ORIGINAL ARTICLE
Abdullah H. Alqahtani1
1 Imam Abdulrahman Bin Faisal University, College of Medicine, Department of Psychiatry, Dammam, Saudi Arabia
Cite: Alqahtani, A. H. (2020). Psychiatric admissions: The first law in Saudi Arabia. International Journal of Risk and Recovery, 3(1), 23–28.
The Mental Health Care Law in Saudi Arabia was passed in 2014. This paper focuses on the articles of the law that are related to psychiatric admissions both voluntary and involuntary. The mental health-care law is similar to the laws in western countries. However, these articles and subsections are curtailed to the limited health systems and to the local culture. As the mental health-care system and culture evolves, the mental health-care law will be modified in the future.
Key words: Mental health, law, Saudi Arabia, legislation
Introduction
For centuries, physicians practised medicine without a law guiding their practice. They took an oath relevant to their region or religion, and they were expected to be knowledgeable and wise. The first known laws regulating the work of physicians are almost 4000 years old: the Hammurabi’s law [1]. Fifteen hundred years later, Aristotle and Hippocrates modified many of the ways physicians interacted with their patients, students, and teachers [2,3]. This was followed by a period when those healing and treating lost the scientific perspective brought by earlier scholars and became magical and surrounded by superstition. In Medieval Europe, supernatural powers were thought to cause illness and the aim was to salvage the soul rather than treat the body [4]. Islam’s teachings, through the Quran and Hadeeth (sayings of the prophet Muhammad) and the translations from Greece and other cultures, shaped medicine in the Islamic era [5].
The first asylum for the sick was called “bimaristan” and was the earliest form of hospitals. The hospital policy was that
the hospital shall keep all patients, men and women, until they are completely recovered. All costs are to be borne by the hospital whether the people come from afar or near, whether they are residents or foreigners, strong or weak, low or high, rich or poor, employed or unemployed, blind or signed, physically or mentally ill, learned or illiterate. There are no conditions of consideration and payment; none is objected to or even indirectly hinted at for non-payment. The entire service is through the magnificence of God, the generous one.
In addition to treating patients, large hospitals had medical schools and libraries attached to them [6].
A Mental Health Care Law was passed in Saudi Arabia in 2014 [7]. It aims to regulate and promote mental health-care services. It also protects the rights and dignity of psychiatric patients, their families, and community. Lastly, it develops a mechanism for dealing with and treating psychiatric patients in a mental health treatment facility.
Before 2014, psychiatric facilities self-regulated and followed the general health law [8,9]. Modern mental health care is only a few decades old, so the need for a mental health-care law is relatively recent. The first psychiatric hospital in Saudi Arabia was built in 1952 in Taif near the holy city of Mecca [10]. By the 1980s, there were only two main psychiatric hospitals. Decentralization of psychiatric services led to the establishment of 21 regional psychiatric hospitals. By 2014, these hospitals were also supported by psychiatric clinics in more than 125 general and private hospitals [10].
In general, many of the articles in the Saudi Mental Health Care Law are similar in principle to the cultural norms in Saudi Arabia. The culture in Saudi Arabia is deeply rooted in Islamic teachings. At the same time, the law is similar to those of western countries. Stating that the Saudi mental health care is rooted in Islam and similar to western laws may seem contradictory, but core western values like democracy, freedom and justice are also found in Islam.
When mentioning admission in psychiatry, an involuntary process and restriction of freedom comes to mind for many. An involuntary admission is a legal procedure when a mentally ill individual is admitted against their will. The history of involuntary admission dates back to the early history of mental illness. Social stigma lead some societies to confine mentally ill patients to their home and their relatives used to hide them. The other extreme involved patients with mental illness being left to wander in the streets, vulnerable, dangerous to others or all three, depending on the nature of their mental disorder and associated behaviour. Today, involuntary admission mainly occurs when the individual with mental illness is considered dangerous to themselves or others, in theory, resulting in a decrease in the rate of mental health-related suicide and crime.
The involuntary admission debate is vast [11-14]. Regulating mental health admission is necessary to avoid the tragedies associated with confining relatively healthy people for extended periods of time or freeing an ill person resulting in suicide or crime [15]. In this article, the author addresses the main concepts of psychiatric care according to the new law in Saudi Arabia, specifically an analysis of voluntary, emergency and involuntary admissions.
