Money and mental health

The following extract is from the Mind website, dealing with financial worries and suggesting ways of coping in the current recessions.

Welcome to Mind’s money and mental health section

With the current turbulent economic climate and the cost of living getting higher and higher many are finding that managing personal finances and good mental health go hand in hand. Struggling to keep control of income and expenditure can affect mental health. This section will help you look at issues that affect you and give you access to information and support about your money.Follow this link:  http://www.mind.org.uk/moneyand if you would like to see the Tame your monster video, then click this link: http://www.mind.org.uk/money/monster.htm

Male Anorexia

The following is from Teens First for Health by Great Ormond Street Hospital.  To reach the site for the article and other information click this link:

 http://www.childrenfirst.nhs.uk/teens/life/campaigns/archive/2006/eating_disorders.html

Male Anorexia

Eating disorders affect more girls than boys, but boys get them too. Sixteen-year-old Mark James* spoke to Anna Bailey about his battle with anorexia.

“I first noticed that I had a problem with food when I become obsessed with a diet I was on. Throughout my teens I had always been overweight so when I hit 16 stone I went on a strict diet and started exercising. But the more weight I started to lose the more compliments I would get and the more weight I wanted to shed. In the end it became a destructive cycle.

Christmas

The crux came at Christmas time. I had lost around six stone in three months. But rather than tucking into all the Christmas trimmings I ate very little because I still thought I looked very fat. At just ten stone my family obviously knew this wasn’t the case and were slightly concerned I had lost weight too quickly. They then suggested I go and see a doctor.

Misdiagnosed

The first doctor I went to see wasn’t very helpful. I was told that boys don’t get anorexia and my eating habits were put down to depression. The leaflets I was given to read were also targeted towards girls. I felt extremely isolated and wondered if I was the only boy in the world who felt they had an eating disorder. Eventually I found a psychiatrist who confirmed what I had been thinking. It was a relief to know that there was something wrong and someone was taking me seriously.

Rock bottom

My anorexia actually got worse before I started to get better. It was all I could think about during the day and I started to calorie count. I wouldn’t eat any food over 100 calories and I cut out all meat, crisps, chocolates, nuts and cakes. At my lowest point I was only having a bowl of cereal in the morning.  This had a huge impact on my energy levels at school and I was falling asleep by eight o’clock at night. But at that point I didn’t care; I was willing to take the risk with my health as long as I wasn’t gaining any weight. My friends thought I was just going through a ‘MK’ (Mary Kate Olsen) diet faze to look cool and would tease me for being too thin, but inside I was very unhappy and ill. Every time I would go to eat I felt so guilty that I would instantly exercise off the weight or make myself sick. I couldn’t help myself; it was that overpowering.

Hospital

Eventually the weight loss took its toll on my heart. I started to get sharp pains and I plummeted to six stone. At this point I was just a couple of days off from being hospitalised and coming near to death. When the doctor told me this it was a real wake up call and I knew that I had to do something about it.

Recovery

In order to get better I started to try and eat a bit more. So instead of eating one bowl of cereal a day I would have two. I also stopped exercising so much and tried to do activities like drama to raise my self-esteem. Through doing new things I meet new friends who have supported me.

Future

I am slowly getting better now and overcoming my anorexia one day at a time.

I don’t know whether I will fully get over it but at least I know now that I am not a freak and that there are people around to help me. I am now an Ambassador for the Eating Disorders Association and it’s great to meet people like me who are getting better. I also wanted to help other boys who might be going through the same experiences as me but don’t know where to turn to. It makes me really mad seeing stick thin images of anorexics in the press because you don’t need to be really thin to have anorexia. You can look fit and muscly but still think in an anorexic way. There isn’t a label or image that fits all and that’s why the disease is so deceptive.

Top tips

My advice to anyone who thinks that they may have anorexia or an eating disorder is to ask for help. Either speak to a friend, your family or the doctor but don’t leave it too late because it can get worse. It’s better to take control before the disorder takes control of your life.

*The real name of this individual has been changed to protect his identity.

For more help and information

For more help and information about eating disorders please contact beat.

My Eating Disorders….

….is a  website is put together by a group of young women with eating disorders.  Each post is reflective of a constant struggle with body image and self esteem.  This blog also contains informational posts.

