  • Substance use and addictive behaviours (including gambling and gaming).
  • Personality disorders.
  • Neurocognitive disorders (delirium, dementia).
• Formulation — a summary that explains why this person has this problem now, using the "4 Ps":
  • Predisposing factors (genetics, childhood adversity, personality).
  • Precipitating factors (triggers — loss, stress, drugs).
  • Perpetuating factors (what keeps it going — isolation, substance use, avoidance, poor adherence).
  • Protective factors (support, strengths).
• Consider each factor at the biological, psychological and social level (the biopsychosocial model) — this guides the management plan.

Mental Health Services

• Primary care — the GP manages most depression and anxiety; mental health practitioners in GP surgeries.
• NHS Talking Therapies (formerly IAPT) — self-referral for anxiety and depression; stepped care: guided self-help and computerised CBT (step 2), then high-intensity CBT and other therapies (step 3).
• Community mental health teams (CMHTs) — psychiatrists, nurses, psychologists, occupational therapists, social workers; care coordination under the Care Programme Approach (being replaced by more personalised care planning).
• Crisis resolution and home treatment teams — 24-hour assessment and intensive support at home as an alternative to admission; NHS 111 "option 2" for mental health crisis.
• Liaison psychiatry — in general hospitals: self-harm, delirium, mental illness in physical illness, capacity questions.
• Early intervention in psychosis (EIP) — first episode psychosis, ages 14–65; treatment within 2 weeks of referral.
• Specialist services — perinatal, eating disorders, addictions, old age psychiatry, learning disability, forensic, personality disorder, CAMHS.
• Inpatient care — acute wards, psychiatric intensive care units (PICU), rehabilitation units; informal (voluntary) or detained.
• Voluntary sector — Samaritans (116 123), Mind, Rethink, SHOUT (text 85258), crisis cafés and safe havens.

Psychological Therapies

ECT and Other Physical Treatments

• Electroconvulsive therapy (ECT) — a brief, controlled seizure induced under general anaesthesia and muscle relaxant:
  • Uses (NICE TA59) — severe, life-threatening depression (not eating or drinking, high suicide risk, depressive stupor), psychotic depression, catatonia, prolonged or severe mania, treatment-resistant depression; often the fastest-acting treatment.
  • Course — usually twice a week, 6–12 sessions.
  • Side effects — memory problems (around the time of treatment — retrograde and anterograde; usually improve), confusion after treatment, headache, muscle aches, anaesthetic risks.
  • Cautions — raised intracranial pressure, recent MI or stroke, uncontrolled heart failure, aneurysms (relative contraindications — anaesthetic and cardiac review).
  • Consent — needed if the patient has capacity, even if detained (an emergency exception under section 62; a valid advance decision refusing ECT must be respected).
• Repetitive transcranial magnetic stimulation (rTMS) — magnetic stimulation of the prefrontal cortex; treatment-resistant depression; no anaesthetic.
• Esketamine nasal spray — licensed for treatment-resistant depression but not recommended by NICE; ketamine used in some specialist services.
• Light therapy — seasonal affective disorder.
• Medication — antidepressants, antipsychotics, mood stabilisers, anxiolytics and hypnotics (see the relevant chapters).

Physical Health in Severe Mental Illness

• People with severe mental illness (schizophrenia, bipolar disorder, other psychoses) die 15–20 years earlier than average — mostly from cardiovascular disease, respiratory disease, diabetes and cancer, not suicide.
• Why — smoking (very common), antipsychotic weight gain and metabolic effects, poor diet, inactivity, substance misuse, poverty, diagnostic overshadowing (physical symptoms blamed on mental illness), poor access to care.
• Annual physical health check (GP and mental health services) — weight and BMI, waist, BP, pulse, HbA1c or glucose, lipids, smoking, alcohol and drugs, cancer screening, dental and eye health, sexual health, medication side effects (prolactin, ECG).
• Action — stop-smoking support (varenicline, cytisine, NRT, e-cigarettes), statins, diabetes management, healthy lifestyle programmes; consider switching antipsychotics with fewer metabolic effects; metformin can limit antipsychotic weight gain.
• Clozapine and smoking — stopping smoking raises clozapine levels (toxicity); starting raises clearance — check levels.

