Involuntary Outpatient Treatment Research Articles

Changes in patterns of coercion during a nine-year period in a Norwegian psychiatric service area.

ObjectiveThere is debate regarding the use of coercion in the psychiatric services and how to minimize its use. We examine changes in the use of coercion in one Norwegian psychiatric service area during a nine‐year period.MethodsAll patients receiving psychiatric services during the periods 2003–2006 and 2008–2012 in the study area were identified, subsequently also only those who had been involuntarily admitted or subjected to involuntary outpatient treatment. Yearwise rates of patients admitted to coercion and coercive treatment‐episodes throughout the study period were calculated.ResultsThe overall number and the rate of coerced patients decreased to the total patient population. Most of the reduction were initially of the observational period. However, the number of coercive episodes per coerced patient increased. The pattern of outpatient versus inpatient modes of coercion both reflected this main trend.ConclusionThe use of coercion seem to be reduced overall, although the increase in treatment‐episodes per patient may indicate a complex pattern in use and registration of coercion. The results may be related to legislative changes, restructuring of psychiatric services, or/and modified attitudes of health‐personnel to coercion following a range of efforts to reduce it.

Informed consent and mental health, mainly in Spain, EU

Introduction: Lawfully given, informed or valid consent is considered by Spanish jurisprudence a fundamental right and entails important repercussions. Method: Critical and theoretical examination of the matter, with special emphasis on the case of the most vulnerable people and those who require involuntary outpatient psychiatric treatment (IOT). Results: Valid informed consent must fulfil the requirements of capacitation, willingness, information and understanding. Timely knowledge and agreement regarding by whom and how this consent must be granted are important in biomedicine and psychology in general, as well as in the specialities of psychiatry and clinical psychology in particular. It is also important to ensure valid consent for any psychotherapy, as it generally also occurs in the case of psychopharmacological treatments. This article will revise the so-named “sliding scale” to determine mental degree of competence. This concept is especially important in order to consider whether a supposed valid consent is appropriate in vulnerable people. We will talk about living will and severe mental illness concerning valid consent. The current state of psychiatric involuntary outpatient treatment in Spain will be mentioned as well as the wills of legally incapacitated individuals, elderly people or when the carer, either an individual or institution, is the main beneficiary. Conclusions: Valid consent is necessary in every biomedical or sanitary action in general. The matter is potentially controversial if wrongful influences bear upon elderly people, incapacitated individuals and others. Keywords: Informed consent; Valid consent; Spain; Will; Severe mental illness

Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit.

Antipsychotic polypharmacy (APP) is a psychopharmacological practice in which two or more antipsychotics are prescribed simultaneously. Despitethe absence of evidence to support it, it is highly prevalent in clinical settings. Another recurrent practice strongly associated with APP is the prescription of high-dose antipsychotics (HDAs). Compulsory treatment is a legal means to impose treatment on an individual suffering from mental illness who refuses therapeutic intervention. Compulsory treatment has been associated with APP and HDAs and rates of both have been proposed to represent indicators of the quality of prescribing. We aimed to perform an antipsychotic prescription audit in a vulnerable psychiatric population, at the psychiatry department of a district hospital in Portugal, across 7years. We evaluated APP and HDAs in 403 compulsorily admitted patients by reviewing their files at discharge. We used logistic regression to search for factors associated with APP andHDAs. APP was found in 70.5% of individuals, whereas HDAs were found in 51.4%. After adjustment, APP was significantly associated with male gender (Odds Ratio[OR] = 1.85 [1.04; 3.30] 95% Confidence Interval [CI]), involuntary outpatient treatment (OR = .40 [.18; .82] 95% CI), activation of thehospital social services (OR = 1.91 [1.08; 3.38] 95%CI), prescription of antidepressants (OR = .43 [.22; .82] 95%CI) and long-acting injectables (LAI) (OR = 28.29 [13.13; 60.97] 95%CI). HDAs were associated with male gender (OR = 1.76 [1.06; 2.94] 95%CI), the prescription of LAI (OR = 12.92 [6.93; 24.09] 95%CI) and oral first-generation antipsychotics (OR = 2.90 [1.51; 5.60] 95%CI).

Psychiatrists' opinion about involuntary outpatient reatment.

