Involuntary Inpatients Research Articles

Survey of post-discharge support for psychiatric involuntary inpatients by health center staff

Survey of post-discharge support for psychiatric involuntary inpatients by health center staff

Perceived fairness as main determinant of patients' satisfaction with care during psychiatric hospitalisation: An observational study

IntroductionPatient satisfaction with care is widely recognized as one of the most important indicator of quality in mental health care. It can impact several treatment outcomes, such as treatment adherence and engagement with services. At the same time, as an outcome in itself, satisfaction with care is also affected by several factors, first and foremost by being coerced. The main aim of this study was to test if perceiving treatment pressures as fair and effective could positively impact patient satisfaction, even more than formal coercive measures. MethodsGlobally, 133 voluntary and involuntary inpatients were interviewed. Socio-demographic and clinical characteristics, including history of previous experiences of formal coercion and legal status of the hospitalisation, were collected through a structured questionnaire and medical charts. The participants were also asked to complete the Index of Fairness and Index of Effectiveness tools as well as a structured questionnaire on satisfaction with care. Simple and multiple linear regressions were performed. ResultsAlthough several factors were found to affect satisfaction with care when taken independently, perceived fairness was the stronger predictor of both satisfaction with treatment (β =.234; p = .022) and satisfaction with decision-making involvement (β =.360; p < .001) when controlling for confounders. ConclusionsOur results point to the paramount importance of developing and implementing interventions that promote procedural fairness in psychiatric treatment and thereby improve patient satisfaction while reducing the risk of disengagement with care.

Mortality among involuntary inpatients of psychiatric hospital

BackgroundMortality is often used as an indicator of public health efforts. Even if mortality in psychiatric hospitals decreased since the introduction of modern treatment, the death toll is still high. The authors have analyzed the forensic autopsy data and the medical documentation regarding 115 death cases from psychiatric hospitals in south-eastern Romania during the period of 2000–2020.ResultsThe average annual mortality rate was 5.13‰, the necropsy data corroborated with those from the medical documentary material indicates acute myocardial infarction as the dominant cause, with 65 (56.5%) cases, followed by upper respiratory tract occlusion with 23 cases (20%) and pulmonary thromboembolism in 4 cases (12.2%). Furthermore, in 6 cases (5.2%) the cause of death was traumatic: 4 cases of cranio-cerebral trauma and 2 cases of hanging.ConclusionsIn the mortality structure of psychiatric patients, cardiac death predominated, being influenced by the cardiotoxic effect of medication administered for the specific pathology; hence, an early involvement of cardiologists in the follow-up of patients and the finding of treatment schemes with a reduced cardiotoxic effect are required.

Patients\u2019 perception of coercion with respect to antipsychotic treatment of psychotic disorders and its predictors

PurposeThe present study investigates perceived coercion in psychiatric inpatients under prescribed antipsychotic medication without a court order. The objective of this study was to investigate whether and to what extent involuntary and voluntary inpatients feel coerced to take their medication and which factors affect perceived coercion.MethodsVoluntarily and involuntarily admitted patients (55 and 36, respectively) were interviewed about the extent of perceived coercion. In addition, socio-demographic and clinical data were collected. The Admission Experience Scale (aAES) was used to assess perceived coercion concerning medication. To measure insight into illness, attitude towards medication, and symptom severity, we used a questionnaire on insight into illness (FKE-10), the Drug Attitude Inventory (DAI-10), and the Brief Psychiatric Rating Scale (BPRS-24), respectively.ResultsVoluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients. The experience of coercion was not related to socio-demographic or clinical variables nor to the BPRS-24 score, but to insight into illness and attitude towards medication. Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion.ConclusionPerceived coercion related to medication is dependent on insight into illness and experience of previous coercive interventions rather than on the severity of psychopathological symptoms. These findings are very similar to a previous study in a forensic psychiatric sample. Having experience of at least one coercive measure seems to be a decisive aspect of the extent of the patients’ perceived coercion.

Giving Patients Choices During Involuntary Admission: A New Intervention.

