Involuntary Care Research Articles

Involuntary admission of psychiatric patients in the Northern Cape Province and the accuracy of the initial psychiatric assessment done by the referring general practitioners

Background Admission to a mental healthcare facility is not always based on the voluntary consent of the patient. Sometimes a patient is unable or unwilling to consent to admission because of his mental status and lack of insight into his mental illness. If a mentally ill person needs admission because of a threat to himself and other people, the law prescribes procedures to admit such a person into an appropriate facility for care, treatment and rehabilitation. Such admissions are called involuntary admissions. Involuntary admissions in a psychiatric hospital have financial, legal and ethical implications. In order to avoid unnecessary involuntary admissions, there is a need to determine and understand the factors causing involuntary admissions. Many previous studies have focused on the differences between patients admitted voluntarily and involuntarily. The goal of this study was to analyse the conditions responsible for the involuntary admission of psychiatric patients in the Northern Cape Province and the accuracy of the initial psychiatric assessment done by the referring general practitioners. Methods This descriptive study included 199 patients admitted to West End Hospital in Kimberley for involuntary treatment during 2003. The data were extracted from clinical records and legal documentation relating to these patients. The patients' final diagnoses were extracted from the discharge summary and were based on the text revision of the fourth edition of DSM (DSM-IV-TR). Only diagnoses on axis I (clinical disorders and other conditions that may be a focus 1 clinical attention), axis II (personality disorders and mental retardation) and axis III (physical disorder or general medical condition that is present in addition to the mental disorder) were included in this study. Results Most patients were male (65.8%) and the patients' ages ranged from 16 to 67 years (mean 32 years). Patients were mostly diagnosed with schizophrenia (57.8%), while 26.6% had substance-related disorders. Few patients (5.0%) were diagnosed with mental retardation and personality disorders. A quarter (24.1%) of the patients had a general medical condition. The majority (81.4%) of patients were found “certifiable” and 77.4% were known psychiatric patients. Two-thirds of the patients were referred by general practitioners doing session for the state hospitals. The overall accuracy of psychiatric diagnosis by the referring doctors was considered correct if any of the provisional diagnoses listed by the referring (certifying) doctor matched with the final diagnosis at discharge from the hospital. Approximately half (49.5%) of the patients were diagnosed correctly by the referring doctors. Conclusions Schizophrenia and psychoactive substance-related disorders were the most important conditions leading to involuntary care in the Northern Cape. General practitioners play a major role in involuntary admission, but only made correct psychiatric diagnoses in approximately half of the patients. South African Family Practice Vol. 49 (6) 2007: pp. 14

Factors in the Selection of Patients for Conditional Release From Their First Psychiatric Hospitalization

Factors in the Selection of Patients for Conditional Release From Their First Psychiatric Hospitalization

Table of Contents

Mental Health WeeklyVolume 16, Issue 8 p. 1-8 Table of Contents First published: 21 February 2006 https://doi.org/10.1002/mhw.20030AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract Involuntary Care Measure Fails to Reach Senate Vote as N.M. Lawmakers Adjourn Michigan Commission Report Card Cites Failure of State to Repair MH System Highlights of N.M. Proposal Magellan to Become Exclusive Sponsor of NAMI Provider Education Program SAMHSA Issues Consensus Statement on Mental Health Recovery Briefly Noted Resources Coming up Volume16, Issue820 February 2006Pages 1-8 RelatedInformation

Individual Rights Must Be Balanced With `Caring Coercion'

