Involuntary Hospital Treatment Research Articles

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion.

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences. This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families. Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries.

Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs. This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. Comparisons between the empirical findings were drawn using a structured expert consensus process. Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns. Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

Can "Model Projects of Need-Adapted Care" Reduce Involuntary Hospital Treatment and the Use of Coercive Measures?

Intensive outpatient models of need-adapted psychiatric care have been shown to reduce the length of hospital stays and to improve retention in care for people with severe mental illnesses. In contrast, evidence regarding the impact of such models on involuntary hospital treatment and other coercive measures in inpatient settings is still sparse, although these represent important indicators of the patients' wellbeing. In Germany, intensive models of care still have not been routinely implemented, and their effectiveness within the German psychiatric system is only studied in a few pioneering regions. An innovative model of flexible, assertive, need-adapted care established in Berlin, Germany, in 2014, treating unselected 14% of the catchment area's patients, was evaluated on the basis of routine clinical data. Records of n = 302 patients diagnosed with severe mental disorders, who had been hospitalized at least once during a 4-year-observational period, were analyzed in a retrospective individual mirror-image design, comparing the 2 years before and after inclusion in the model project regarding the time spent in hospital, the number and duration of involuntary hospital treatments and the use of direct coercive interventions like restraint or isolation. After inclusion to the project, patients spent significantly less time in hospital. Among patients treated on acute wards and patients with a diagnosis of psychosis, the number of patients subjected to provisional detention due to acute endangerment of self or others decreased significantly, as did the time spent under involuntary hospital treatment. The number of patients subjected to mechanical restraint, but not to isolation, on the ward decreased significantly, while the total number of coercive interventions remained unchanged. Findings suggest some potential of intensive models of need-adapted care to reduce coercive interventions in psychiatry. However, results must be substantiated by evidence from randomized-controlled trials and longer observation periods.

Shared decision-making with involuntary hospital patients: a qualitative study of barriers and facilitators.

Last year, there were more than 63 622 involuntary admissions to psychiatric hospitals in England. One of the core principles stipulated in the code of practice for care under the Mental Health Act is involving involuntary patients in care decisions. Identifying barriers and facilitators to shared decision-making with involuntary patients. Focus groups and individual interviews with patients and clinicians who have experience with involuntary hospital treatment were carried out. Data were subjected to thematic analysis. Twenty-two patients and 16 clinicians participated. Barriers identified included challenges in communication, and noisy and busy wards making one-to-one meetings difficult. Patient involvement was identified as easier if initiated early after admission and if the whole clinical team was on board. Carers' presence helped decision-making through providing additional information and comfort. The barriers and facilitators identified can inform changes in the practice of involuntary care to increase patient involvement. None.

Next of kin's experiences of involvement during involuntary hospitalisation and coercion.

BackgroundNorway has extensive and detailed legal requirements and guidelines concerning involvement of next of kin (NOK) during involuntary hospital treatment of seriously mentally ill patients. However, we have little knowledge about what happens in practice. This study explores NOK’s views and experiences of involvement during involuntary hospitalisation in Norway.MethodsWe performed qualitative interviews-focus groups and individual-with 36 adult NOK to adults and adolescents who had been involuntarily admitted once or several times. The semi-structured interview guide included questions on experiences with and views on involvement during serious mental illness and coercion.ResultsMost of the NOK were heavily involved in the patient’s life and illness. Their conceptions of involvement during mental illness and coercion, included many important aspects adding to the traditional focus on substitute decision-making. The overall impression was, with a few exceptions, that the NOK had experienced lack of involvement or had negative experiences as NOK in their encounters with the health services. Not being seen and acknowledged as important caregivers and co sufferers were experienced as offensive and could add to their feelings of guilt. Lack of involvement had as a consequence that vital patient information which the NOK possessed was not shared with the patient’s therapists.ConclusionsDespite public initiatives to improve the involvement of NOK, the NOK in our study felt neglected, unappreciated and dismissed. The paper discusses possible reasons for the gap between public policies and practice which deserve more attention: 1. A strong and not always correct focus on legal matters. 2. Little emphasis on the role of NOK in professional ethics. 3. The organisation of health services and resource constraints. 4. A conservative culture regarding the role of next of kin in mental health care. Acknowledging these reasons may be helpful to understand deficient involvement of the NOK in voluntary mental health services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12910-016-0159-4) contains supplementary material, which is available to authorized users.