If you want to look at it, follow this link:     

 http://myeatingdisorders.wordpress.com/

Boys get anorexia too.

For information provided by a family with direct experience click on the following link:

http://www.boyanorexia.com/

Monmouthshire Mental Health Service User and Carer Network

Mental Health Service User and Carer

Network Meeting

 

 

Date:    Wed 10th Dec 2008

 

Time:   1:30pm – 3:30pm (mince pies included)

 

Location: Mental Health Resource Room,

Sessions House, Usk, NP15 1AD

 

 

Agenda:   

 

1) Discussion with Jill Jones from the Genesis Project

         

2) Consultation on the ‘Talk To Me’ Suicide and Self harm national action plan

 

3) Discussion around service user and carer representatives on the Adult Mental Health Strategic Planning Group

 

4) Any Other Business

                  

 

Monmouthshire Mental Health Internet Blog: SpeakEasy in Mons

SpeakEasy is an internet ‘Blog’ which also doubles as a web resource for information, links, discussion, and events.  It contains a substantial list of Help Line information, and links to sites for specific issues for young people, adults, older adults and carers.

To reach the ‘Blog’ type SpeakEasy in Mons into the Google search bar.  It also registers on NTL Broadband, MSN, and Yahoo. Try it, use it, send in your comments on what is already there, and write your own piece about anything to do with mental health. You can also feed back any comments or suggestions for improvement.

Library and Self Help Resources at the MH Resource Room, Sessions House, Usk.

A resource of books, cd-roms, videos and dvd’s supporting people with mental ill health and their carers and families is available for individual loan or to discussion groups, and is being continually enlarged.   A portable dvd player can also be borrowed.  Contact Richard or Jen on 01291-673728 for info (answerphone).

Stronger in Partnership 2. WAG publication.

This document, issued by the Welsh Assembly Government in the past week, looks at key issues:

“Involving Service Users and Carers in the design, planning, delivery and evaluation of mental health services in Wales”.

If you are a service user experiencing difficulty in getting meaningful involvement, then there is some interesting stuff here.   Let’s hope that some people of influence in the service providers, including the statutory organisations, CVC’s and voluntary organisations also find some tine to read and digest the contents.

The document is available in full under Pages/Essential Reports on this blog.  Click on the document and be a little patient as it loads.   If you have any comments to make about the document, or about how involvement is presently being managed/mismanaged then please send them in to me by e-mail to oberon92.wordpress.com or caradoc.who2@ntlworld.com.   We will be pleased to publish your views.

Survey shows steady improvements in community mental health services

Published: 11 September 2008

A Healthcare Commission survey of people using community mental health services, published today, has shown continued improvements in care.

A larger percentage of service users say that they have confidence in mental health professionals, receive copies of their care plan and have a number to contact out-of-hours when in a crisis situation.

Overall, most respondents continued to rate their care highly, with 78% describing it as “excellent”, “very good” or “good”, 13% as “fair” and 9% as “poor” or “very poor”. These figures remain consistent with previous surveys.

But the survey also shows there is still some way to go before community mental health services are accessible to all people who need them and include all service users in decisions about their care.

The Healthcare Commission coordinates an annual survey of service users in NHS trusts providing community mental health services in England.  In 2008, these included mental health trusts, as well as foundation trusts and primary care trusts providing community mental health services, and more than 14,000 people responded.

The survey invited feedback from people who were receiving care under the Care Programme Approach (CPA), which was established in 1991 for those who regularly access mental health services. The CPA sets out guidelines for how care should be coordinated and how service users should be involved in decisions.

Under the CPA, all service users should know who their care coordinator is and should receive a copy of a care plan, which they should have been involved in developing and agreeing.  They should also have regular care reviews to discuss their care and treatment with health professionals.

In 2008, 74% of respondents say they know who their care coordinator is, up from 67% in 2004. Over the same period, the proportion of service users who say they received a copy of their care plan increased from 49% to 59%.  The proportion reporting not having had a care review in the last year has fallen from 51% in 2004 to 45% in 2008. 

However, the survey shows that more attention needs to be paid to involving people in their care. In 2008, almost a quarter (24%) of people say they were not involved in deciding what was in their care plan, suggesting no significant improvement over previous years.  Furthermore, 16% of service users say their diagnosis was not discussed with them.

