Mental health strategy still seems elusive

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

What’s the difference between "excited delirium" and "autonomic hyperarousal state?"

Not much. In fact, in the provincial government’s response to the Hyde Inquiry report, the second term is used as a replacement for the first.

The inquiry, headed last year by provincial court Judge Anne Derrick, studied the death of Howard Hyde, a Dartmouth man who died in custody in 2007 at the Central Nova Scotia Correctional Facility in Dartmouth. Hyde suffered from mental illness and the cause of his death was initially identified by a coroner as "excited delirium."

Derrick rejected that as a "red herring." She found that Hyde died as a result of a restraint technique used on him by guards during a struggle.

Hyde had been repeatedly shocked with a stun gun during his 30 hours in custody. Derrick found that while the use of the stun gun did not cause Hyde’s death, the repeated shocks contributed to his deteriorating mental state.

Derrick’s report also strongly called for improved training for law enforcement officers who come in contact with people suffering from mental illness. The judge painted a clear path towards the use of de-escalation techniques in advance of the use of stun guns.

But the province seems to be struggling to find the right balance between public safety issues and the use of stun guns by officers. It has yet to finalize its guidelines for stun gun use, though Justice Minister Ross Landry said Thursday they will be released within a few weeks.

The minister did not explain why there has been a delay in issuing the guidelines or why, if only a few more weeks were needed, the province’s response to the inquiry report was not delayed so the documents could be released together.

But it speaks volumes that the use of the stun guns has already dropped by over 70 per cent since Hyde’s death in 2007, as The Canadian Press reported on Thursday.

In addressing what is now being described as an "autonomic hyperarousal state," the report released Thursday did not rule out using a stun gun on a person who may be mentally ill. But plenty of work remains to be done on the training side of the equation.

"Law enforcement officers must have appropriate tools to assist them in maintaining public safety," says the report. "At the same time, people living with mental illness may already be experiencing a high level of anxiety and the use of restraint could escalate the situation.

"The province and policing partners agree that the use of conducted energy weapons should only occur when a person’s behaviour is aggressive or violent and could harm the person or the public or the police officer. Additional direction is required regarding the restraint of individuals with mental illness."

The delay in providing that direction is not explained but Landry is clearly not comfortable with the current level of knowledge and training.

"It’s very difficult in situations where . . . there’s a high level of disturbance for the police officer to determine whether the person is suffering from mental illness," the minister told reporters on Thursday after the response was released.

In fairness to police, officers are often called on to make very quick decisions about the use of force in highly charged situations. But the death of Howard Hyde, among other cases, provides a reminder of the responsibilities that accompany the use of force, including the use of stun guns and other various forms of restraint.

There are federal guidelines available to help officers make those judgment calls and the province has said its stun gun rules will consider the federal document as well as expert advice provided by a panel of psychiatrists.

Derrick was clearly on the right track in emphasizing the need for much better levels of training. And in fairness to the province, some progress has already been made in addressing areas of concern raised in the inquiry report.

But the wheels continue to grind slowly towards the judge’s most important recommendation, adopting a provincial mental health strategy. The government is still waiting for a report from stakeholders.

It has been nearly two years since the NDP formed government and promises to improve mental health policies and services are growing stale.

(mstephenson@herald.ca)

Image credit

Focus on training, not terminology

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson [pictured]

A DEBATE OVER whether so-called "excited delirium" is a valid condition is a waste of time. What is more significant — in terms of how police and jail guards react to it — is the risk of death for a person in this state and how to best respond when high-risk situations unfold.

Last week Justice Minister Ross Landry released a report from an expert panel struck to review the condition last year. The panel was formed in response to the 2007 death of Howard Hyde of Dartmouth. He died in custody after a struggle with police. He had been shocked with a stun gun by them 30 hours earlier.

A death inquiry, led by Judge Anne Derrick, is already underway and its outcome is separate from the report. A pathologist has already concluded that Hyde died of excited delirium — a condition the panel says would be better labelled autonomic hyperactivity syndrome (AHS) — and not from the stun gun shock he received the day before.

We can expect from the inquiry, at the very least, another truckload of recommendations targeting how first responders deal with mentally ill people. A doctor who checked out Hyde after he was shocked with the stun gun has already testified that she would never have released him to the police had she known he would not receive the psychiatric assessment she had requested. Hours later, he was dead.

Dr. Stan Kutcher, a psychiatrist at Dalhousie University, served as chairman of the panel. He told The Chronicle Herald in an interview that "the most important thing here is to realize that this is a medical emergency and that this situation requires the combined efforts of law enforcement and medical first responders."

Police and jail guards will get extra training to ensure they are better equipped to recognize the symptoms of AHS and to call in medical assistance in those circumstances, says Landry. This is one of the key recommendations in a report that contains many useful guidelines for moving forward towards better responses to people experiencing AHS.