ABSTRACTIntroductionInvoluntary outpatient treatment (IOT) is a kind of compulsory outpatient treatment, whose aim is to improve the adherence to the treatment in people with severe mental illness and with no awareness of disease. In these cases, therapeutic abandonment involves a high risk of relapse, with appearance of disruptive and/or self-aggressive or hetero-aggressive behavior, repeated hospitalizations and frequent emergencies. The application of IOT is not an issue without contention. Therefore, the need of legislative regulation in Spain has been a controversial subject for several years, and there are both advocates and opponents.Objective The objective of this study is to bring together the opinion of clinical psychiatrists and resident doctors in psychiatry on the involuntary outpatient treatment and its legislative regulation.Material and method This study is descriptive in nature. The study population consists of 42 clinical professionals in mental health (32 psychiatrists and 10 resident doctors in psychiatry). At the beginning of this study (March 2018), some of these professionals were working in the Psychiatry Department’s facilities of the University Hospital Complex of Huelva. A personal survey in paper form consisting of ten questions about IOT was carried out to each member of this study.Results85.7% of clinicians know the current initiative that tries to carry out the legislative regulation of IOT, and 92.8% of them agree to such regulation. In this sense, 83.3% of them are against the fact that more coercive measures for the psychiatric patients such as the involuntary commitment or the civil incapacitation are regulated and IOT is not. On the one hand, 78.6% of the professionals in mental health believe that IOT is beneficial for the patients. Moreover, 95.2% of them think that is beneficial for their relatives, too. On the other hand, 78.6% of clinicians do not consider that the application of IOT to mentallyill patients is stigmatizing.ConclusionThe vast majority of clinicians think that the legislative regulation of involuntary outpatient treatment is necessary in Spain, and they think this treatment is beneficial not only for the patient but also for their family.

Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders

This is a summary by Catriona Kennedy of the Cochrane Review of Kisely, S.R., Campbell, L.A., O'Reilly, R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2017, Issue 3, Art No: CD004408. DOI: 10.1002/14651858.CD004408.pub5.

Esquizofrenia y delincuencia: análisis de la jurisprudencia del Tribunal Supremo entre 2008 y 2018

El riesgo de violencia en esquizofrenia se ve incrementado por factores como el consumo de drogas, la falta de tratamiento, la marginación social y laboral o el bajo nivel educativo. En esta investigación se lleva a cabo un análisis de la jurisprudencia del Tribunal Supremo con el fin de determinar, por un lado, qué factores de riesgo reconocidos en la literatura científica tienen un reflejo en la doctrina penal y, por otro, el tratamiento de la imputabilidad de estas personas efectuado por el Alto Tribunal. Se analiza también la presencia del tratamiento ambulatorio involuntario como medida de seguridad no privativa de libertad en estos casos y se incluye una entrevista al magistrado de la Audiencia Nacional Fermín Javier Echarri Casi. Como resultado de la revisión se obtiene que la esquizofrenia paranoide, la ausencia de tratamiento y el consumo de drogas son los factores de riesgo con más presencia en las sentencias analizadas. Que los criterios que abordan la imputabilidad se basan en el nexo causal y en la afectación de las capacidades, dando como resultado la aplicación de los artículos del Código Penal 20.1, 21.1 o 21.7 según sea el caso. Y que el Tribunal Supremo nunca establece el tratamiento ambulatorio involuntario como medida de seguridad no privativa de libertad.