The survey also showed room for improvement around access to counselling services such as talking therapies. Of the 62% of service users who did not receive any counselling almost a third of those (32%) would have liked to.

There was continued improvement in the number of people who say they have the number of someone from their local NHS mental health service to call out-of-hours, up from 49% in 2004 to 55% in 2008.  However, this still leaves 45% of service users without access to a crisis number to call out-of-hours.  

A greater share of service users report that they are definitely involved in decisions about their medication, up from 40% in 2004 to 44% in 2008. But almost a third (32%) of those who had been given new prescriptions over the previous year say that they were not told about possible side effects – although this has fallen from 35% in 2004.

The survey also showed continued improvement in service users’ relationships with healthcare professionals.  A greater proportion report that they have confidence in their psychiatrist, up from 59% in 2004 to 63% in 2008, and that their psychiatrist “definitely” listens carefully, from 68% in 2004 to 72% this year.  Likewise, 75% report that they “definitely” had trust and confidence in their community psychiatric nurses (CPNs), up from 73% in 2004.

Since the survey, the Care Programme Approach has been revised by the Department of Health. As of October, a new system will be introduced whereby only those with more complex mental health needs will be part of the programme. While many of those currently on standard CPA will no longer be part of this formal approach, an assessment of their needs, the development of a care plan and a review of that care by a professional involved, will continue to be good practice for all.

Commenting on the survey results, Anna Walker, chief executive of the Healthcare Commission, said:

“The survey shows steady improvement in how service users rate key aspects of their care. This is good news for trusts and good news for the people who access community mental health services. But more must be done to improve access to care, in particular to talking therapies and out-of-hours crisis care, and to involve people in decisions about their treatment.”

Speaking about the changes to the Care Programme Approach, she said:

“People may need to access a range of community mental health services from a number of healthcare professionals, so it’s critical that the care is coordinated and accessible. We also know that treatment is more effective when people are involved in their care and are supported to make decisions about their treatment.

“While the improvements are to be commended, the survey shows that there remains a significant number of service users who say that their care is not coordinated and that they aren’t involved in decisions about their treatment.

“When the new system comes into effect, trusts should ensure that the principles of the CPA should continue to apply to every service user and that the improvements made over the last few years are sustained and built upon. Service users’ care should be co-ordinated by one person, they should be involved in decisions about their care and they should have access to a range of therapies and services.”

The Commission welcomed the government’s announcement last year of an extra £170 million to improve access to talking therapies for people with a wide range of mental health problems.

The Healthcare Commission will use the survey results to assess mental health trusts in the 2007/2008 annual health check performance rating. In 2008/2009, the annual health check will use a broader set of indicators to assess the performance of mental health trusts, looking at many of the issues identified in this survey. The indicators include a focus on coordinated care in mental health, access to crisis resolution services, mental health data quality, and will continue to incorporate the views of service users.

The survey was co-ordinated on behalf of the Commission by the National Centre for Social Research (NatCen).

Survey of users of mental health services 2008

Information provided by the Healthcare Commission: Link below:

http://www.healthcarecommission.org.uk/homepage.cfm

BBC – ‘Mental risk’ of Facebook teens

Any comments from Facebook users on the following report? 

Children growing up alongside the rise of social networking websites may have a “potentially dangerous” view of the world, says a leading psychiatrist.

Dr Himanshu Tyagi said sites such as Facebook and MySpace may be harmful.

He told the Royal College of Psychiatrists annual meeting people with active online identities might place less value on their real lives.

And the West London Mental Health NHS Trust expert added this could raise the risk of impulsive acts or even suicide.

 

It may be possible that young people who have no experience of a world without online societies put less value on their real world identities Dr Himanshu Tyagi West London Mental Health NHS Trust

Dr Tyagi said that people born after 1990 did not know a world without the widespread use of the internet.

He warned that the current crop of psychiatrists were perhaps not fully prepared to help young people with internet-related problems.

While social networking sites offered great benefits, he said, there were potential pitfalls.

‘Unstimulating’

“It’s a world where everything moves fast and changes all the time, where relationships are quickly disposed at the click of a mouse, where you can delete your profile if you don’t like it, and swap an unacceptable identity in the blink of an eye for one that is more acceptable.”

He said: “People used to the quick pace of online social networking may soon find the real world boring and unstimulating.

