BJPsych Kaleidoscope May 2019

magazine-coverThere has been much recent focus on the Mental Health Act in the UK; how does involuntary detention vary elsewhere?

Kaleidoscope reports on a paper looking at this across Europe and Australasia. The UK comes in about mid-range, at 114 detentions per 100,000 population, far fewer than Austria (282/100,000); far more than Italy (14/100,000). Of course this begs the follow-on question of what figure is ‘right’? I’m guessing many of us are glad we don’t the very high figure of Austria as it feels perhaps we are getting something right in the community, but can things be that much better in Italy or are people there being missed? It really highlights that we don’t know. Further, the rates have been going up in the UK, but stable or decreasing in other countries. The different legal frameworks didn’t seem to make a difference, but having a greater mental health spend and more beds did - it puts one in mind of the phrase “build it and they will come”.

Community Treatment Orders (CTOs) don’t work. They haven’t stopped “revolving door patients” (who invented that horrible phrase?): sorry clinicians, academics have undercut your poor practice.

You disagree, eh? You want to start a fight with science for missing the anecdotal instances you have seen in your special practice? I like starting this argument, just to be awkward, but remain agnostic (whilst following the data). But here’s a fascinating thought: have we been measuring the wrong thing? Kaleidoscope looks at a paper that went beyond the “do they stop admission” argument, and looked at the care provided to those on CTOs. Fascinatingly those on CTOs were more likely to have their physical health monitored - including being checked for smoking status and drug use - to have an up-to-date care plan, and to be offered psychological therapy. One can debate causality: more vulnerable individuals are presumably being put on CTOs so one might expect they need more input, but it’s intriguing to consider whether being under such restrictions focusses professionals input.

Finally, we’re all familiar, consciously or not, with movie tropes: how to tell the bad guy? Look out for the facial scar, the cat-on-lap, and the maniacal laugh. Equally, we have lots of ways to hint who we should root for, and which characters might be on ‘our side’ of the story. This offers an interesting way to investigate more natural in- and out-group behaviour - how we respond to those with whom we might relate. Kaleidoscope reports on a paper that neuroimaged participants before and after a movie when looking at the main protagonist’s face. In the film, it is gradually revealed that the character is gay, and it describes some of the life challenges this caused him. The neuroimaging data showed that study participants who self-identified as gay showed stronger activation in brain regions linked with empathy, social perception, and self-referential thinking when looking at him. What is clever about the work is that it is a much more naturalistic and real world approach than typical neuroimaging studies of more simplistic ‘happy’ or ‘sad’ faces. As for me, I tried a variation of the protocol with neuroimaging colleagues, and showed similar self-identification brain changes when viewing Daniel Craig in action. Possibly.


  1. At about 114 involuntary detentions per 100,000 individuals, the UK has the highest such rate in Europe.
  2. Community Treatment Orders (CTOs) have been consistently shown to not impact readmission rates; a recent study also shows that those on CTOs fare no better in terms of the community physical and mental health care they receive.
  3. A network meta-analysis of different CBT approaches in depression showed that guided self-help was considered less acceptable than being on a waiting list.


  1. False, Austria clocks in at 282 (and Italy on 14.5).
  2. False, this study shows they had better physical health monitoring, more up to date care plans, and more likely to get psychological support.
  3. True, which is problematic given the growth in this to counter waiting lists...
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