The Mental Health Act 1983

• What it does: Allows people with a mental disorder to be assessed and treated in hospital without their consent when this is needed for their health or safety, or to protect others, and less restrictive options won't work. Applies in England and Wales (Scotland and Northern Ireland have their own laws).
• Mental disorder — "any disorder or disability of the mind". Dependence on alcohol or drugs alone is not a mental disorder under the Act (but related conditions — e.g. alcohol-induced psychosis — are).
• Learning disability — only counts for longer-term sections (e.g. section 3) if associated with abnormally aggressive or seriously irresponsible conduct.
• Key people:
  • Approved Mental Health Professional (AMHP) — usually a social worker (or nurse, OT, psychologist) who makes the application and coordinates the assessment; checks less restrictive alternatives.
  • Section 12 approved doctor — a doctor with expertise in mental disorder (usually a psychiatrist); one of the two medical recommendations should ideally come from a doctor who knows the patient (often the GP).
  • Approved clinician / responsible clinician (RC) — the clinician in charge of the detained patient's care.
  • Nearest relative — has rights to be consulted, to apply for or object to certain sections, and to request discharge (being replaced by a "nominated person" under the 2025 Act).
  • Independent Mental Health Advocate (IMHA) — helps detained patients understand and use their rights.
• Guiding principles (Code of Practice) — least restrictive option and maximising independence; empowerment and involvement; respect and dignity; purpose and effectiveness; efficiency and equity.
• Patients' rights — information about rights (section 132), appeal to the First-tier Tribunal (Mental Health) and to hospital managers, an IMHA, the Care Quality Commission oversees detention.

Mental Health Act Sections

⚠️ Safety Pearl: Section 5(2) can't be used in the emergency department — patients there aren't inpatients. If an ED patient with a mental disorder lacks capacity and is trying to leave in a dangerous state, use the Mental Capacity Act (best interests, proportionate restraint) and request an urgent MHA assessment.

Treatment, Leave and Aftercare Under the MHA

• Section 63 — medical treatment for the mental disorder can be given without consent to detained patients (on most longer sections — not sections 4, 5, 135, 136). Includes treating the consequences of the disorder (e.g. nasogastric feeding in anorexia, treating self-harm wounds in some cases).
• It does not cover unrelated physical illness — e.g. a detained patient with appendicitis who refuses surgery: use the Mental Capacity Act if they lack capacity.
• Section 58 — medication after 3 months — needs the patient's consent (certified by the RC) or approval by a second opinion appointed doctor (SOAD).
• Section 58A — ECT — a patient with capacity who refuses ECT cannot be given it (except in emergency under section 62); if they lack capacity, a SOAD must approve it and it must not conflict with a valid advance decision.
• Section 62 — urgent treatment (e.g. to save life or prevent serious deterioration) can be given without the safeguards above.
• Section 17 leave — the RC can authorise leave from hospital (escorted or unescorted) with conditions.
• Section 117 aftercare — free health and social care aftercare for people discharged from section 3, 37, 47 or 48 — continues as long as needed.
• Discharge — by the RC, hospital managers, the tribunal, or the nearest relative (the RC can bar this if the patient would be dangerous).
• Restraint and seclusion — only as a last resort, proportionate, for the shortest time; Mental Health Units (Use of Force) Act 2018 requires recording and reporting.

The Mental Health Act 2025

• The Mental Health Act 2025 (England and Wales) received Royal Assent on 18 December 2025. It amends the 1983 Act and is being brought in gradually — a few provisions started in February 2026, a new Code of Practice is expected, and the first major changes are planned from 2027. Until then, the 1983 Act rules above still apply.
• Main changes:
  • Stricter detention criteria — a "serious harm" test (to the patient or others), considering how likely and how serious the harm is, and a clear therapeutic benefit.
  • Autism and learning disability — will no longer be grounds for longer-term detention (section 3) on their own — a co-occurring psychiatric disorder needing hospital treatment is required; more community support (dynamic support registers).
  • Nominated person replaces the nearest relative — chosen by the patient.
  • Statutory care and treatment plans for detained patients.
  • Treatment refusal — a patient with capacity refusing treatment can be overruled only for a "compelling reason", with SOAD review.
  • Advance choice documents — to record wishes about future treatment.
  • Police cells and prisons no longer used as places of safety; a 28-day time limit for transferring prisoners to hospital.
  • CTOs — tighter criteria, need agreement of a community clinician.
  • More frequent tribunal reviews and wider access to advocacy.