“It may be possible that young people who have no experience of a world without online societies put less value on their real world identities and can therefore be at risk in their real lives, perhaps more vulnerable to impulsive behaviour or even suicide.”

He called for more investigation and research into the issue.

However, Graham Jones, a psychologist with an interest in the impact of the internet, said that while over-use of social networking sites could lead to problems, the risks posed by them had been overplayed.

He said: “For every new generation, the experience they have of the world is a different one.

“When the printing press was first invented, I am sure there were crowds of people saying it was a bad thing.

“In my experience, the people who tend to be most active on sites such as Facebook or Bebo are those who are most socially active anyway – it is just an extension of what they are already doing.”

Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/7487723.stm

Published: 2008/07/03 12:30:52 GMT

© BBC MMVIII

DIPEx.org

DIPEx shows you a wide variety of personal experiences of health and illness. You can watch, listen to or read their interviews, find reliable information on treatment choices and where to find support.

The site covers cancers, heart disease, mental health, neurological conditions, screening programmes, pregnancy, teenage health, chronic illnesses and many others.

DIPEx was voted by the Times as one of the top 3 patient health sites (2006), was in the Guardian’s top 10 health websites (2004) and was singled out in a recent study (Times article March 2007) as a favourite, trusted site for patients.

Link to site:  http://www.dipex.org/DesktopDefault.aspx

Independent Police Complaints Commission – Report on S136

 

Twice as many people are detained in unsuitable police custody for assessment under the Mental Health Act as those taken by the police to hospital for this purpose, according to research published by the Independent Police Complaints Commission (IPCC) today (10 September).

During a one year period (2005/06) over 11,500 people were detained in a police cell as a place of safety under section 136 of the Mental Health Act. In the same period 5,900 people were taken to and detained in a hospital.

The IPCC’s report, ‘Police Custody as a “Place of Safety”: a National Study Examining the Use of Section 136 of the Mental Health Act 1983′, examines the nature and extent of the use of police custody as a place of safety across England and Wales. It is the first time national data on the use of section 136 by all 43 police forces has been collated. The report makes a number of recommendations for the police and health services to improve practice and the experiences of the many thousands of people detained by the police under this power.

Under section 136, police officers can detain people, believed to have a mental disorder, who are in a public place and take them to a place of safety such as a hospital or police station for assessment.

Ian Bynoe, IPCC Commissioner with national responsibility for mental health, said: “Someone whose distress or strange behaviour causes the police concern needs rapid medical and social assessment in a safe environment. It is therefore intolerable that even though it has been Government policy since 1990 that a hospital is the preferred place of safety for such an assessment our research shows that twice as many people are detained in police custody as in a more fitting hospital environment.

“Police custody is an unsuitable environment for someone with mental illness and may make their condition worse, particularly if they are not dealt with quickly, appropriately and don’t receive the care they need. The continued use of cells not only diverts police resources from fighting crime, but criminalises behaviour which is not a crime. A police cell should only be used when absolutely necessary, for example when someone is violent, and not as a convenience.”

Key findings

• An estimated 11,500 people were detained in police custody as a place of safety in 2005/06. This compares with about 5,900 people in a hospital environment that year.
• The use of section 136 varies significantly between police forces. The average rate of detention across England and Wales was 55 detentions per 10,000 people in custody. Low rates of detention were reported by Cheshire and Merseyside Police (1 per 10,000 people in custody). High rates were reported by Sussex Police (277 per 10,000) and Devon and Cornwall (174 per 10,000).
• Just under two thirds of people (61%) detained in police custody were male.
• The average age of those detained was 36 years, but the ages ranged from 12 to 89 years. Four per cent of detainees were aged 17 or under. Four people were 12 years old.
• Almost eight out of 10 (78%) of detainees were White; 4% were Black; 3% were Asian; 2% other ethnic origins and 14% were of unknown ethnicity. When compared to the general population the rate of detention for Black people was almost twice (1.7 times) as high than for White people.
• The majority of people (78%) were detained in police custody for 12 hours or less. The average length of time spent in police custody was nine hours and 36 minutes. Ten individuals were detained for over the legal limit of 72 hours. Almost two thirds (65%) of section 136 detainees arrived in police custody outside of normal office hours (between 6 p.m. and 9 a.m.).

