MEDICATIONS

The symptoms of most psychiatric illnesses are greatly reduced by the use of medicine which is prescribed by your family doctor or psychiatrist (psychiatrists are doctors who specialize in treating mental diseases). Much research has gone into improving these medications in recent years. The prescribed drugs used to treat different symptoms are getting better all the time. Many people with severe psychiatric disorders may now able to function quite well, as long as they keep taking the proper medicine, and follow other prescribed treatment.

While there is still no cure for psychiatric illnesses, it is important to understand that most symptoms can be treated with prescribed medications. This is like some other diseases that cannot yet be cured. With diabetes, for example, a person must take carefully prescribed and regulated medicine and be on a strict diet. If the doctor’s directions are followed, the person usually keeps healthy and active. If not, the person will likely become very, very ill. It is the same with a psychiatric illness like Schizophrenia or bi-polar syndrome. Those who keep taking the medications which are prescribed for them usually keep well, but when medications are stopped, the symptoms will return.

With all medications, there are sometimes unpleasant side effects. Fortunately medications are improving, and with the newer drugs to treat mental illnesses, there are fewer side effects. It is usually helpful for continuity of care reasons to have a doctor who has known you for a long time, and understands how the various medications affect you. Some persons, however, may wish to see another psychiatrist who they find is easier to talk to or who they believe may be more familiar with the newer medications. In any case, it is important for you to keep in close touch with your doctor, to report any changes in your symptoms, or changes in side effects.

Unfortunately in Saskatchewan, some psychiatrists do not stay at the same place very long so it may not always be possible to keep seeing the same doctor. Do try to find a psychiatrist you feel comfortable with and can talk to freely. Then stay with the same psychiatrist as long as possible. That will give you the best chance to get the best medicine to meet your particular needs.

Anyone who is taking prescribed medication to treat a psychiatric illness must be aware that you have to avoid drinking alcohol or using street drugs. Otherwise you will likely get a very bad reaction, and your prescription medicine won’t help you. This is also true of other diseases including diabetes. It is not always easy to follow your doctor’s advice but that is the best way to stay healthy.

There is information about programs to help you pay for your medications in the section titled “Who Pays for Mental Health Services?”.

HOSPITALIZATION

1. A person may be admitted to a hospital for psychiatric treatment if the person:

• asks to be hospitalized, and a doctor with admitting privileges agrees,
• accepts the recommendation of a doctor with admitting privileges that hospitalization is advisable.

2. A person who does not give consent may be hospitalized for a mental health assessment or treatment under certain conditions.

• The person must be seen by two doctors. At least one of the doctors must be able to admit persons to a mental health ward and one has to be a psychiatrist.

Each doctor must certify that the person:

• has a mental disorder and needs to be in hospital for treatment,
• does not understand the need for treatment because of the mental condition, and cannot give informed consent,
• is likely to harm him or herself or others, or his or her mental or physical health is likely to get much worse without treatment in hospital.

Note: It is not necessary for a person to be dangerous in order to be committed to hospital for psychiatric treatment. If the doctor believes the person’s health is at risk if treatment is not provided, and if the other criteria are met, the person may be hospitalized without giving consent.

• Two medical certificates give authority to the police or anyone else named in the certificates to take the person to a hospital. Individuals who could be authorized to accompany the person to hospital may, for example be relatives, friends, or mental health workers. The person may then be kept in hospital for up to 21 days for psychiatric treatment, care or supervision.
• If it is not possible to get two doctors to examine the person, one certificate will allow the person to be taken to hospital and kept there for three days. Once in hospital, a second doctor must examine the person within the three days, and if the second doctor also certifies that hospital treatment is necessary, the person may be kept in hospital involuntarily up to 21 days. Either the first or second examining doctor has to be a psychiatrist.

Once in hospital, the person may agree to stay voluntarily. The certificates are then cancelled. The person may then leave the hospital at his or her own request, or on the advice of a doctor.

If more than 21 days in hospital is needed to treat the person’s condition and the person does not agree to stay voluntarily, two doctors, including a psychiatrist must examine the person again. The person may be re-certified for up to 21 days at a time, if the person’s condition requires ongoing treatment in hospital.

3. A person who has committed a crime, and because of a mental disorder is:

• considered unfit to stand trial,
• considered to be “not criminally responsible”,
• acquitted;

may be admitted to a psychiatric hospital for involuntary treatment, on a Court Order, or Warrant.

When the Order or Warrant expires, the person must be assessed by two doctors, at least one of whom is a psychiatrist, to decide whether the person should continue to receive involuntary treatment in a hospital.