Assessment of outpatient commitment in randomised trials

The randomised controlled trial (RCT) is the gold standard of research and the clearest way to establish causal certainty. This design, however, was misapplied in three RCTs of involuntary outpatient civil commitment (also known as community treatment orders). 1 Swartz M Swanson JD Wagner HR Burns BJ Hiday VA Borum R Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry. 1999; 156: 1968-1975 PubMed Google Scholar , 2 Burns T Rugkåsa J Molodynski A et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013; 381: 1627-1633 Summary Full Text Full Text PDF PubMed Scopus (255) Google Scholar , 3 Steadman HJ Gounis K Dennis D et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Serv. 2001; 52: 330-336 Crossref PubMed Scopus (280) Google Scholar In contrast with the positive outcomes regarding outpatient commitment in epidemiological studies, 4 Segal SP Hayes SL Rimes L The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Serv. 2017; (published online Aug 1.)DOI:10.1176/appi.ps.201600161 Crossref Scopus (19) Google Scholar , 5 Link BG Epperson MW Perron BE Castille DM Yang LH Arrest outcomes associated with outpatient commitment in New York state. Psychiatric Serv. 2011; 62: 504-508 Crossref PubMed Scopus (39) Google Scholar a subsequent Cochrane review of these RCTs, 6 Kisely SR Campbell LA O'Reilly R Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2017; 3 (CD004408.) Crossref PubMed Scopus (66) Google Scholar suggested that outpatient commitment “was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard ‘voluntary’ care”. This conclusion is potentially harmful for patients in need of oversight to protect their health and safety, and that of others. The conclusion is also unjustified because the outpatient commitment RCTs have major design, measurement, implementation, and analytical flaws. Randomised controlled trials and outpatient commitmentSteven Segal's criticism1 of each of the published randomised controlled trials (RCTs)2–4 on outpatient commitment and the subsequent Cochrane systematic review5 are not new. We believe the criticisms reflect a limited understanding of: the clinical practice of outpatient commitment, the conduct of clinical effectiveness RCTs, and the stringent requirements for the inclusion of studies in Cochrane reviews. Psychiatry owes it to patients, their families, and the profession, to take uncomfortable research findings seriously and either conduct even better trials or change clinical practice. Full-Text PDF Randomised controlled trials and outpatient commitmentSteven Segal's critique1 of randomised control trials (RCTs) of outpatient commitment makes several incorrect assertions about these studies. For example, the North Carolina study did not completely exclude violent patients as Segal claims. Rather, patients with a documented history of serious violence were enrolled in a separate, non-randomised arm of the study. Participants were assigned to outpatient commitment at discharge but were followed up in the community with the same protocol as the one used for the other study participants, whether or not they remained under court-ordered treatment (many did not). Full-Text PDF

The decentralization and integration of Norwegian psychiatric services and possible implications for coercive practices

Introduction : During the last 20 years, there has been a shift in Norway, with an increase in services provided at local district psychiatric units and in municipalities and a reduction in centralized hospital services [1]. Simultaneously, attention has been directed to the negative effects of use of coercion within the services [2]. While it has been pointed out that rates of coercion in Norway are relatively high, few have examined the implications of this organizational change for the use of coercion [3]. Methods : Drawing on data obtained from the Norwegian Patient Register, we analyzed all episodes of specialized psychiatric care given in the area of Vesteralen and Lofoten, North Norway, for the periods 2003-2006 and 2008-2012 (data from 2007 were unavailable). Patients subjected to involuntary admission and involuntary outpatient treatments were identified. Results : The number of patients being treated in the study area increased from 886 in 2003 to 1347 in 2012. The number of involuntarily admitted patients and patients in involuntary outpatient treatment fell from 110 in 2003 to 30 in 2012. Discussion, limitations and lessons learnt : Our data suggest that while the number of patients in treatment increased with more than 50% during the study period, the number of patients being coerced was reduced with more than 70%. Several factors (on which we lack data here) may be of importance to rates of involuntary admission and treatment, including patients’ diagnoses [4, 5] and staffs’ attitudes [5, 6]. However, the increased provision of decentralized psychiatric services is likely to be one important factor in the reduction of coercion [3]. Local and low-threshold psychiatric services increase access and give patients the opportunity to get help at an earlier stage, which may reduce the need for coercion [3, 5]. Further studies are needed to examine the importance of psychiatric services organization on rates of coercion. References : 1. Myklebust LH, Olstad R, Bjorbekkmo S, Eisemann M, Wynn R, Sorgaard K. Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway. Int J Integr Care. 2011;11:e142. 2. Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. Int J Psychiatry Clin Pract. 2006;10(4):247-51. 3. Myklebust LH, Sorgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res. 2014;14:64. 4. Myklebust LH, Sorgaard K, Rotvold K, Wynn R. Factors of importance to involuntary admission. Nord J Psychiatry. 2012 Jun;66(3):178-82. 5. Rotvold K, Wynn R. Involuntary psychiatric admission: The referring general practitioners' assessment of patients' dangerousness and need for psychiatric hospital treatment. Nord J Psychiatry. 2015;69(8):637-42. d 6. Wynn R, Kvalvik AM, Hynnekleiv T. Attitudes to coercion at two Norwegian psychiatric units. Nord J Psychiatry. 2011;65:133-7.