Voluntary Admission
The principles of the voluntary admission are specified in Article 10. It states that an
admission to a mental health treatment facility shall be voluntary upon written consent of a psychiatric patient if capable of giving consent, or his guardian. A patient may leave if he so wishes unless involuntary admission applies to him.
Article 10 solves a long-time problem in Saudi Arabian psychiatric facilities. It was a common defensive practice to only discharge a patient if a relative came to collect them. This put a strain on already limited psychiatric beds. The number of beds is 1.25 per 10,000 population, compared with 8.7 and 3.3 in Europe and the Americas, respectively [16]. The news media has noted that there were 356 patients in the main psychiatric hospital that should have been discharged, but nobody came to collect them [17].
The problem becomes more complicated when the psychiatric patient is female. This is due to the common practice that a woman is always accompanied by her legal guardian (father, brother, son or husband) when conducting official business, including admission, discharge, and consent for any medical procedure. This is not based on any law. The basic law of Saudi Arabia, Article 31, says that the state takes care of health issues and provides health care for every citizen without differentiating between males and females in any subsections [18]. If a patient was admitted voluntarily, they can be discharged against medical advice unless the conditions of an involuntary admission are present.
Emergency Admission
The legal requirements of an emergency admission are considered in Articles 11 and 12 of the Mental Health Care Law. Article 11 provides the background of the emergency admission. It states that
a physician working in emergency departments in all hospitals shall have the authority to provisionally admit a psychiatric patient under emergency admission for observation and treatment purposes if the involuntary admission conditions set forth in Article 13 of this law, excluding paragraph 3 of said Article, apply to said patient.
Article 13 is the first article of the Mental Health Care Law that refers to involuntary admission. Any physician covering the emergency room can admit “a psychiatric patient” against their will for up to 72 hours. The conditions for emergency admission are similar to involuntary admission, without the need for two psychiatrists’ evaluation and signature. The first condition is the clear evidence of severe mental disorder that represents an actual or potential threat to self or others at the time of examination. The second condition is that the admission is necessary for the recovery, improvement or control of the deterioration of the mental condition.
As soon as the patient is admitted, they will be evaluated by two psychiatrists and the emergency admission will either be converted to an involuntary admission or revoked. If the emergency admission is conducted in a non-psychiatric facility, then the emergency physician should inform management about the emergency admission. Arrangements should be made to transfer the patient to a psychiatric facility in the same city if a bed is available or any nearby mental health facility.
Article 12 of the law allows other health-care professionals to decide whether to keep someone in hospital during the initial phase of their evaluation. It specified that:
In the absence of a specialized psychiatrist or any other physician to assess the condition of a psychiatric patient, a psychologist, social worker, counsellor or psychiatric nurse may involuntarily detain said psychiatric patient in the hospital on a temporary basis.
In this article of the law, a psychologist, social worker, counsellor or psychiatric nurse may involuntarily detain a psychiatric patient for 8 hours. The wording of the law is “detention” not “admission” because these health professionals do not have the privilege of admitting.
The author is not aware of any other mental health legislation that permits a social worker, counsellor, psychiatric nurse or psychologist to detain patients.
The most likely reason for including other health professionals in this article of the law is the great shortage of psychiatrists. In 2016, there were 718 qualified psychiatrists serving 32 million Saudis, compared with 2200 psychiatrists serving 34 million Canadians.
Another possible reason for including other health professionals is that the need to detain individuals sometimes arise outside of the hospital, and the first responders are social workers or nurses, not physicians. In cases where there is an immediate danger to the patient or others, it may be more effective to train more people in mental health first aid. All health-care professionals in Saudi Arabia are required to attend emergency training when renewing their licences (such as taking a cardio-pulmonary resuscitation course).The person making a temporary involuntary detention decision will inform the physician on duty and the administration of the mental health treatment facility of the condition of the psychiatric patient. The temporary involuntary detention period expires after 8 hours or when a physician’s evaluation of the patient.
The exclusion of the third section of Article 13 is because many emergency departments are not covered by psychiatrists. Therefore, to prevent actual or potential harm to self or others, it is the duty of the emergency department physicians to assess and decide if an emergency admission is necessary. Ideally, a psychiatrist will examine the patient within a relatively short time and make a proper evaluation before either continuing the involuntary admission or revoking the emergency admission. In unfortunate situations, when psychiatrist is not available, it is not clear whether the duration of the emergency admission can be extended by the emergency physician or the team following the patient. Usually, management is involved as early as possible to arrange to transfer the patient to a mental health facility or to have the patient assessed by the psychiatrist.