Symptoms — which can lead to hyperthermia, cardiac arrhythmia and sudden death — include extreme agitation, aggressive behaviour, paranoia or delirium, incoherent and rambling speech, extraordinary strength, numbness to pain, and profuse sweating.

The report says that "mortality rates are increased in the presence of the signs and symptoms of excited delirium — even with medical intervention or in the absence of use of restraints by law enforcement."

The panel also found that "it is reasonable to consider that, when further stressed by physical struggle or the application and continuation of physical restraints (including the CED), an individual exhibiting the syndrome of excited delirium may be at increased risk for sudden death.

"Similarly, the pre-existence of a medical or psychiatric condition (such as a psychotic illness, pre-existing cardiac condition, delirium with or without the use of psychostimulant drugs) may increase the risk for sudden death in an individual showing signs and symptoms consistent with excited delirium."

That is the nub of the issue: People who suffer from mental illnesses that end up in a state of excited delirium are at an increased risk of death. While police and jail guards may well be the people who are first required to be on the scene of such a situation, additional training is clearly needed to ensure they know when it is paramedics, rather than restraints and a physical struggle, that is more likely to bring a safe outcome to the situation.

Police officers and jail guards are often in very challenging, high-stress situations, where public safety, their own safety and the safety of the person they are trying to subdue must be judged at lightning speed.

They must be provided with every tool possible to make the right decisions in those moments. If that means more training to properly assess, arrest and/or subdue people with mental illness, then it should happen as soon as possible. Calling for medical assistance should be considered a first option, not a last resort.

Even one Howard Hyde outcome is one too many.

Also see:

Vulnerable targets

More training in mental illness

An article published in today's edition of The Chronicle Herald:

Report: Emergency workers need latest information on excited delirium

By David Jackson, Provincial Reporter

Police and jail guards will get more training to recognize mental illnesses and how to deal with people afflicted with them, Justice Minister Ross Landry said Friday.

The province commissioned an expert panel last year to look at the phenomenon called excited delirium and what role it could play in in-custody deaths, to examine the risks of using stun guns and other restraints on people in that state, and to recommend how law enforcement officials should deal with those people.

Mr. Landry said the most significant recommendation in the eight-member panel’s new report is ensuring that front-line justice workers are trained to recognize people with symptoms of excited delirium, or as the panel suggests calling it, autonomic hyperarousal state.

The minister, a former RCMP officer, said officers do get training in dealing with people with mental illnesses but new information is always coming along, as with this condition.

"A couple of years ago, who knew about this?" Mr. Landry said in a telephone interview. "It’s not that long ago. And yet, people over time have passed away in this condition."

It was the death of Howard Hyde, a Dartmouth man who had a history of mental health issues, that led to the panel’s review. Mr. Hyde died in November 2007, 30 hours after Halifax Regional Police Tasered him when he scuffled with them at the police station.

The province’s chief medical examiner, Dr. Matthew Bowes, said Mr. Hyde died of excited delirium due to paranoid schizophrenia. Dr. Bowes said the death was accidental and he found no evidence that the Taser caused the death.

The death led to a provincial review of Taser use, and that led to the review of excited delirium.

The panel, of which Dr. Bowes was a member, said the symptoms of excited delirium are common to other medical and psychiatric conditions and recommended that the term autonomic hyperarousal state be used for people showing those symptoms.

Panel chairman Dr. Stan Kutcher, a psychiatrist at Dalhousie University, said there’s been a useless debate about whether excited delirium is or isn’t a medical diagnosis. He said the panel found the phenomenon well-described in medical literature going back 120 years, just under different names.

The symptoms include extreme agitation, aggressive behaviour, paranoia or delirium, incoherent and rambling speech, extraordinary strength and numbness to pain, and profuse sweating, the report said.

Dr. Kutcher said the key thing to keep in mind in dealing with people in that state is they need medical attention.

"I think the most important thing here is to realize that this is a medical emergency and that this situation requires the combined efforts of law enforcement and medical first-responders," he said in an interview.

The panel recommends creating a provincial training program for all first-responders in recognizing signs of mental illness and responding appropriately.

The report also says call-takers and dispatchers should get special training to help them recognize whether a call involves someone with a mental illness.

Dr. Kutcher said a dispatcher can get an indication of that by asking certain questions, such as whether the caller knows if the person they’re calling about is aware of his or her surroundings. The information would help a dispatcher know whether to send police and paramedics to the scene right away.

The panel recommended first-responders first try to calm the person in a hyperaroused state by talking to them, but if that doesn’t work, to restrain them quickly because a prolonged struggle could jeopardize the person’s life.

Dr. Kutcher said the panel couldn’t find scientific evidence suggesting that one form of restraint is better or safer than another, including stun guns. He said that’s why the panel recommended the province create a database on incidents involving the use of force.

Halifax Regional Police already adhere pretty well to the review’s goals, said Const. Brian Palmeter, the force’s spokesman.

"Our training and practices are consistent with the recommendations," he said.