CONSENT FOR TREATMENT

When a person is in hospital on a voluntary basis, diagnostic or treatment services may only be carried out with the consent of the person.

If the person is not able to give consent because of the mental disorder, the nearest relative must give consent. However, a person who wants someone who is not the nearest relative to give consent on his or her behalf, may apply to a judge to have someone else appointed for that purpose. A person may also name a proxy to give consent for health care on his or her behalf under the Health Care Directives Act.

When a person is in hospital on an involuntary basis, the doctor may carry out any diagnostic or treatment procedures considered to be consistent with good medical practice, without the consent of the person.

The purpose and nature of each test or treatment procedure and the various alternatives must be explained to an involuntary patient. The doctor must consider the patient’s views including the choice of therapists.

Consent for Special Treatment

Some treatments such as Electro-Convulsive Therapy (ECT) are “special treatments” and may only be given to involuntary patients under strict guidelines. For ECT to be carried out, two doctors, including a psychiatrist, must first examine the person, and certify that ECT is needed and is the only treatment that will be effective. The Official Representative must then visit the person, to discuss his or her right to appeal before ECT is permitted to be administered. For more details about the Official Representative see the section under “Appeals” on page 14.

No psychosurgery or experimental treatment may be given to an involuntary patient.

COMMUNITY TREATMENT ORDER

When a person with a mental disorder does not follow recommendations while out of hospital (for example, is not taking prescribed medication), a psychiatrist may issue a Community Treatment Order (CTO) for that person.

A CTO gives authority to provide psychiatric treatment for someone, without the person having to be in hospital, and without the consent of the person. It allows a person who has a mental illness the freedom to live in the community, even when the person’s judgement is too impaired by the illness to give informed consent for treatment.

Before a person may be given a CTO, there are a number of conditions that have to be met:

• Within the last two years, he or she must:
  • have been hospitalized involuntarily
    • at least three times, OR
    • for a total of at least 60 days, OR
    • have had a previous CTO.
• A psychiatrist must examine the person and be satisfied that:
  • the person is suffering from a mental disorder and needs treatment, care or supervision; AND
  • the treatment or care can be provided in the community; AND
  • if the person doesn’t get treatment, is likely to harm him or herself or others,
  • the person’s health is likely to get much worse; AND
  • because of the mental disorder, the person is unable to fully understand or to make an informed decision about the need for treatment; AND
  • the person is capable of following the conditions in the treatment order.
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• The psychiatrist also has to be sure that the services the person needs:
  • exist in the community;
  • are available to the person; and
  • will be provided to the person

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• If all these conditions are met, the psychiatrist may issue a CTO.
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Copies of the CTO must go to:

• the person concerned;
• the person’s nearest relative;
• the Official Representative.

Before a CTO comes into effect, a second doctor has to examine the person and confirm the findings and decisions of the first doctor.

A CTO must name the person who will be getting treatment, the psychiatrist or physician who will provide the treatment, and the Case Manager who will coordinate the services. The services and treatment that will be provided must be listed on the CTO. The attending psychiatrist or physician is responsible to ensure that the needed treatment and services are provided.

The person who is getting the treatment must attend scheduled appointments, follow prescribed treatments and meet stated conditions. That could include matters such as living arrangements, or participation in social activities, life skills training, job preparation, or anything else considered necessary so the person can continue living in the community without having to be hospitalized.

If a person does not follow the conditions of a CTO, the psychiatrist may make an Order to have the person brought in for an assessment. That assessment will determine whether involuntary hospitalization is necessary. The Order may go to the police, a friend or relative of the person involved, or to anyone else identified in the Order.

A CTO is in effect for three months. It may be renewed as often as needed by a psychiatrist and another doctor who may also be a psychiatrist.

The psychiatrist may cancel a CTO at any time if it is no longer considered necessary or appropriate.

It is expected that CTO’s will help prevent recurring hospitalizations and assist some people with psychiatric disorders to avoid getting into trouble with the law. All too often, persons with mental illnesses who are not getting adequate treatment, commit crimes and end up in jail. Ensuring that treatment is continued by means of a CTO may also help prevent suicides by some mentally disturbed persons.

Note: A CTO is not necessary to get psychiatric treatment as an out-patient in the community. Most people will continue to get psychiatric treatment in the community on a voluntary basis. CTO’s are only for those who need treatment but are unable to give informed consent because of the psychiatric illness.

“Informed consent” means that the proposed treatment has been clearly explained to the person, including what will likely happen if treatment is not provided. It also means that the person is capable of understanding that information, and making a choice about it.

What if you disagree with your treatment?