Differences across England and Wales

The IPCC’s research examined why the rates of the use of section 136 varied so much between police forces.

The strongest factor in explaining the differences in the rates of use of police custody is the availability of alternative places of safety. Alternative places of safety were more readily available and more commonly used in low rate and some medium rate forces, than higher rate areas.

A strong factor in some forces was suicidal behaviour associated with high local populations of transient and deprived populations, along with well known ‘suicide spots’ such as seaside cliffs in the police force area. These tended to be in areas where there was little or no alternative to police custody and so had the effect of pushing rates of detention up.

A number of people were being repeatedly detained and released under section 136. They were often felt to be more difficult to assess and care for due to the complexity of their problems, for example having a combination of mental disorder and substance abuse. In some areas outreach work was being conducted in order to reach these people and reduce the numbers of detentions in future.

Other examples of differing practice include officers in forces with lower rates of the use of section 136 finding it less bureaucratic to arrest for minor offences such as breach of the peace, compared to officers in higher rate forces where the reverse was true. This could account for some differences in the rates of detention.

Inconsistent and incomplete data recording by police forces means that information is not available on what happened to section 136 detainees after they were released from police custody. This makes it difficult to establish whether the power is being used appropriately.

Mr Bynoe said: “The strongest factor in explaining the differences in the rates of section 136 use by police is the availability of alternative places of safety. Our research found that alternative places of safety were more readily available and more commonly used in low rate forces.

“When senior police officers and senior staff within health and social care recognise this is a joint problem which requires a coordinated approach it becomes more likely that alternative places of safety will be developed.”

Action

The IPCC report sets out 22 recommendations to improve practice in the future:

Recommendations

NHS commissioners should:

Recommendation 1: work with relevant organisations to develop alternative places of safety to police custody. Consideration should be given to using existing facilities, such as hospital emergency departments and psychiatric units where it may be possible to set aside a space that can be used as a place of safety. These facilities should adhere to the Royal College of Psychiatrists’ standards on places of safety (2008).

Recommendation 2: consider applying for Department of Health funding to set up purpose built facilities where necessary; taking into account how they will staff these facilities using their existing resources. This funding does not apply to Wales and health boards there will need to consider local funding arrangements.

Recommendation 3: consider what preventative outreach work might be conducted to help individuals who are detained under section 136 frequently. Such outreach work may help to prevent some section 136 detentions and ensure that at risk individuals receive appropriate care and treatment.

Recommendation 4: use specialists, such as community psychiatric nurses, to provide outreach services to police custody and arrange mental health assessments. Joint funding from both the police and primary care trust/NHS commissioner would increase staff availability outside normal working hours.

Police forces should:

Recommendation 5: consider ways to improve the co¬ordination and timeliness of mental health assessments. For example, where specialists such as community psychiatric nurses are not available to arrange assessments, agreements could be made for approved social workers to co-ordinate assessments.

Recommendation 6: raise any problems with lengthy delays in mental health assessments in hospital emergency departments with the relevant primary care trust/NHS commissioner to see if a solution can be agreed – for example, the implementation of target times.

Recommendation 7: ensure that officers on the street have adequate training to recognise symptoms of mental disorder, understand their powers under the Mental Health Act 1983, and know what their local arrangements are for places of safety.

Recommendation 8: agree with other agencies that officers can contact individuals with mental health expertise, such as approved social workers, to get advice on particular individuals.

Recommendation 9: ensure that custody officers and staff receive refresher training on mental health symptoms and section 136 processes so that detainees held in police custody

Recommendation 9: ensure that custody officers and staff receive refresher training on mental health symptoms and section 136 processes so that detainees held in police custody receive appropriate care and attention.

Police forces and NHS commissioners should jointly:

Recommendation 10: meet at a strategic level to review the current arrangements with regard to section 136 detentions in their area. This should include a review of the effectiveness of existing protocols and agreements, if they exist. Section 136 should be seen as a joint problem and joint solutions should be sought.

Recommendation 11: review their arrangements for detaining under section 136 people who are intoxicated and/or violent to ensure that they get the most appropriate care. It might be possible to provide a non-police facility where individuals can be safely detained and assessed with police officers present.

