Variation in the use of mental health legislation in New Zealand

Abstract

Background Variation has been a feature of the use of mental health legislation (civil commitment) in New Zealand since at least the 1980s. In recent years rates per 100,000 have shown an up to fivefold difference between District Health Boards in use of community treatment orders, and a threefold difference in use of provisions for acute admission. Variation raises the question of what drives committal decisions, and whether the criteria of legislation are being interpreted consistently across districts. The relatively low rates of committal in some districts offers the possibility of reduced use of legislation in districts whose rates are currently high. Another question is whether certain social groups might be more at risk than others of committal. Aims This doctoral thesis with publications explores factors associated with use of legislation in New Zealand and develops a theoretical account of use of community treatment orders. As a doctorate with publications, the thesis presents: a contextual framework consisting of background, literature reviews, and historical analysis; a theoretical framework; a range of analytical and empirical work; and an integrating discussion of the main findings. Theoretical framework The thesis uses the ecosocial theory of Nancy Krieger and the theories of Michel Foucault to develop a theoretical framework that understands civil commitment within a historical context and at multiple levels of organisation. Methods The methods used to explore mental health legislation include historical analysis, and epidemiological methods including surveys and analysis of administrative data. Results Civil commitment is a medical and legal procedure that serves different social policy objectives at different historical moments. Contradicting the perception of compulsory community care as a new phenomenon, New Zealand legislation since 1846 has always made provision for compulsory community care. New Zealand rates of compulsory community treatment are high by international standards. Rates of civil commitment are associated with area level social deprivation, and availability of inpatient beds, with differences in associations for acute committal and compulsory community treatment. District Health Board rates of civil commitment are not related to individual clinicians’ perceptions of civil commitment, but are associated with clinician perceptions of the necessity for and benefits of committal. Nurses and psychiatrists have different views of necessity and benefits. Conclusions In addition to individual level factors such as diagnosis, civil commitment is related to societal, social, and institutional level variables. Theoretically informed multiple level analysis is necessary to understand variation in civil commitment. Compulsory community treatment can be understood using the concept of “the production of the committed subject”. Any reform of legislation in response to emerging human rights concerns needs also to address variation in rates of committal, the clinical and social outcomes of committal, and alternatives to committal.