The Mental Health Act is currently under review. Our findings support the need for treatment to be maintained in patients who would be at substantial risk of suicide or violence if they were to relapse. It is clearly unacceptable that patients who have a history of violence, or serious aggressive behaviour, in the context of mental illness should be allowed to be non-compliant with any effective treatment or to lose contact with services, as occurred in several cases prior to homicide. The same is also true of patients at high risk of suicide.

In these patients it is not safe to wait until risk has clearly manifested itself before turning to the use of the Act. It should be possible to treat high-risk patients as soon as there are clear signs that a familiar sequence of events has begun which will lead to suicide or serious violence.

The Mental Health Act Commission has clarified that the Act can be used before relapse has become severe.10 Our data show that clinical relapse in the sense of mental state symptoms frequently does not occur prior to suicide and homicide, but that many patients show "proxy indicators", including simple non-compliance with treatment. The new Act must allow treatment in the community at the earliest point in cases of high risk (Recommendation 25).

However, this extension of its powers increases the need for more skilled assessments and suitable training. These too should become a requirement of the Act, placed on the professionals who will use it. It also needs to be emphasised that the proportion of suicides and homicides that will be prevented by enforced community treatment is small. If, for example, the target of such treatment were people with schizophrenia or affective disorder who in their last admission had to be detained under the Mental Health Act, and if all suicides and homicides were prevented in which non-compliance or non-attendance had recently occurred, then according to our data, 30 suicides and 2 homicides would be prevented per year.