Background: People who receive involuntary treatment are some of the most vulnerable in psychiatric services. They are more likely to have poorer social and clinical outcomes and to be disillusioned with and disengaged from care. Research indicates that patients’ experience in the first week of involuntary treatment is a critical period: a better experience of care in the first week predicts better quality of life and reduced readmission 1 year later. Patients have identified involvement in clinical decisions as key to improving their experience of care. The aim of this study was to test the feasibility and acceptability of an intervention to facilitate involvement in decision making for involuntary inpatients called OPeNS (Options, Preferences, Negotiate, and Summarise). Methods: This was a mixed method study. The OPeNS intervention was developed based on previous research carried out by a multidisciplinary team. Clinicians were trained to deliver it to involuntary inpatients. Feasibility indices (rates of participation in the intervention and time required to deliver it) were collected. Patients (N = 14) and clinicians (N = 5) provided qualitative data on their experience of the intervention in semi-structured interviews which were analysed using thematic analysis. Results: The OPeNS intervention was found to be acceptable by both patients and clinicians and feasible to conduct within the first week of involuntary treatment. Patients’ and clinicians’ experiences of the intervention fall into two themes: ‘Enabling a different dynamic’ and ‘Clashing with usual practices and priorities’. Conclusion: The OPeNS intervention provides a structure that can be used by clinicians across disciplines to facilitate involving involuntary patients in decision making. Although challenges related to changing usual practices were identified, the intervention was received positively and was feasible to conduct in the first week of involuntary treatment.

Categorical mental capacity for treatment decisions among psychiatry inpatients in Ireland

This study aimed to assess mental capacity for treatment decisions among psychiatry inpatients in Ireland and explore the relationship, if any, between mental capacity and various demographics and clinical variables. We assessed mental capacity for treatment decisions in 215 psychiatry inpatients in four psychiatry admission units. Almost half of the participants were female and the most common diagnoses were schizophrenia or a related disorder and affective disorders. Overall, 1.9% of participants lacked mental capacity for treatment decisions; 50.7% had partial mental capacity; and 47.4% had full mental capacity. These proportions did not differ between female and male patients. On multi-variable regression analysis, greater mental capacity was significantly associated with, in order of strength of association, voluntary admission status, Irish ethnicity, being employed and younger age. However, while these relationships were statistically significant (i.e. were unlikely to have occurred by chance), together they accounted for just 27.6% of the variance in mental capacity between participants (i.e. they were not very strong). The relatively high rate of “partial mental capacity” identified in our work suggests that decision-making supports are likely to be of substantial importance in assisting psychiatry inpatients making decisions about treatment, especially involuntary inpatients whose mental capacity is especially likely to be impaired. Future research could usefully clarify and quantify the role of cognitive and other factors in relation to the unexplained variance (72.4%) in mental capacity identified in this study; and explore which models of supported decision-making are most likely to assist the substantial proportion (50.7%) of psychiatry inpatients who have partial mental capacity for treatment decisions, as well as the minority lacking such mental capacity (1.9%).

Whose insight is it anyway?

IntroductionThere is little research comparing patients’ views with those of their treating psychiatrists. In a survey of patients’ views conducted in 1993 for MIND (UK) by Rogers, Pilgrim and Lacey only 10% saw their problems in terms of mental illness. This highlights the tension between psychiatric codifications of mental abnormalities and explanations provided by patients themselves.AimsThis pilot project explores the perceptions of mental health issues in patients and their psychiatrists in a regional Western Australian setting.MethodsA mixed methods approach including semi-structured interviews of patients and their treating psychiatrists. Recruiting 5 consecutive people in the categories of involuntary in-patients, voluntary in-patients, patients on CTO, community patients and their psychiatrists.Questions asked of the patients were:– Why are you here?– What problems do you have?– What can be done?– What control do you have?– What control do other people have?Psychiatrists were asked similar questions. Responses were recorded, transcribed and thematically analyzed to reveal key themes. Quotations are used to illustrate points participants wished to make.ResultsWe report on differences in understanding in both groups. This study reveals areas for further enquiry.ConclusionsConsiderable diversity is revealed. A key conclusion is that insight is a concept relevant both for treated and treating.Disclosure of interestThe authors have not supplied their declaration of competing interest.

"Restricted Community Members": Research Protections and Opportunities for Individuals Committed to Assisted Outpatient Treatment.

Several forms of mandated community treatment exist in the United States. One mechanism, assisted outpatient treatment (AOT), has become both more common and more controversial in recent years. The status of individuals committed to AOT remains unclear within regulatory guidelines aimed at protecting research participants. Should individuals on AOT be considered psychiatric inpatients, prisoners, community members, or something else? The authors argue that persons on AOT inhabit a gray area wherein they should be given some of the ethical protections afforded to involuntary inpatients and prisoners, but they should also enjoy freedoms as members of the community. The authors' term for this population is "restricted community members." The need to protect individuals in this population from potentially coercive forces of AOT while also offering them the opportunity to participate in research is especially acute in areas of research where the need is great: serious mental illness and substance use disorders.