Back to table of contents Previous article Next article From the PresidentFull AccessIndividual Rights Must Be Balanced With `Caring Coercion'Steven S. Sharfstein, M.D.Steven S. SharfsteinSearch for more papers by this author, M.D.Published Online:2 Sep 2005https://doi.org/10.1176/pn.40.17.00400003Until just 40 years ago, most people who were seriously mentally ill were coerced and confined (see related article on Original article: page 24). The combination of fear and compassion led Western society, through legal and medical means, to restrict the “insane.” Now the majority of people with mental illness reside in the community and receive treatment in the “least-restrictive settings.”One compelling reason, however, remains for involuntary hospitalization: fear of violence, especially from individuals who are behaving erratically or preoccupied with delusions and lacking a fundamental awareness of their mental illness and their need for treatment. Yet even this fundamental and historical justification for psychiatric coercion is controversial today, clashing with deeply held notions of individual liberty and autonomy.In recent years the civil rights of mentally ill people have been in the forefront of discussion and debate, in terms of—depending on your point of view—their right to treatment when resources are dwindling or their right to refuse treatment. Society expects psychiatric physicians to exercise good clinical judgment in protecting psychotic patients from themselves or others. Since most inpatient care, including involuntary care, is short term, the issue of coercion has shifted, in part, from involuntary hospitalization to mandatory outpatient treatment.Mandatory outpatient, or assisted, treatment is court-ordered outpatient care for certain individuals who have a severe mental disorder and do not comply with treatment. It is a preventative approach to trying to avoid not only inpatient care but also the much more deleterious outcome of homelessness and incarceration—the modern epidemic for severely and persistently mentally ill people in America.As of today, 42 states and the District of Columbia have outpatient commitment statutes, although most of these states implement this authority in a haphazard and inconsistent manner. Assisted treatment has received media attention due to some well-publicized papers on violence in the community committed by mentally ill persons such as Russell Weston, who killed three U.S. Capitol police officers in 1998, and Andrew Goldstein, who pushed Kendra Webdale onto the subway tracks in New York.The Goldstein case led to the passage of “Kendra's Law,” establishing mandatory outpatient treatment in New York (Psychiatric News, August 19). Recent data from the New York State Office of Mental Health on the first five years of implementation of Kendra's Law indicated that of those participating (several thousand individuals), 77 percent fewer experienced hospitalizations.In New York there is widespread acknowledgement that this law, despite the protests from some civil libertarians, has been an outstanding example of what I would term “caring coercion.”A randomized, controlled study in North Carolina found that patients who received intensive routine outpatient services without a court order did not lead to reduced hospital admission rates. But when patients were given the same level of services (at least three outpatient visits a month, with a median of 7.5 visits a month) combined with assisted treatment of six months or more, hospital admissions were reduced by 57 percent and the length of stay by 20 days, compared with individuals without court-ordered treatment.Despite the above findings, outpatient commitment, or assisted treatment, remains controversial, and currently there is no such law in Maryland, where I live and work.Another example of “caring coercion” is mental health courts. These courts use their judicial authority to impose treatment compliance as a condition of release from jail or bail or as an alternative to jail. Failure to comply results in the imposition of sanctions up to and including incarceration. The court-ordered treatment alternatives are another example of trying to deal with the number of people with severe mental illness caught up in the criminal justice system.One of the great tragedies of modern psychiatry is the large number of incarcerated individuals who are mentally ill or drug addicted. This is the inevitable consequence of our reluctance to use caring, coercive approaches such as assisted treatment. A person suffering from paranoid schizophrenia with a history of multiple rehospitalizations for dangerousness and a reluctance to abide by outpatient treatment, including medications, is a perfect example of someone who would benefit from these approaches. We must balance individual rights and freedom with policies aimed at caring coercion. Our responsibility to each other and our respect for personal rights lie at the center of our social and moral choices as Americans. ▪ ISSUES NewArchived

Experiences of coercion during investigation and treatment

According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care ( n = 39), or with previous experience of assessment and involuntary care ( n = 35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p < .05) and they were more positive towards the final decision (60% vs. 24%, p < .05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.

Brief Reports: Outcomes of Patients in a Low-Intensity, Short-Duration Involuntary Outpatient Commitment Program

This study examined the outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program. After release from inpatient commitment, one group (N = 150) entered an involuntary outpatient commitment program that lasted up to six months; a comparison group (N = 140) was released into the community without further involuntary care. After the analysis adjusted for confounding variables, patients who were in the involuntary outpatient commitment program had greater use of follow-up outpatient and residential services and psychotropic medications than patients in the comparison group. No differences were found between the groups in follow-up acute psychiatric hospitalization or arrests. Low-intensity, short-duration involuntary outpatient commitment appears to have a limited, but important, impact.