The Mental Capacity Act 2005

• Applies to people aged 16 and over in England and Wales who may lack capacity to make a particular decision (any decision — medical, financial, living arrangements).
• Five principles:
  • Presume capacity unless it is shown otherwise.
  • Take all practicable steps to help the person decide (time, interpreter, hearing aids, simple language, the best time of day).
  • An unwise decision does not mean a person lacks capacity.
  • Decisions made for someone lacking capacity must be in their best interests.
  • Choose the least restrictive option.
• Assessing capacity — decision-specific and time-specific. Can the person:
  • Understand the information relevant to the decision?
  • Retain it (long enough to decide)?
  • Use or weigh it as part of the decision?
  • Communicate the decision (by any means)?
  • If they can't do one of these — is that because of an impairment or disturbance in the functioning of the mind or brain (e.g. dementia, delirium, learning disability, intoxication, psychosis)?
• Best interests — consider the person's past and present wishes, feelings, beliefs and values; consult family, carers and anyone with authority (LPA); can the decision wait until they regain capacity? Encourage participation.
• Lasting Power of Attorney (LPA) — health and welfare LPA (can refuse life-sustaining treatment only if this is stated) or property and financial affairs LPA; must be registered with the Office of the Public Guardian.
• Advance decision to refuse treatment (ADRT) — made while they have capacity; legally binding if valid and applicable; refusing life-sustaining treatment must be written, signed, witnessed and state "even if my life is at risk". Can't demand treatment.
• Independent Mental Capacity Advocate (IMCA) — for serious decisions (major treatment, change of accommodation) when the person has no one else to consult.
• Court of Protection — disputes, complex decisions, deputies.
• Restraint — allowed if necessary to prevent harm and proportionate (section 6).
• Emergencies — treat to save life or prevent serious deterioration in best interests if capacity can't be assessed in time.

Deprivation of Liberty

• Deprivation of liberty — the "acid test" (Cheshire West, 2014): a person who lacks capacity to consent to their care arrangements, is under continuous supervision and control and is not free to leave — even if they seem content.
• Deprivation of Liberty Safeguards (DoLS) — authorise this in hospitals and care homes (age 18+):
  • The hospital or care home (managing authority) grants an urgent authorisation (up to 7 days, extendable by 7) and applies to the local authority (supervisory body) for a standard authorisation (up to 1 year).
  • Assessments by a best interests assessor and a mental health assessor; a relevant person's representative; right to challenge in the Court of Protection.
• In other settings (supported living, at home, under 18s) — authorisation by the Court of Protection.
• Liberty Protection Safeguards (LPS) — the planned replacement for DoLS (Mental Capacity (Amendment) Act 2019) was delayed; the government has announced a consultation in 2026. DoLS remain in force for now.
• Note — if a person is detainable under the MHA and needs treatment for mental disorder in a psychiatric hospital, the MHA usually takes priority over DoLS.

MHA or MCA?

Confidentiality, Driving and Firearms

• Confidentiality (GMC) — share information with consent where possible. You may disclose without consent in the public interest — to prevent serious harm or death to others (e.g. a patient with a credible plan to harm a named person), serious crime, or when required by law. Share only what is necessary; record why.
• Carers and families — you can listen to them without breaching confidentiality; share general information; encourage the patient to agree to involvement.
• Safeguarding — children and adults at risk (see the Safeguarding chapter); a patient's mental illness may affect their ability to care for children.
• Driving (DVLA — check current guidance):
  • Patients must not drive while acutely unwell with psychosis, mania or severe depression (especially with suicidal thoughts or significant concentration problems) and must tell the DVLA about relevant conditions.
  • Return to driving usually needs a period of stability (e.g. 3 months for car licences after psychosis or mania, longer for bus and lorry licences) and adherence to treatment, with no medication side effects affecting driving.
  • Dementia, alcohol and drug dependence also need notification.
  • If a patient continues to drive when unfit and won't tell the DVLA, the GMC allows you to inform the DVLA (after telling the patient).
• Drug-driving — some prescribed medicines (benzodiazepines, opioids) are covered by drug-driving laws; driving is legal if taken as prescribed and not impaired.
• Firearms — GPs are asked to flag firearms licence holders; consider telling the police if a patient with a firearms licence is at risk of harming themselves or others.