Clinical vignette – Aripiprazol long acting injection monotherapy as long-term treatment for bipolar disease

IntroductionOver the last decade a number of effective maintenance treatments for bipolar disorder (BPD) have been developed. Lithium remains the best-established option, but valproic acid, lamotrigine, olanzapine, and quetiapine are also effective maintenance drugs. However, oral administration contributes to lower adherence rates with these drugs. In the United States and Europe, aripiprazole is approved for the acute management of manic and mixed episodes and maintenance in BPD. It presents the advantage of a low risk of metabolic side effects, sexual dysfunction, and sedation, which can facilitate treatment adherence and help improve clinical outcomes.ObjectivesThe authors present an illustrative case on which aripiprazol long acting injection monotherapy was effective as maintenance treatment in a patient with long history of BPD with several hospital inpatient admissions and very poor therapeutic adherence.MethodsCase report based on the patient's file. Narrative review of articles available in PubMed about the use of aripiprazol in BPD.ResultsFor this patient, aripiprazol long acting injection has proved to be an excellent choice for long-term treatment of BPD. The once-a-month injection promotes therapeutic adherence, which in this case was combined with involuntary outpatient treatment, ensuring therapeutic compliance.ConclusionsAripiprazol has been shown to be safe and effective in the maintenance treatment in BPD. It shows similar efficacy and a superior tolerability profile when compared with other well-established treatments. Further studies are needed, warranted by its potential advantages, particularly on patients with poor insight and adherence.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders.

It is controversial whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning. To examine the effectiveness of compulsory community treatment (CCT) for people with severe mental illness (SMI). We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (2003, 2008, 2012, 8 November 2013, 3 June 2016). We obtained all references of identified studies and contacted authors where necessary. All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre-existing form of CCT such as supervised discharge. Authors independently selected studies, assessed their quality and extracted data. We used Cochrane's tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% confidence interval (95% CI) and, where possible, the number needed to treat for an additional beneficial outcome (NNTB). For continuous outcomes, we calculated a fixed-effect mean difference (MD) and its 95% CI. We used the GRADE approach to create 'Summary of findings' tables for key outcomes and assessed the risk of bias of these findings. The review included three studies (n = 749). Two were based in the USA and one in England. The English study had the least bias, meeting three out of the seven criteria of Cochrane's tool for assessing risk of bias. The two other studies met only one criterion, the majority being rated unclear.Two trials from the USA (n = 416) compared court-ordered 'outpatient commitment' (OPC) with entirely voluntary community treatment. There were no significant differences between OPC and voluntary treatment by 11 to 12 months in any of the main health service or participant level outcome indices: service use - readmission to hospital (2 RCTs, n= 416, RR 0.98, 95% CI 0.79 to 1.21, low-quality evidence); service use - compliance with medication (2 RCTs, n = 416, RR 0.99, 95% CI 0.83 to 1.19, low-quality evidence); social functioning - arrested at least once (2 RCTs, n = 416, RR 0.97, 95% CI 0.62 to 1.52, low-quality evidence); social functioning - homelessness (2 RCTs, n = 416, RR 0.67, 95% CI 0.39 to 1.15, low-quality evidence); or satisfaction with care - perceived coercion (2 RCTs, n = 416, RR 1.36, 95% CI 0.97 to 1.89, low-quality evidence). However, one trial found the risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50, 95% CI 0.31 to 0.80, low-quality evidence).The other RCT compared community treatment orders (CTOs) with less intensive and briefer supervised discharge (Section 17) in England. The study found no difference between the two groups for either the main health service outcomes including readmission to hospital by 12 months (1 RCT, n = 333, RR 0.99, 95% CI 0.74 to 1.32, moderate-quality evidence), or any of the participant level outcomes. The lack of any difference between the two groups persisted at 36 months' follow-up.Combining the results of all three trials did not alter these results. For instance, participants on any form of CCT were no less likely to be readmitted than participants in the control groups whether on entirely voluntary treatment or subject to intermittent supervised discharge (3 RCTs, n = 749, RR for readmission to hospital by 12 months 0.98, 95% CI 0.82 to 1.16 moderate-quality evidence). In terms of NNTB, it would take 142 orders to prevent one readmission. There was no clear difference between groups for perceived coercion by 12 months (3 RCTs, n = 645, RR 1.30, 95% CI 0.98 to 1.71, moderate-quality evidence).There were no data for adverse effects. These review data show CCT results in no clear difference in service use, social functioning or quality of life compared with voluntary care or brief supervised discharge. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and low- to moderate-quality evidence. In addition, clinical trials may not fully reflect the potential benefits of this complex intervention.