Involuntary Admission
Articles 13, 14, 16 and 24 of the Mental Health Care Law dictate the legal conditions of a psychiatric involuntary admission. The conditions for involuntary admission are the same as an emergency admission with the addition of the evaluation of two psychiatrists justifying the need for the admission. The legal process is similar to many mental health acts in other countries; however, in the Saudi law, no attempt is made to differentiate whether the individual has insight or not. Safety of the psychiatric patient and others takes precedence over their right to consent to the admission. Also, the interpretation of the actual and potential threat is left to the judgment of the attending health-care professional in the case of an emergency admission or the psychiatrists in the case of involuntary admissions.
These legal requirements involve other services because the detention can occur outside the mental health facility. The transfer of involuntarily admitted patients to a mental health facility is of the responsibility of the following government sectors:
- Red Crescent (RC)
- Ministry of Interior
- police department.
When the RC is called to transfer the patient, the patient should be accompanied by a family member. If the patient resists transfer or threatens the RC with a weapon, police are called. RC personnel phone the receiving mental health facility for any queries about the transfer and ensure that the patient is settled before arriving at by the facility.
The Ministry of Interior will be involved if the patient is carrying a weapon. Once under control, the patient should be kept in the same area where they were initially assessed, and the RC becomes responsible for transferring the patient to the mental health facility.
If the patient has already committed a crime, they are taken to the police station.
The RC trains its personnel about psychiatric disorders, addiction and how to effectively respond to aggressive psychiatric patients. The Ministry of Health directs this training.
The Ministry of Health is responsible for receiving patients from the RC or the police. Indeed, it is the ministry’s responsibility to ensure the RC and the police have access to the addresses and phone numbers of the mental health institution to facilitate direct contact with the on-call psychiatrists. In addition, the ministry provides private security services inside the mental health facilities.
The initial duration of the involuntary admission is similar to emergency admission (72 hours). This can be extended to 30 days, then 90 days and 180 days, if needed. Each time an involuntary admission is extended, the psychiatrists immediately notify the administration of the mental health-care facility. Once the justifications for the involuntary admission cease to exist, the admission should be terminated even if the stipulated period of admission has not expired. For each extension, two psychiatrists provide a report justifying the extension of the involuntary admission. The condition of the admission and the justification for its continuation are reviewed regularly.
If the patient is still unstable after 180 days, the local supervisory board for mental health-care reviews the case and makes the decision to continue with the involuntary admission. The patient, their guardian or legal representative have the right to request the discontinuation of the involuntary admission by the mental health facility. A response is given within 7 days. If the mental health facility rejects the patient’s request and they wish to appeal, they can apply to the local supervisory board for a review of the decision. A response is given within 21 days. In addition, when an involuntarily admitted patient poses an actual or potential threat to someone, the guardian or legal representative as well as the police are informed. The same process applies when a patient escapes, with the addition of the administration of the mental health treatment facility coordinating with law enforcement agencies to recommit the patient.
To ensure that psychiatric patients’ rights are respected, the mental health treatment facility is required to review all the conditions and procedures of involuntary admissions. The local supervisory board for mental health care is notified of the names of involuntarily admitted inpatients within 48 business hours from the time of admission. The mental health treatment facility is required to maintain a record of the patient’s name, age, nationality, distinctive features, identification number, date of issuance, admission and discharge dates, name of the person who brought them in, if any, and all other necessary information. The mental health treatment facility should allow the members of the general and local supervisory boards for mental health care, representatives thereof, and committees set up thereby, to perform their supervisory functions provided for in this law in all departments of the treatment facilities. Articles 3 to 8 cover the law regulating the general and local supervisory boards for mental health care. Both boards are not yet well-established.
Conclusion
This first mental health law in Saudi Arabia has been a major step in the improvement of the care of psychiatric patients. It has helped organized the processes that regulate their admissions. Saudi Arabia is making progress in creating these laws and implementing them. The Mental Health Care Law is now similar in many ways to those applied in western countries. Many of the articles and subsections are interpreted in the context of the available health system. As Saudis see an improvement in the mental health system and an increase in the number of psychiatric facilities and psychiatrists, the mental health law will continue to evolve.