Decisions about providing mental health services for someone may be appealed to a Review Panel. Appeals may be made regarding decisions for mental health services for persons considered to be unable to give informed consent because they have a mental illness. That includes decisions for:

• involuntary hospitalization (up to 21 days) on the basis of medical certificates,
• transfer to a hospital in another district,
• a Community Treatment Order (up to three months),
• certain special treatments such as Electro Convulsive Therapy.

To ensure that rights of persons getting involuntary treatment are protected, the Minister of Health must appoint an Official Representative and a Review Panel for each mental health region. The Official Representative is usually a lawyer. The Review Panel consists of three persons including a doctor and a lawyer.

Whenever a person is hospitalized, is scheduled to be transferred to another area involuntarily, becomes the subject of a Community Treatment Order, or if two doctors agree that an involuntary patient needs ECT, that person and the Official Representative, as well as the person’s nearest relative must be notified. The Official Representative must visit the person as soon as possible to explain the right of appeal. If the person decides to appeal, the Official Representative will help make the necessary arrangements.

The Official Representative, a relative or anyone with a sufficient interest may make an appeal on behalf of the person.

A notice is sent to the Review Panel for an automatic appeal:

• Whenever medical certificates to keep a person in hospital involuntarily for up to 21 days are renewed, unless there was an appeal to the Review Panel in the previous 21 days;
• After every six months that a person has been kept in hospital involuntarily, on the basis of medical certificates.

The appeal goes to the Review Panel. The Review Panel must immediately investigate, and invite the person concerned, and any other person who could be affected by the appeal to a hearing. All three members of the Panel must be present for a hearing.

The person making the appeal has the right:

• to be represented by a lawyer;
• to see any written evidence given to the Review Panel;
• to hear any verbal evidence given to the panel;
• to provide evidence; and
• to question anyone else giving evidence.

The Review Panel:

• considers the evidence presented at the hearing;
• makes a decision within three days of receiving the appeal notice;
• depending on what is being appealed, decides whether or not the person is:
  • kept in hospital involuntarily for up to another 21 days;
  • transferred to another hospital;
  • given ECT;
  • continued on a CTO for up to three months more.

  Note: regarding a CTO, the Review Panel may decide to:

  • change some conditions of the CTO;
  • keep the CTO as it is;
  • cancel it.
• sends a notice of the decision to the:
  • person concerned;
  • nearest relative;
  • Official Representative;
  • Officer-in-Charge of the hospital where the person is a patient, if the Appeal concerns hospitalization;
• informs the person about the right to appeal to the Court of Queen’s Bench, if the Review Panel decides that the person should stay in hospital.

If the person or anyone else on behalf of the person, decides to appeal to the Court, the Official Representative will help with that process. A notice is given to the Director of Mental Health Services, to the Officer-in-Charge of the hospital where the person is a patient, and to anyone else that the Court considers advisable.

The person making the appeal must give a sworn statement to the Court stating why hospital treatment is not considered appropriate. The Court will obtain any other evidence considered necessary.

The Court may uphold or reverse the decision of the Review Panel. There is no appeal from the Court decision.

LONG TERM TREATMENT, CARE, AND SUPERVISION

If a person has been in hospital at least 60 days on an involuntary basis, and the staff considers that long term treatment is necessary, the Officer-in-Charge of the hospital may apply to the Court of Queen’s Bench for an Order to keep the person in hospital for up to one year.

Notices of the application to the Court must go to:

• the person concerned;
• the nearest relative of the person;
• the Official Representative.

At a Court hearing, the Judge must make certain that the person has been kept in hospital involuntarily at least 60 consecutive days. Then the Judge must decide if the person:

• has a mental disorder and needs treatment, care, or supervision which can only be provided in a hospital;
• because of the mental disorder, does not fully understand, and cannot give informed consent about the need for treatment;
• is likely to harm him or herself or others, OR
  

  would risk serious deterioration in physical or mental health if treatment is not provided;

• has a severely disabling ongoing mental disorder that is likely to continue for more than 21 days in spite of treatment.

If the judge decides that these conditions are all met, a Detention Order may be made to keep the person in hospital for up to one year to obtain treatment, care or supervision.

A Long-Term Detention Order may be reviewed by the Court if an application is made by:

• the person concerned;
• the person’s nearest relative;
• the Officer-in-Charge of the hospital where the person is a patient;
• the Official Representative;
• any other person with a sufficient interest.

Notices of the application for review must go to all persons involved in getting the Detention Order.

When reviewed, the Court may decide that the Detention Order:

• continue as it is;
• be changed; or
• be cancelled.

When a Detention Order expires or is cancelled, the person’s doctor must send a written notice to:

• the person concerned;
• the person’s nearest relative;
• the Official Representative.