Suicidality and Hostility following Involuntary Hospital Treatment.

BackgroundPsychiatric patients showing risk to themselves or others can be involuntarily hospitalised. No data is available on whether following hospitalisation there is a reduction in psychopathological indicators of risk such as suicidality and hostility. This study aimed to assess changes in suicidality and hostility levels following involuntary admission and their patient-level predictors.MethodsA pooled analysis of studies on involuntary treatment, including 11 countries and 2790 patients was carried out. Suicidality and hostility were measured by the Brief Psychiatric Rating Scale.Results2790 patients were included; 2129 followed-up after one month and 1864 after three months. 387 (13.9%) patients showed at least moderate suicidality when involuntarily admitted, 107 (5.0%) after one month and 97 (5.2%) after three months. Moderate or higher hostility was found in 1287 (46.1%) patients after admission, 307 (14.5%) after one month, and 172 (9.2%) after three months. Twenty-three (1.2%) patients showed suicidality, and 53 (2.8%) patients hostility at all time-points. Predictors of suicidality three months after admission were: suicidality at baseline, not having a diagnosis of psychotic disorder and being unemployed. Predictors of hostility were: hostility at baseline, not having a psychotic disorder, living alone, and having been hospitalized previously.ConclusionsAfter involuntary hospital admission, the number of patients with significant levels of suicidality and hostility decreases substantially over time, and very few patients show consistently moderate or higher levels of these symptoms. In patients with psychotic disorders these symptoms are more likely to improve. Social factors such as unemployment and isolation could hamper suicidality and hostility reduction and may be targeted in interventions to reduce risk in involuntarily admitted patients.

Therapeutic relationships and involuntary treatment orders: service users' interactions with health-care professionals on the ward.

There is increasing evidence that an involuntary hospital admission and treatment can undermine the therapeutic relationship. While good relationships with staff are important factors influencing long-term recovery, there is little information on how people experience their relationships with staff while under an involuntary treatment order (ITO). Twenty-five involuntary inpatients were interviewed about their experiences of an ITO. The interviews were analysed by a general inductive approach. Participants described the following themes: (i) the ITO admission was a daunting and frightening experience; (ii) staff behaviours and attitudes shaped their experiences in hospital; (iii) importance of staff listening to their concerns; (iv) importance of having a space to make sense of their experiences; (v) importance of staff ability to look beyond their illness and diagnosis; and (vi) importance of staff working in partnership. These findings highlight that when using recovery principles, such as an empathic engagement with the patients' lived experience, forging partnerships with patients in treatment decision-making to enhance agency, an involuntary treatment order does not have to limit the ability to establish positive relationships.

Which values are important for patients during involuntary treatment? A qualitative study with psychiatric inpatients

Involuntary hospital treatment is practised throughout the world. Providing appropriate treatment in this context is particularly challenging for mental health professionals, who frequently face ethical issues as they have to...

Operationalising the capability approach for outcome measurement in mental health research

Amartya Sen's multidimensional capability approach focuses on the importance of freedoms to be or do things people have reason to value. It is an alternative to standard utilitarian welfarism, the theoretical approach to quality-adjusted life years (QALYs) and cost-utility analyses. Despite the limitations of the utility approach in capturing non-health benefits and broader welfare inequalities, there have been very limited applications of the capability approach in the mental health context where these issues are imperative.We report the development and application of a multidimensional instrument, the OxCAP-MH, which aims to operationalise the capability approach for outcome measurement in mental health research. The study was carried out as part of an ongoing programme on community coercion experienced by service users with severe and enduring mental illness being treated using Community Treatment Orders. Capabilities data were collected at baseline in the OCTET RCT for 333 ‘revolving door’ mental health service users who were in involuntary hospital treatment at the time of recruitment in England (2008–2011). The research focused on the identification of capabilities domains most affected by mental illness and their association with socio-demographic and clinical factors and other measures of well-being such as the EQ-5D and Global Assessment of Functioning (GAF) scales.The OxCAP-MH item response rate was 90%–68%. There were significant correlations between service users' overall capability scores and the GAF, EQ-5D VAS and EQ-5D-3L utilities (corr = 0.249, 0.514, 0.415, respectively). The most affected capability domains were: ‘Daily activities’, ‘Influencing local decisions’, ‘Enjoying recreation’, ‘Planning one's life’ and ‘Discrimination’. Age had a mixed effect, while female service users and those with a primary diagnosis of schizophrenia or longer illness duration reported significantly lower capability scores. The results support the feasibility and validity of directly measuring human capabilities for the mentally ill and the potential for applying the approach to outcome measurement.