A legal framework is necessary to regulate the rights and duties of individuals living in a community. The Mental Health Care Law in Saudi Arabia is present to ensure that professionals act responsibly with individuals who may be vulnerable due to their mental disorder.
Conflict of interest: None
References
1. Halwani TM, Takrouri MSM. Medical laws and ethics of Babylon as read in Hammurabi’s code (history). The Internet Journal of Law, Healthcare and Ethics. 2018;4(2). (accessed on October 27, 2020).
2. Dunn PM. Aristotle (384–322 bc): philosopher and scientist of ancient Greece. Arch Dis Child Fetal Neonatal Ed. 2006 Jan; 91(1): F75-77. doi: 10.1136/adc.2005.074534. (accessed on October 27, 2020).
3. Imran M, Samad S, Maaz M, Qadeer A, Najmi AK, Aqil M. Hippocratic oath and conversion of ethico-regulatory aspects onto doctors as a physician, private individual and a clinical investigator. J Midlife Health 2013 Oct-Dec;4(4):203-209. doi: 10.4103/0976-7800.122232. (accessed on October 27, 2020).
4. Hornstein G, Eghigian G. From madness to mental health: psychiatric disorder and its treatment in western civilization. New Brunswick: Rutgers University Press; 2010.
5. Larkin M. Modern medicine’s Islamic roots revealed. The Lancet 2000;356(9225):263. doi: 10.1016/S0140-6736(05)74522-0.
6. The Islamic roots of the modern hospital. Aramco World: 2018. (accessed on October 27, 2020).
7. اللائحة التنفيذية لنظام الرعاية الصحية النفسية [Implementing Regulations of the Mental Health Care Law] (accessed on October 27, 2020).
8. Almutairi AF. Mental illness in Saudi Arabia: an overview. Psychol Res Behav Manag. 2015;8:47-49. doi: 10.2147/PRBM.S79268. (accessed on October 27, 2020).
9. Qureshi NA, Al-Habeeb AA, Koenig HG. Mental health system in Saudi Arabia: an overview. Neuropsychiatr Dis Treat. 2013;9:1121-1135. (accessed on October 27, 2020).
10. Koenig HG, Al Zaben F, Sehlo MG, Khalifa DA, Al Ahwal MS. Current state of psychiatry in Saudi Arabia. Int J Psychiatry Med. 2013;46(3):223-42.
11. Pinfold V, Bindman J. Is compulsory community treatment ever justified? Psychiatric Bulletin 2001;25(7):268-270. (accessed on October 27, 2020).
12. Mickle C. Safety or freedom: permissiveness vs. Paternalism in involuntary commitment law. Law & Psychology Review 2012;36:297.
13. Player CT. Involuntary outpatient commitment: the limits of prevention. Stanford Law & Policy Review 2015;26(1):159-238.
14. Large MM, Nielssen O, Ryan CJ, Hayes R. Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2008;43(3):251-256.
15. Giacco D, Priebe S. Suicidality and hostility following involuntary hospital treatment. PLoS one 2016;11(5): e0154458. doi 10.1371/journal.pone.0154458. (accessed on October 27, 2020).
16. Al-Habeeb AA, Helmi BA, Qureshi NA. Mental and social health atlas: An update, Ministry of Health, Saudi Arabia, 2015. International Neuropsychiatric Disease Journal. 2016;6(3):1-20. doi 10.9734/INDJ/2016/23002. (Accessed on October 27, 2020).
17. مستشفى «شهار».. 356 نزيلا ترفض عائلاتهم استلامهم! [Shihar Hospital. 356 inmates whose families refuse to receive them]. Okaz: Nov. 23, 2016. (accessed on October 27, 2020).
18. The First Report on Human Rights Conditions in the Kingdom of Saudi Arabia. Saudi Arabia: National Society for Human Rights; 1427H-2006G, 104- 110.
19. Davis M. Plato’s Minos: The Soul of the Law. The Review of Politics 2016;78(3):343-363.
Corresponding author
Abdullah H Alqahtani, P.O. Box 40237, Khobar 31952, Saudi Arabia, email: abalqhtani@iau.edu.sa.