Drug and Treatment Reference Table

Spot the Answer

Exam-style Scenarios

1. A 45-year-old man on a medical ward after an overdose says he will go home and "finish the job". He tries to leave. He is an informal inpatient.
Answer: Section 5(2) holding power.

• The doctor in charge of his care (or their nominated deputy, e.g. on-call doctor) can detain him for up to 72 hours.
• Arrange an urgent Mental Health Act assessment (AMHP and section 12 doctor).
• Section 5(2) doesn't authorise treatment without consent — use the MCA for physical treatment if he lacks capacity.

2. A 32-year-old woman with known schizophrenia has stopped her medication, believes her neighbours are poisoning her and has barricaded her flat. She refuses to see anyone.
Answer: Mental Health Act assessment, likely under section 3.

• AMHP coordinates; section 135(1) warrant may be needed to enter the home.
• Diagnosis known and appropriate treatment available — section 3 rather than section 2.
• Consult the nearest relative; consider less restrictive options (home treatment team).

3. An 82-year-old woman with delirium from pneumonia refuses IV antibiotics and tries to leave the ward.
Answer: Assess capacity; treat under the Mental Capacity Act in her best interests.

• Can she understand, retain, weigh and communicate? Is the inability due to delirium?
• Least restrictive approach; involve family; consider an urgent DoLS authorisation if she is deprived of liberty.
• Treat the cause of delirium; reassess capacity as she improves.

4. A 55-year-old man with psychotic depression has stopped eating and drinking and has acute kidney injury. He has capacity and refuses ECT.
Answer: Life-threatening depression — urgent ECT may be given under section 62 if he is detained.

• A capacitous patient's refusal of ECT normally can't be overruled (section 58A).
• Section 62 allows urgent treatment immediately necessary to save life.
• Treat the AKI and dehydration; involve senior psychiatrists and the legal team; document carefully.

5. A 28-year-old man tells you he has thoughts of killing his ex-partner and knows where she lives.
Answer: A serious risk to an identifiable person — disclosure in the public interest.

• Assess intent, plans, means, mental state and substance use; consider MHA assessment if mental disorder.
• Discuss with a senior; inform the police (and potential victim if appropriate) even without consent.
• Document the decision and reasoning; consider safeguarding of any children.

Key Points

• Always ask directly about suicidal thoughts and thoughts of harming others.
• MSE: appearance, speech, mood and affect, thought form and content, perception, cognition, insight.
• Don't use risk scales to predict suicide — do a needs-based assessment and a safety plan.
• Think organic: older age, sudden onset, visual hallucinations, confusion, neurological signs, new drugs.
• Severe mental illness shortens life by 15–20 years — annual physical health checks and stop-smoking support.
• Alcohol or drug dependence alone is not a mental disorder under the MHA.
• Section 2: assessment, 28 days. Section 3: treatment, 6 months. Section 4: emergency, 72 hours, one doctor.
• Section 5(2): doctor, informal inpatients, 72 hours (not ED). Section 5(4): nurse, 6 hours.
• Section 136: police, public place. Section 135: warrant for a private home.
• After 3 months, medication needs consent or a SOAD; capacitous refusal of ECT can only be overruled in an emergency (section 62).
• Section 117: free aftercare after section 3.
• MHA 2025: Royal Assent December 2025; phased changes from 2027 — 1983 rules still apply for now.
• MCA: presume capacity; decision-specific; understand, retain, weigh, communicate; best interests if lacking.
• Unwise decisions don't mean lack of capacity.
• ADRT refusing life-sustaining treatment must be written, signed, witnessed and say "even if my life is at risk".
• DoLS: hospitals and care homes, 18+; urgent authorisation 7 days.
• The MHA treats mental disorder and its consequences; unrelated physical illness needs the MCA.
• Patients must not drive when acutely unwell with psychosis, mania or severe depression — DVLA rules.