Recommendation 12: look for solutions that improve the availability and/or timely attendance of doctors approved under section 12 of the Mental Health Act 1983, where this is a problem. Forces should require their forensic medical examiner provider to ensure that sufficient forensic medical examiners are section 12 approved. This could be particularly helpful in increasing the availability of specialist doctors outside normal working hours.

Recommendation 13: accurately and consistently record section 136 detentions both in police custody and hospital environments. The records should include key demographic details such as age, gender and ethnicity, along with the length and outcome of the detention (for example, whether the individual was taken to hospital). We support the Royal College of Psychiatrists’ (2008) suggestion that one national recording form for England and Wales is introduced. Police forces should also work to ensure that offenders with mental disorders are captured on their systems in order to identify the true scale of the detention in police custody of people with mental disorders.

Police forces, NHS commissioners, ambulance services, and social services should jointly:

Recommendation 14: agree a policy on the transportation of section 136 detainees being admitted to hospital following an assessment (within the wider conveyance policy required under the Mental Health Code of Practice). This should include detainees being held in police custody and at alternative places of safety. Ambulances should generally be used for transportation, unless there is sufficient risk to ambulance staff due to the violence of the individual. In such cases it may be acceptable to use a police vehicle. It is imperative that the transportation of a detainee occurs as promptly as possible, so as not to prolong their detention in police custody. It is therefore important that appropriate and realistic target times for transportation are set, agreed and adhered to.

Recommendation 15: agree a policy on the transportation of section 136 detainees being released back into the community (when transportation is necessary). This should include detainees being held in police custody and at alternative places of safety. The policy should specify which organisations are responsibility for transportation in the different circumstances, and which is responsible for paying for the costs involved in using taxis.

Recommendation 16: monitor section 136 detentions by multi-agency groups at a local level to identify any problems. This should include monitoring of the new power to transfer between places of safety to see how it is being used in practice.

The Healthcare Commission, and its successor, the Care Quality Commission, should:

Recommendation 17: collate annual data on section 136 to improve data collection and increase understanding of the use of section 136. If a national form is adopted for recording all section 136 detentions in custody and alternative places of safety, as suggested by the Royal College of Psychiatrists (2008), this information should be collected locally. The information can then be provided to the Care Quality Commission for collation.

Recommendation 18: conduct analysis into the data gathered on section 136 detentions, such as the make up of the detainees, length of time they are detained and the outcome of section 136 detainees to see what happens to the individuals. This will help to determine whether this power is being appropriately used across police forces. The data should be presented annually and be made available to the public.

The police, social services and mental health trusts should:

Recommendation 19: provide joint training on section 136 and mental health. This will help to improve communication and understanding about the different roles and responsibilities between the various organisations.

Recommendation 20: clarify the current situation by providing joint training on information sharing and what can be shared legally about a section 136 detainee.

Further research should:

Recommendation 21: examine and seek to explain disproportionality in the ethnic make up of section 136 detainees.

Recommendation 22: explore the experiences and perceptions of section 136 service users’ experiences. This is an important gap in our knowledge and understanding the experiences of these individuals could help improve the detention process and the care that people receive.

Mr Bynoe added: “This is an important piece of research which has implications for the police, health and social care services. We have written to the chief xxecutives of all primary care and mental health trusts, as well as all chief constables of police forces in England and Wales to make them aware of the findings and recommendations and encourage them to act upon these.

“Over the next year IPCC Commissioners will monitor whether their forces and local health and social care authorities have developed new protocols on the use of section 136 in their area taking account of the new Mental Health Act and the revised Code of Practice limiting the use of police custody to exceptional situations.”

“The IPCC will now work with ACPO, the Royal College of Psychiatrists and the Sainsbury Centre for Mental Health to ensure that our work and recommendations are taken forward.”

* ‘Police Custody as a “Place of Safety”: Examining the Use of Section 136 of the Mental Health Act 1983′,
Maria Docking, Kerry Grace and Tom Bucke, IPCC, London ISBN 978-0-9556387-1-8.

The report can be found here or is available from the IPCC,

90 High Holborn, London WC1V 6BH.

-ends-

 

For further information please contact:

Richard Offer, Head of Media
Tel: 020 7166 3214
Fax: 020 7166 3514
Mob 07710 381890
Journalists only out of hours: 07717 851 157
Email: richard.offer@ipcc.gsi.gov.uk

 

IPCC publishes major study on use of s136 Mental Health Act