Previous forensic mental examination is a useful marker indicating effective violence relapse prevention among psychotic patients

Background: Patients with schizophrenia have an increased risk of violent behavior. Aims: The aim of this study was to find predictive indicators of high risk of violent behavior among outpatients with psychosis. Methods: A total of 206 individuals were involuntarily ordered to hospital treatment as forensic patients after a forensic mental examination in Finland from 1995–1999. The information was collected from the registers of the National Authority for Medicolegal Affairs, and was obtained from 194 persons of which 184 had been accused of a violent crime. Results: Twenty percent (22/110) of those forensic patients, who had received a psychosis diagnosis before the index crime, had previously undergone a forensic examination. This subgroup was 12% of the total study population (22/184), which is about 300 times higher than expected (i.e. if no risk increase assumed). Ten of the 22 persons in this subgroup had been committed in forensic psychiatric inpatient care and later discharged. The same number of persons had been sentenced to prison and subsequently released after the previous forensic mental examination. Conclusions: While primary prevention of crime for the larger population of all patients with psychosis is not feasible, secondary prevention (prevention of reoffending) might be possible by focusing on the small subgroup, which had undergone a previous forensic mental examination. Obligatory follow-up and treatment in outpatient care would probably decrease recidivistic offending among discharged forensic psychiatric patients and among those offenders found not guilty by reason of insanity but not considered to fulfill criteria for involuntary hospital treatment.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study

Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment. To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment. A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission. A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement. Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

P02-177 - Profile of involuntary hospitalized patients

The involuntary hospital treatment is presented as one of the most current problems in psychiatry at all, but not enough explored in Serbia. Because of extremely high percentage of involuntary hospitalized mentally ill people in Serbia, it’s particularly important to study all aspects of involuntary hospitalization. The aim of this paper is to determine recognizable profile of involuntary hospitalized patients, based on a detailed analysis of the social-demographic characteristics. This study included 8762 patients, hospitalized in Special Hospital for Psychiatric Disorders Gornja Toponica nearby Nis, during the period of five calendar years. There were 2812 voluntary hospitalized patients (32.1%) and 5950 involuntary hospitalized patients (67.9%). Comparative analysis of the involuntary hospitalized, showed statistically significantly greater number of male patients, not of the Serbian national or ethnic origin, who were not married, unemployed, who reside in southeastern Serbia outside the place where the hospital is located. Given the fact that 1298 patients or 21.8% of total involuntary hospitalized were hospitalized because of F10 (Disordines mentales et disordines morum propter usum alcholis), the paper discusses details of the validity for the involuntary hospitalization in these and other diagnostic categories. This data is a valuable contribution to the forthcoming reform of psychiatric services in the Republic of Serbia and practical contribution to the changing criteria for involuntary hospitalization to its reduction.

P02-236 - The determined reasons for involuntary hospital treatment

The involuntary hospital treatment is presented as one of the most current problem in psychiatry at all, but not enough explored problem in Serbia. In spite of the fact that it has come to important contemporary of psychiatric service, however the number of involuntary hospitalized patients is still on high level - in some countries above 80% in relations to totally number of hospitalized patients. A primary aim of this study was to adjust comparative analysis of determined reasons for voluntary or involuntary hospital treatment of mental ill persons. This study involved 1274 patients which were hospitalized in Special Psychiatric Hospital nearby Nish, during the period of one calendar year. There were 435 voluntary hospitalized patients (34,1 %) and 839 involuntary hospitalized patients (65,9 %). The most often determined reasons for involuntary hospitalizations were: delusions, hallucinations and aggressive behavior.