"That being said, we are looking forward to working with the province to review and update our training where necessary."

Still, Const. Palmeter doubts there will ever be a single case in which an officer would be able to handle the crisis and follow all the recommended advice completely.

Mr. Landry said his department will consult with police, jail guards and sheriff’s services in developing procedures for dealing with people with mental illnesses. He said officers often have to make split-second decisions when dealing with people, so he wants them to have the information to help them make good decisions.


Joanna Blair holds a photo of her brother Howard Hyde, taken when he was in his early 20s. (BRIAN MEDEL / Yarmouth Bureau)


Dr. Hunter Blair, whose wife Joanna Blair is Mr. Hyde’s sister, thinks a dispatcher won’t always be able to get enough information from an excited caller to know whether to send an ambulance to a scene involving a person with mental illness.

The main issue, he said, is how to handle that person once you get there, and the review doesn’t seem to contain much new information.

"They’ve produced what you would have expected them to produce, given the current state of knowledge or non-knowledge," he said from his Shelburne home Friday.

He is happy with the recommended plan to track all calls to study the outcomes of various restraint methods and treatments.

"That’s a good move," he said. "They started doing this in Ontario some time ago."

Health Minister Maureen MacDonald said officials in her department will consult with district health authorities and Emergency Medical Care Inc., which provides ambulance services, about the report.


HANDLING EXCITED DELIRIUM

The following is a summary of the nine recommendations found in the Panel of Mental Health and Medical Experts Review of Excited Delirium:

• The panel prefers the term autonomic hyperarousal state (AHS) over excited delirium, which is confusing and incorrectly suggests a defined medical diagnosis.

• People showing signs of AHS should be considered at risk of sudden death by hospital emergency staff who should be trained to identify and treat them. Once restrained, these individuals should undergo a thorough medical examination. Hospital staff should be ready to resuscitate.

• When it comes to first-responders called to possible cases of AHS, whoever takes such a call should dispatch police and Emergency Health Services simultaneously. If police encounter someone who may have AHS, they should call for EHS and backup immediately. Officers should de-escalate the situation by removing potentially hazardous objects and people from the area and trying to calm the individual without challenging him or her. If restraint must be used, it should be applied quickly. Immediately take the person to hospital and monitor him or her along the way.

• When restraints are used, they should be the least restrictive means that would bring the subject under control. If such a person is restrained, it should be treated as a medical emergency and EHS should be called immediately.

• A database should be created to track the use of various restraint methods to see their effect on people with AHS.

• Studies should be done to review the relationship between the characteristics of subjects and the outcomes of different methods of restraint.

• There should be a unified provincial training plan to help first-responders recognize signs of mental illness and respond correctly. Dispatchers and other call-takers should be trained to recognize signs of mental illness.

• A formal protocol should be developed in each area of the province describing the role of law enforcement and health professionals concerning mentally ill people, including those with AHS.

• An evaluation process should be set up to evaluate the effectiveness of the above-mentioned recommendations.

Source: Panel of Mental Health and Medical Experts Review of Excited Delirium

With Dan Arsenault, crime reporter

Also see:

N.S. excited delirium report recommends first responders get more training

More police, paramedic training urged for excited delirium

Paramedics needed in delirium cases: report

Excited delirium is a real risk, Nova Scotia report into taser death warns

Excited delirium: Consideration of selected medical and psychiatric issues

Minister Releases Excited Delirium Report

A media release issued today by the Nova Scotia Department of Justice:

Department of Justice
September 4, 2009 11:31 AM

A report on excited delirium was released today, Sept. 4, by Justice Minister Ross Landry.

The province commissioned the 38-page Report of the Panel of Mental Health and Medical Experts Review of Excited Delirium in November 2008, to make recommendations to help law enforcement officers when responding to individuals showing excited delirium symptoms.

The report contains nine recommendations to develop new principles, protocols and procedures to deal with individuals who come into conflict with the law and display extreme agitation, aggressive and paranoid behaviour. It also outlines the need for further training and research.

The volunteer panel members included physicians, government staff and experts in the area of mental illness. Dr. Stan Kutcher from the department of psychiatry at Dalhousie University chaired the group.

"I want to thank the experts who offered their advice on this issue which is of great importance to those responsible for public safety and those who deliver medical help," said Mr. Landry.

Government will now consult other health and justice first responders.

The full report is available [by clicking here (PDF)].

FOR BROADCAST USE:

A report on excited delirium was released today (September 4th), by Justice Minister Ross Landry.

The province commissioned the 38-page Report of the Panel of Mental Health and Medical Experts Review of Excited Delirium in November 2008.

It contains nine recommendations to help develop new protocols for Nova Scotia's law enforcement officers when responding to individuals displaying excited delirium symptoms.

The province will now seek input from Justice and Health first responders.

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Media Contact:

Sherri Aikenhead
Department of Justice
902-424-3313
E-mail: aikenhsl@gov.ns.ca