Étude observationnelle d’une cohorte de 103 patients admis en soins psychiatriques sans consentement en application de la loi du 5 juillet 2011

Abstract

IntroductionThe French Mental Health Act was reformed by the law of July 5th 2011. This included the new possibility of involuntary admission to a psychiatric hospital, justified by the need for psychiatric care “due to an imminent danger”, in case a written application is unavailable. This previously non-existent procedure deserves to be compared to the usual one: Application by a third party for an admission order. We present a study comparing two groups of patients involuntarily admitted to psychiatric wards: “Immediate danger” procedure versus a third party's application. Material et methodsWe designed an observational study. The sample included adult patients for which an admission order was established at Angers’ University Hospital (CHU d’Angers) over the period of 90 days: July 16th through October 15th 2012. We gathered information regarding socio-demographical data, admission procedure, the reason for the absence of a written application (when necessary) and ICD-10 diagnosis. Follow-up was performed 60 days after the initial assessment by reviewing the patient's medical record and extracting data concerning the duration of involuntary treatment (main endpoint), the total duration until discharge, the type of procedure that ended involuntary treatment and the outpatient treatment plan at hospital discharge. We hypothesized that no statistical difference should be found between the characteristics of the two groups in terms of medical care. ResultsA cohort of 103 patients were included (18 to 83years of age, mean=42): 39 (37.9%) were admitted according to the “imminent danger” procedure and 64 (62.1%) according to a third party's application. There were no significant differences in terms of socio-demographical data. The average length of involuntary treatment for the sample was 16.5 days, namely 14.7 days for the first group and 17.6 days for the second (P=0.42). The average length of hospital stay for the entire sample was 20 days (16.2 for the “imminent danger” group versus 22.4 for the “third party's application”, P=0.07). Nine admission orders were still ongoing after 60 days (8.7%). Among the other 94 cases, a single one had been revoked by judge order, the rest on medical grounds. Within this 94-case sub-population, we identified a significant statistical difference between the two procedures in terms of involuntary treatment duration (9.4 days for the first group versus 14 days for the second, P=0.05) as well as hospital stay (13.2 days for “imminent danger” versus 19.3 for “third party's application”, P=0.03). No difference was found concerning the planned follow-up after discharge. DiscussionOur hypothesis was confirmed by the observed length of involuntary treatment and hospital stay. The proportion of “immediate danger” procedures was twice higher in our sample than the usual rate reported in France. This may show an underlying local tendency to initiate involuntary admissions for “immediate danger” in crisis situations which would benefit from a quick resolution. By comparing diagnosis in our sample to national levels, we identified more mood disorders (36.7% versus 19%) and less psychotic disorders (35.9% versus 50%). The mean hospital stay (20 days) was shorter than the national average of 34.2 days. The fact that most “immediate danger” patients see their compulsory measure revoked before meeting the judge may pose the question of insufficient guarantees against arbitrary admissions and could prove an incentive for a judge intervention earlier than the current two-weeks delay. ConclusionThe observed differences between the two admission procedures are likely due to several factors. It is important to identify these factors in order to maximise referral for psychiatric emergencies, as well as harmonising medical practice and providing adequate treatment for the entire population.