The relationship between the services available to patients in primary care and at local psychiatric clinics and the use of coercion: recent findings from Northern Norway

Introduction: Psychiatric patients may be subjected to coercion in many different forms, including involuntary admission to psychiatric hospital, involuntary outpatient treatment, and involuntary treatment with medications [1]. The use of coercion in the psychiatric services involves a range of ethical, clinical, and legal issues [2,3]. The Norwegian authorities have stated that it is a goal to reduce the use of coercion in the psychiatric services, as it is believed that this will improve the services and increase the quality of care [4]. Purpose and methods: We review and discuss findings from studies on coercion in North Norway, focusing on the relationship between the services available to patients in primary care and at local psychiatric clinics and the use of coercion. Results and discussion: A lack of services at the municipal level might increase the use of coercion. For instance, approximately half of the involuntary admissions had been referred from doctors working at municipal out-of-hours clinics [5]. These doctors often felt pressured to commit patients to psychiatric hospital, as few other options were available at nights and week-ends [5-7]. The increased availability of other services at nights and week-ends could therefore possibly result in reduced levels of coercion. Having sufficient resources available at the secondary level might also reduce the amount of coercion patients are subjected to. For instance, an area that had beds available for emergencies at local psychiatric clinics had significantly fewer (95% CI for EXP(B)=1.133-2.206, p=0.005) involuntary admissions than a comparable area without such beds [8]. While much of the coercion of psychiatric patients takes place at the tertiary/hospital level, this study suggests that the availability of services at the primary and secondary levels might influence the level of coercion at the tertiary/hospital level. Conclusion: The present study suggests that increasing the availabilty of voluntary psychiatric services at the primary and secondary levels might represent one way of achieving the goal of reducing coercion in the psychiatric services. This relationship should be examined further in future research involving the North Norwegian psychiatric health services.

Ethics Considerations of Involuntary Outpatient Treatment

Ethics Considerations of Involuntary Outpatient Treatment

APA Board Approves Position Statement on Involuntary Outpatient Commitment

APA Board Approves Position Statement on Involuntary Outpatient Commitment

Clinical vignette – aripiprazol long acting injection monotherapy as long-term treatment for bipolar disease

Introduction Over the last decade a number of effective maintenance treatments for bipolar disorder (BPD) have been developed. Lithium remains the best-established option, but valproic acid, lamotrigine, olanzapine, and quetiapine are also effective maintenance drugs. However, oral administration contributes to lower adherence rates with these drugs. In the United States and Europe, aripiprazole is approved for the acute management of manic and mixed episodes and maintenance in BPD. It presents the advantage of a low risk of metabolic side effects, sexual dysfunction, and sedation, which can facilitate treatment adherence and help improve clinical outcomes. Objectives/aims The authors present an illustrative case on which aripiprazol long acting injection monotherapy was effective as maintenance treatment in a patient with long history of BPD with several hospital inpatient admissions and very poor therapeutic adherence. Methods Case report based on the patient's file. Narrative review of articles available in PubMed about the use of aripiprazol in BPD. Results For this patient, aripiprazol long acting injection has proved to be an excellent choice for long-term treatment of BPD. The once-a-month injection promotes therapeutic adherence, which in this case was combined with involuntary outpatient treatment, ensuring therapeutic compliance. Conclusions Aripiprazol has been shown to be safe and effective in the maintenance treatment in BPD. It shows similar efficacy and a superior tolerability profile when compared with other well-established treatments. Further studies are needed, warranted by its potential advantages, particularly on patients with poor insight and adherence.