The importance of safety, agency and control during involuntary mental health admissions

Background: Constructs such as personal recovery, patient engagement and consumer involvement are central in mental health care delivery. These approaches emphasise the importance of empowerment and choice.Aims: Under some circumstances Involuntary Treatment Orders (ITO) allow a person to be treated for a mental illness without their consent. This study explores the tensions between the principles of empowerment and control and involuntary treatment.Methods: Twenty-five involuntary inpatients of a major teaching hospital were interviewed about their experiences of being placed under an ITO. The interviews were analysed thematically.Results: Being able to have some sense of agency and re-asserting personal control are critical components of an involuntary mental health admission. Participants wanted information about their treatment, the ITO process and their environment. They also spoke about the importance of a space where they felt safe from themselves and others to make sense of the experience.Conclusions: This study suggests that for coercive treatment to aid, rather than disrupt recovery, treatment services need to focus on: the provision of rights; the creation of a sense of safety; establishing supportive relationships; carrying hope and finding ways to foster a strong sense of agency and empowerment.

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.

The experiences of the legal processes of involuntary treatment orders: Tension between the legal and medical frameworks

3An involuntary treatment order (ITO) allows a person to be treated for a mental illness without consent under some circumstances. While the treatment and assessment of mental illness are essentially clinical decisions, involuntary mental health admissions are governed by a framework of legal principles, safeguards and procedures. The underlying philosophy of these laws is based on therapeutic jurisprudence. This approach focuses on the importance of the legal process as a social force and suggests that this can either protect or empower people. The legal processes can however adversely impact upon people's states of mind. This study reports on 25 qualitative interviews with involuntary inpatients of a major teaching hospital. The interviews were analysed thematically using a general inductive approach. The analysis focused on the patients' general experience of being placed under an ITO and their understanding of the ITO process. Generally, those who described the experience of an ITO in more positive terms, also experienced the ITO as a positive right. In addition to providing them with the treatment needed, they also felt that the ITO gave them protection and guidance. Conversely, those who experienced being placed under an ITO in more negative or mixed ways, described feeling powerless in the process, as they felt that the ITO took away their rights. By and large the ITO process was experienced as arbitrary when patients did not understand the reasons for their admission. In addition, these patients had limited or no information about their involuntary treatment order and they did not know what was expected of them to have the ITO revoked. Most importantly, they did not feel that there were any meaningful legal protections in place. These experiences highlight the importance of the legal processes and how these can be used as clinical tools.

Quality of involuntary hospital administration in Switzerland

This study aims at investigating the formal and content-related quality of medical certificates directing compulsory hospital admissions before the scheduled alteration of the Swiss civil legislation in January 2013. A comparison between physicians with different professional backgrounds concerning certificates and patients was conducted. Retrospective investigation of medical records of involuntary inpatients at the University Hospital of Psychiatry in Zurich during a period of six months (N=489). Considerable deficits concerning formal and particularly content-related aspects of the certificates were found. Psychiatrists issued certificates of the highest quality followed by emergency physicians, hospital doctors and general practitioners. Patients differed with respect to several sociodemographic and clinical variables. The quality of certificates directing involuntary hospital admission has to be improved considering the impact on the individual concerned. The consequences of the new legislation on the quality of the admission practices should be inquired in order to improve professional training on the issue.

Factorial validity and measurement equivalence of the Client Assessment of Treatment Scale for psychiatric inpatient care — A study in three European countries

Patients' views of inpatient care need to be assessed for research and routine evaluation. For this a valid instrument is required. The Client Assessment of Treatment Scale (CAT) has been used in large scale international studies, but its psychometric properties have not been well established. The structural validity of the CAT was tested among involuntary inpatients with psychosis. Data from locations in three separate European countries (England, Spain and Bulgaria) were collected. The factorial validity was initially tested using single sample confirmatory factor analyses in each country. Subsequent multi-sample analyses were used to test for invariance of the factor loadings, and factor variances across the countries. Results provide good initial support for the factorial validity and invariance of the CAT scores. Future research is needed to cross-validate these findings and to generalise them to other countries, treatment settings, and patient populations.