Psychiatrists' Perceptions of Administrative Review: A Victorian Empirical Study

In 1987, the Mental Health Review Board commenced operations under the Mental Health Act 1986. Its principal purpose was to provide an independent review of persons involuntarily detained for treatment of mental illness. These legislative changes reflected a governmental desire for greater accountability and transparency in the provision of involuntary treatment and care, and a much greater focus on the protection of the rights of people with serious mental illness. At that time, independent review of psychiatric decisions was novel in Victoria, and was met with a degree of hostility and resentment by some public sector psychiatrists. In 1995, I conducted interviews with 22 senior public sector psychiatrists from across Victoria, in order to determine whether, and if so how, administrative review had impacted on them and their psychiatric practice between 1987 and 1995. I revisited the research in 2004 in interviews with 15 psychiatrists. In general terms, the 2004 findings reflected an increased level of support for the functions of the Board, and a significant increase in those who considered Board procedures and decisions had impacted on their clinical practice. Consistent with the 1995 findings, the 2004 research confirmed the legitimating effect of the Board for some psychiatrists, and also suggested an increase in those who may seek either to devolve responsibility for decision-making to the Board in difficult cases, or to share a degree of responsibility in such cases. The majority of those interviewed remained sceptical about the capacity of administrative review to raise standards of treatment and care or bring about positive therapeutic outcomes for patients. In view of this finding, it is argued that there is a role for increased education of, or promotion to, clinicians and Board members concerning the positive therapeutic potential of administrative review.

Involuntary Commitment in Health Care; An Analysis of the Status and Rights of Involuntarily Treated Psychiatric Patients in Comparison with Patients Treated Involuntarily under Other Acts

AbstractA number of international legal and ethical guidelines attempt to safeguard patients' rights in various health care areas. On the national level, health care legislation defines the rights of different patient groups more concretely in everyday practice. In general, the right to decide about one's own treatment — and to refuse treatment — is considered to be of the greatest importance. Several patient groups can, however, be treated involuntarily. In addition to minors, psychiatric patients in certain situations form a group of patients whose own will can be overridden in health care. In Finland also intoxicant abusers, the mentally retarded and patients suffering from certain communicable diseases can in special situations be taken into involuntary care. This article discusses the differences between the status and rights of involuntarily treated patients in different social and health care acts in Finland. Several paragraphs of the laws studied were identified that assign more rights to patients treated involuntarily under the Act on Social Work with Intoxicant Abusers and the Act on Special Care for the Retarded than to involuntary psychiatric patients. The practical implications of this article will be discussed.

Efficacy of continuing advocacy in involuntary treatment.

The effectiveness of an experimental model of personal advocacy for involuntarily hospitalized psychiatric patients was examined. In the model, a personal advocate represented the needs and best interests of patients throughout the period of involuntary hospital treatment. The sample consisted of 105 involuntarily hospitalized psychiatric inpatients in Canberra, Australia. Fifty-three consecutive patients received personal advocacy, which started soon after they entered the hospital and lasted through the commitment process to the time of discharge from involuntary care. The outcome of this group was compared with that of 52 consecutive patients in a control group who received routine rights advocacy from hospital entry through the commitment hearing only. The experimental and control groups were similar in demographic characteristics, diagnosis, and severity of illness. At the start of hospital care, satisfaction with care was similar in both groups; however, it improved significantly in the experimental group while it declined in the control group. Aftercare attendance was significantly better in the experimental group. The experimental subjects' risk of involuntary rehospitalization was less than half the risk of control subjects, and community tenure was significantly increased. Clinical staff reported that the experimental advocacy facilitated management of patients. Compared with routine rights advocacy, the experimental advocacy based on patients' needs and best interests, which was maintained throughout the patients' involuntary hospitalization, significantly improved patients' and staff members' experience of involuntary treatment. Better compliance with aftercare among patients receiving personal advocacy led to a statistically and economically significant reduction in rehospitalization.