Ethical aspects of involuntary outpatient treatment

IntroductionInvoluntary outpatient treatment (IOT) is a type of non-voluntary treatment applied in the community, which tries to ensure the therapeutic compliance of patients that have a severe mental illness.In Spain, a specific legal regulation about this matter does not exist; however, it is a fact in clinical practice. The application of IOT is not without controversy, with advocates, who consider it a way of achieving therapeutic compliance, and detractors, who think it is an infringement of the fundamental rights of a person.Objectives/methodologyAn evaluation of the knowledge on IOT in Spain. Analyze the four ethical principles found in this treatment.ResultsThe protection of the patient is encompassed in the principle of beneficence. And how could we combine this with the principle of autonomy? The answer should be individualized and based on a determined disorder. Starting with non-maleficence, we ask if IOT would provoke a rejection so that the patient would distance himself further from the therapeutic environment. As for the principle of justice, the high cost by patients that do not comply with the treatment would be diminished if we are able to have them follow the treatment with higher effectiveness. This would allow a greater number of patients to access these resources.ConclusionsThe proposal of IOT should be preceded by a deliberative process. This process should include a psychiatric diagnosis that includes not only psychiatric aspects, but psychological, familial and social as well. This would compel us to create a personalized design of the therapeutic needs of each patient.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study.

BackgroundAssertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT.MethodsThis naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics.ResultsWhen the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT.ConclusionThe findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users.

Mental health law profile on the Republic of Ireland.

This article provides a brief overview of the legislation that has been enacted in Ireland with respect to mental health, in particular the 2001 Mental Health Act. Although that Act was a positive step towards developing an Irish mental health service that protects the human rights of service users, a number of concerns remain, including issues related to consent and capacity, involuntary out-patient treatment and admission, the adversarial nature and timing of tribunals, and the lack of safeguards for voluntary patients.

Reconceptualizing involuntary outpatient psychiatric treatment: From “Capacity” to “Capability”

Justifying involuntary psychiatric treatment on the basis of a judgment that a person lacks capacity is controversial because there are questions about the meaning and utility of the concept in this context. There are complexities to using capacity in this way, which are further amplified in the community outpatient setting compared with acute inpatient care. A richer account of capacity, its meanings, and practical applications in context, is required. This qualitative study sought to build inductively a model of capacity in the context of involuntary outpatient psychiatric treatment, based on 38 interviews with stakeholders from New South Wales, Australia. The emergent model incorporates multiple capacities: to manage illness, for self-care, and to maintain social roles. It identifies core values that correspond with the capabilities approach, elaborating the justifications and processes of involuntary outpatient psychiatric treatment. This proposed model of capability may have a range of benefits to sound and ethical practice and scrutiny of systems of involuntary outpatient treatment.

Violence by and against people with mental illnesses

There is robust evidence for an increased risk of violence through people with psychotic disorders. Until recently this was frequently denied to prevent stigmatization. Alcohol and drug abuse equally increases the risk, while appropriate treatment reduces it drastically. Staff in psychiatric hospitals is exposed to an elevated risk of aggressive assaults. A limited number of severely ill and socially disintegrated patients accounts for these incidents, which are often recurrent. Besides patient characteristics, factors such as ward climate, staffing levels, education and attitudes of staff, and physical environment play a major role in aggressive escalations. On the other hand, mentally ill people, particularly women, are themselves at a higher risk of becoming victims of violent and non-violent crime. This also applies after correction for variables such as social status and living environment. Additionally mentally ill people are confronted with violence in the form of coercive interventions legitimised by the state (involuntary admission, involuntary treatment, freedom-restrictive measures such as seclusion or manual/physical restraint). In contrast to other countries in Central and Western Europe, involuntary outpatient treatment has never been legalized in Germany. Efforts to reduce violence and coercion in psychiatric facilities by evidence-based interventions are widespread nowadays, treatment guidelines are available.

Involuntary outpatient treatment (IOT) in Spain

In recent decades there have been significant legislative changes in Spain. Society develops faster than laws, however, and new challenges have emerged. In 2004, the Spanish Association of Relatives of the Mentally Ill (FEAFES) proposed amending the existing legislation to allow for the implementation of involuntary outpatient treatment (IOT) for patients with severe mental illness. Currently, and after having made several attempts at change, there is no specific legislation governing the application of this measure. Although IOT may be implemented in local programmes, we consider legal regulation to be needed in this matter.