Personality Disorders and Unmet Needs Among Psychiatric Inpatients

Personality Disorders and Unmet Needs Among Psychiatric Inpatients

Self-reported symptoms and treatment outcome among non-offending involuntary inpatients

The mediating effects of patient legal status on the accuracy of self-reported psychiatric symptoms have not been systematically explored. Problematically, involuntary hospitalization may be associated with a decreased willingness to accurately report symptoms, which may negatively impact choice of treatment intervention and subsequent treatment outcome. The following study examined the association of patient legal status with self-reported psychiatric symptoms and treatment outcome. Self-report data (BDI and SCL-90-R) and clinician-based ratings (BPRS-A) were collected from 131 inpatients during an index period of 8 months. The results showed involuntarily admitted patients endorsed fewer psychiatric symptoms both on the SCL-90-R and on the BDI. This finding was specific to patients with schizophrenia or bipolar disorder, and did not generalize to patients with clinical depression. BPRS-A ratings did not differ between the voluntary and involuntary groups, suggesting an inherent difference among patients with regard to willingness and/or ability to endorse psychiatric symptoms. Involuntarily admitted inpatients also remained hospitalized longer and may have shown poorer treatment outcome. The findings highlight the importance of acknowledging patient legal status when using self-report data to guide assessment and treatment among involuntarily admitted individuals with schizophrenia or bipolar disorder. Potential methods to circumvent this problem are outlined.

Patient perceptions of coercion in mental hospital admission

Patient satisfaction with care is widely recognized as one of the most important indicator of quality in mental health care. It can impact several treatment outcomes, such as treatment adherence and engagement with services. At the same time, as an outcome in itself, satisfaction with care is also affected by several factors, first and foremost by being coerced. The main aim of this study was to test if perceiving treatment pressures as fair and effective could positively impact patient satisfaction, even more than formal coercive measures.Globally, 133 voluntary and involuntary inpatients were interviewed. Socio-demographic and clinical characteristics, including history of previous experiences of formal coercion and legal status of the hospitalisation, were collected through a structured questionnaire and medical charts. The participants were also asked to complete the Index of Fairness and Index of Effectiveness tools as well as a structured questionnaire on satisfaction with care. Simple and multiple linear regressions were performed.Although several factors were found to affect satisfaction with care when taken independently, perceived fairness was the stronger predictor of both satisfaction with treatment (β =.234; p = .022) and satisfaction with decision-making involvement (β =.360; p < .001) when controlling for confounders.Our results point to the paramount importance of developing and implementing interventions that promote procedural fairness in psychiatric treatment and thereby improve patient satisfaction while reducing the risk of disengagement with care.

Some personality correlates in a group of drug addicts

The Eysenck Personality Questionnaire (EPQ) was administered to three groups of male, Saudi, drug addicts treated at Al-Amal Hospital, Jeddah. Each group consisted of 50 patients. The three groups were: volunteer in-patients (VIP), volunteer out-patients (VOP) and involuntary in-patients (IIP). The IIP group scored significantly higher than the VIP and VOP groups on the P scale ( P < 0.05), the N scale ( P < 0.01 and P < 0.001, respectively), and on the L scale ( P < 0.05 and P < 0.001, respectively). On the E scale the IIP scored significantly higher than the VOP ( P < 0.05). The only significant difference between the VIP and the VOP was on the N scale ( P < 0.01) in favour of the former. Addicts were also compared with the normative Saudi population and scored significantly higher than university students on the P, N and L scales ( P < 0.001) and higher than secondary students on the N and L scales ( P < 0.001). Only the E and the L scales correlated positively ( r = 0.17). The other scales showed independence.

Clinical and demographic characteristics of voluntary and involuntary psychiatric inpatients.

Voluntary and involuntary psychiatric inpatients were compared on demographic, social and clinical characteristics. Chi-squared tests of independence revealed significant differences in age and financial support based on status at admission. No significant differences were found with respect to diagnostic category. It was concluded that demographic, social and clinical characteristics do not clearly discriminate between voluntary and involuntary inpatients.

Development of an emergency psychiatric treatment unit.

The increasing number of deinstitutionalized patients in crisis are placing new demands on general hospital emergency rooms. The authors discuss the approaches used in staffing and operating a psychiatric emergency service at a large general hospital in western Massachusetts. After studying the disposition of patients seen on the service, the authors determined that overnight hospitalization and crisis management could substantially reduce the need for longer hospital admissions. Subsequently a proposal was developed for a seven-bed emergency psychiatric treatment unit to provide brief, intensive psychiatric care for both voluntary and involuntary inpatients. The authors describe the staffing and layout of the unit, and the population to be served.