Systematic review of qualitative research on coercive treatment

This paper reports findings of a review of qualitative studies exploring patients' experiences of involuntary hospital treatment. Thematic analysis was used to synthesize emerging issues from different studies. Only five studies with a total sample of 54 patients fulfilled the inclusion criteria of the review. Main themes in the studies were a) patients' perceived autonomy and participation in clinical decision-making, b) the extent to which they felt cared for and c) their sense of self-respect. In all these areas both negative and positive aspects of involuntary admissions and treatments were found. However, studies are also characterised by major methodological shortcomings. Thus, the potentials of qualitative research in this area have not yet been fully utilized.

Patient's experiences of involuntary hospital admission and treatment: A review of qualitative studies

This study aimed to explore psychiatric patients' experiences of involuntary admission and treatment by reviewing qualitative studies. Qualitative studies investigating patients' experiences of involuntary treatment were identified. Relevant databases were searched and authors were contacted. Thematic analysis was applied for the synthesis of emerging issues. Five studies fulfilled the inclusion criteria. The main areas that appear to be of importance are: patients' perceived autonomy and participation in decisions for themselves, their feeling of whether or not they are being cared for and their sense of identity. In these areas both negative and positive consequences from involuntary admission were mentioned. However, methodological weaknesses were also found, such as small sample sizes. Furthermore, it is not described whether these themes are mentioned by all participants as negative and positive aspects of their experience or whether they reflect views supported by distinct groups. Although the perceived impact of involuntary treatment is fairly clearly described, differences between distinct patient groups are not examined. Future research should investigate such differences in order to inform relevant policy decisions for particular groups.

Involuntary psychiatric admissions: A retrospective study of 460 cases

Introduction: We collected the data relating to involuntary hospital treatment (IHT) in the University Psychiatric Ward at Novara Hospital between 1991 and 2002, and compared them with those relating to Piedmont and the whole of Italy. Methods: The data were collected from the ward medical records. Results: IHT was much more frequent among young male schizophrenics living with their families of origin. Most of the subjects were not working at the time of admission. There was a statistically significant correlation between male gender and the risk of being admitted for a period of less than 12 days. The risk of being admitted for more than 12 days significantly correlated with the province of birth and residence, as well as with a diagnosis of schizophrenic psychosis. Conclusions: Schizophrenia is the diagnosis that is most frequently associated with IHT.

Coercion, involuntary treatment and quality of mental health care: is there any link?

This paper summarizes major results and debates in the field of coercive or involuntary treatment of the mentally ill and how these relate to the quality of care, as published in literature during 2002 and 2003. Studies focus on four major issues: involuntary hospital placement and treatment of mentally ill patients, compulsory outpatient treatment, attitudes towards or perceived coercion, and ethics of coercive measures in mental health care. Studies suggest a complex correlation between the involuntary placement of mentally ill patients, coercive measures, and outcomes. Outcome indicators for the quality of mental health care are not standardized, but vary with the point of view of the individual or collective assessor. None of the results question the necessity or the legality of involuntary treatments or conclude to refrain from employing coercive measures in mental health care if these cannot be avoided. Many results of research on attitudes towards involuntary treatments or perceived coercion suggest an acceptance of the application of coercive measures, even by the persons concerned, if the legal conditions are clearly defined. Research standards or study designs may benefit from some improvement. Study samples usually are small and only in rare cases has their selection been representative. Research activities are remarkably few in number, especially considering the frequency of involuntary measures and the controversial perception or discussion of these measures among the persons concerned, professionals, or a wider public. Many basic research questions still remain to be adequately addressed, such as the long-term effects of involuntary treatment.

Involuntary psychiatric hospital treatment among 12- to 17-year-olds in Finland: A nationwide register study

Information on involuntary psychiatric hospital treatment of all 12- to 17-year-old minors in 1990 and 1993 in Finland was collected from the national hospital discharge register. Involuntary treatment was associated with older age, psychosis diagnosis, and treatment in adult psychiatric ward. Treatment year, sex, and having previous psychiatric hospital treatment were not associated with involuntary treatment. Considerable differences were found when different health care districts were compared. In 12 of 22 districts there were no minors in involuntary treatment in 1993. For ethical and legal reasons the involuntary treatment of minors in adult settings can hardly be justified.