The development and evaluation of a hybrid decision support system for clinical decision making: The case of discharge from the military

This article reports on the development, implementation, and evaluation of a decision support system (DSS), a hybrid of a statistical model (regression equation) and expert rules, to support this decision. The study focused on the decisions made by social workers, psychologists, and psychiatrists serving as military mental health officers to recommend discharge from compulsory duty in the Israeli army because of mental or emotional difficulties. The process involved three consecutive steps: modeling decisions by statistical analysis of past and current decisions and by eliciting expert rules, developing o hybrid decision support system, and evaluating the DSS through empirical validation and a user survey. The validity of this hybrid DSS was established. The DSS was able to predict 86.5 percent of new decisions made by mental health officers and 70 percent of post decisions. User acceptance, on the other hand, was low. This article discusses these findings and their implications for practice. Key words; clinical judgment; decision support systems; expert rules; mental health officers; military Social workers and other helping professionals make clinical judgments on a routine basis. Many of these decisions have important consequences for clients. Relying on clinical judgment and expertise, practitioners make daily decisions whether to accept clients for treatment, render services, hospitalize, discharge, or commit to involuntary care; such decisions can be of immeasurable significance to people's lives. Our empirical study of these important judgments and decisions made in the helping professions revealed how these professions are fallible and prone to error (Gambrill, 1990; Gibbs & Gambrill, 1996; Nisbett & Ross, 1980). Almost all clinical decisions are made under some degree of uncertainty (Hogarth, 1980). Many factors in the decision-making process, such as incomplete or unreliable information relevant to the decision, and errors or inconsistencies in the application of decision-making rules introduce uncertainty. Much of the uncertainty results from the probabilistic nature of the outcomes of decisions. Decisions made under what seem to be identical situations lead to different outcomes (Cooksey, 1996). Fallibility, therefore, is an inseparable feature of clinical judgment under uncertainty. Our study focused on the decisions made by social workers, psychologists, and psychiatrists serving as military mental health officers (MHOs) to recommend discharge from compulsory duty in the Israeli military services because of mental or emotional difficulties. This decision has significant consequences for the individual soldier, as well as for the soldier's social environment. Compulsory service in the military is a major duty and right of all Jewish citizens in Israel (most non-Jewish citizens are exempt from compulsory service). A discharge on the basis of psychiatric dysfunction stigmatizes the individual in civilian life. Consequences range from difficulties in obtaining a driver's license or in securing employment to less blatant discriminatory attitudes in Israeli society. On the other hand, a misguided decision not to discharge a dysfunctional soldier may lead to dire outcomes such as psychotic breakdown, suicide, and violent behavior within the unit, which in turn could lead to failure in battle (Benbenishty, Zirlin-Shemesh, & Kaplan, 1993). Military MHOs, the majority of whom are social workers, assess the soldier and decide whether or not to lower the soldier's medical rating on psychiatric grounds, thereby causing an immediate dismissal from the military. This decision is based on clinical judgment and not on any preset requirements or guidelines. Thus, it is open to the same problems in judgment identified in so many other contexts. Furthermore, given the consequences of the decision, the need to maintain consistency among MHOs making the decision is of special importance. …

Correlates of Perceived Coercion During Psychiatric Hospital Admission

Involuntary care is a feature of mental health services around the world. In addition to involuntary admission and treatment, specific coercive practices include seclusion and physical restraint. Our study aimed to determine the relationships, if any, between these practices and perceived coercion on admission among psychiatry inpatients in Ireland, as well as any relationships between perceived coercion on admission and variables such as age, gender and diagnosis. We included 107 psychiatry inpatients aged 18 years or over who were admitted to the acute psychiatry admission units in Tallaght University Hospital and Connolly Hospital, Dublin, Ireland over a 30-month period between September 2017 and February 2020. Over a quarter (27.1%) of participating patients had involuntary status; nine (8.4%) had experienced at least one episode of seclusion, and ten (9.3%) had experienced at least one episode of restraint. Perceived coercion on admission was significantly associated with involuntary status and female gender; perceived negative pressures on admission were significantly associated with involuntary status and positive symptoms of schizophrenia; perceived procedural injustice on admission was significantly associated with fewer negative symptoms, involuntary status, cognitive impairment and female gender; and negative affective reactions to hospitalisation on admission were significantly associated with birth in Ireland and being employed. Total score across these four subscales was significantly associated with involuntary status and positive symptoms, and had borderline significant associations with birth in Ireland, being employed and female gender. Overall, perceived coercion on admission, assessed in retrospect by the patient, is more closely associated with involuntary status and symptoms than it is with subsequent formal coercive practices, such as seclusion and restraint. The role of gender merits particular attention in future research, especially in relation to procedural injustice on admission and perceived coercion on admission.

Moral responsibility and mental disease

The problem of moral responsibility is much more acute in psychiatry than in somatic medicine. We can sketch a clinically and morally relevant decision problem as a son of moral dialogue between two parties: a psychiatrist (=PS) considering the alternatives within the axis voluntary versus involuntary psychiatric care and a patient candidate (=X), possibly in need of psychiatric hospitalization independently of his (or her) own will. The aim of my paper is to put forward a sketch of some new guidelines of PS's decision problem, from the point of view of moral philosophy. Themes scrutinized with clinical examples are, for example, the concept of reflective equilibrium, intuitive versus critical thinking, comparative versus non comparative justice Coherence, Comparative versus non comparative justice, Correspondence, Intuitive versus critical thinking, Moral dialogue.

Need for treatment and New York's revised commitment laws: An empirical assessment

In recent years, psychiatric and law journals have been concerned with the nature and impact of “the new commitment laws.” The emphasis in these laws is alleged to be on patients’ civil liberties, alternatives to hospital commitment, and community based treatment resources (Shore, 1978; Cockerham, 1981; Gove et al., 1982). These laws appear to be informed in part by the following elements of the 1972 American Psychiatric Association position statement: (1) most persons who need hospitalization should be admitted voluntarily; (2) community based outpatient facilities should be used in place of inpatient hospital admissions as far as possible; (3) involuntary care should be reserved for persons who may harm themselves or others; and (4) involuntarily committed persons who are hospitalized should be provided full legal rights of due process. Despite these aims, which have not always been incorporated perfectly in the new laws, the most recent theoretical literature indicates that the criteria for involuntary hospitalization and due process are so vague that they are ultimately unworkable and ill-advised (Diamond, 1974; Arons, 1977; Schoenfeld, 1977; Toews et al., 1980; Langman, 1980; Shah, 1981a, 1981b; Wexler, 1981). Furthermore, most of the empirical studies of the impact of the new laws indicate, first, that a sizable portion of involuntarily committed patients are not admitted to inpatient care following the mandatory observation period; second, that involuntary commitments continue to outnumber voluntary admissions; third, that patient recidivism is increasing; and finally, as Hiday (1983, p, 114) recently put it, “there is still lingering deference to psychiatric recommendation, commitment without evidence of facts of dangerousness, and passive or nonadversary counsel.” These generalizations may be drawn from the Gudeman et al. (1976) study of Hawaii patients; Luckey & Berman’s (1979, 1981) studies in Nebraska; Miller & Fiddleman’s (1981, 1982) and Hiday’s (1982) studies in North Carolina; Haupt & Ehrlich’s (1980) study of Pennsylvania patients; Lipsitt & Lelos’ (1981) study in Massachusetts, Shore et al. (1981) study of Oregon patients, and Hiday’s (1983) recent review of studies in mental health law. New York State’s revised commitment laws have not yet been empirically