Involuntary Psychiatric Care Research Articles

Patient clinical and demographic factors associated with involuntary psychiatric admission in the northern territory top end.

Australia has inadequate publicly available data regarding the use of involuntary psychiatric care. This study examined the association between patient clinical/demographic factors and involuntary psychiatric admission following initial psychiatric assessment in Royal Darwin Hospital. Retrospective review of 638 psychiatric assessments followed by covariate analysis of patient variables associated with involuntary psychiatric admission. Most of the 225 psychiatric admissions were involuntary (92%). Male patients and those with a preferred language other than English had the highest risk of being admitted involuntarily (RR 1.09, χ2 [1] = 3.9, p = .048, and RR 1.11, p = .036, respectively). Further research regarding the influence of patient demographics and clinical factors on rates of involuntary admissions, particularly for Aboriginal patients, is recommended. The findings prompt discussion on strategies to improve monitoring of involuntary care and barriers to voluntary treatment.

The relationship between area levels of involuntary psychiatric care and patient outcomes: a longitudinal national register study from Norway

BackgroundMental health legislation permits involuntary care of patients with severe mental disorders who meet set legal criteria. The Norwegian Mental Health Act assumes this will improve health and reduce risk of deterioration and death. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care thresholds, but no studies have investigated whether high thresholds have adverse effects.AimTo test the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations over time compared to areas with higher levels. Data availability precluded analyses of the effect on health and safety of others.MethodsUsing national data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 was associated with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014–2017 predicted an increase in the standardized suicide ratios in 2014–2018. Analyses were prespecified (ClinicalTrials.gov NCT04655287).ResultsWe found no adverse effects on patients’ health in areas with lower standardized involuntary care ratios. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care.ConclusionsLower standardized involuntary care ratios are not associated with adverse effects for patients with severe mental disorders in Norway. This finding merits further research of the way involuntary care works.

In-patient psychiatric care and non-substance-related psychiatric diagnoses among individuals seeking treatment for alcohol and substance use disorders: associations with all-cause mortality and suicide.

The largest excess mortality risk has been reported for combinations of psychiatric disorders that included substance use disorders. To study the associations of different non-substance-related in-patient psychiatric diagnoses with all-cause mortality and suicide up to 28 years of age after entering substance use treatment. National register data on psychiatric hospital admissions and death were combined with the treatment records of over 10 000 individuals in substance use treatment between 1990 and 2009. Cox regression was used to calculate hazard ratios (HRs) with 95% CIs for all-cause and suicide-specific mortality from the time of entering substance use treatment. Nearly one-third (31.4%; n = 3330) of the study population had died during follow-up or by their 65th birthday, with more than one in ten (n = 385) from suicide. Over half of the study population (53.2%) had undergone psychiatric in-patient care and 14.1% involuntary psychiatric care during the study period. Bipolar disorder and unipolar depression were associated with a 57% (HR 1.57, 95% CI 1.18-2.10) and 132% (HR 2.32, 95% CI 1.21-4.46) increase in risk of suicide, respectively. Involuntary psychiatric care was associated with a 40% increase in risk of suicide (HR 1.42, 95% CI 1.05-1.94). Severe psychiatric morbidity is common among individuals seeking treatment for alcohol and/or substance use and specifically mood disorders appear to increase the risk of suicide. Treatment service planning needs to focus on integrated care for concomitant substance use and psychiatric disorders to address this risk.

Dignity, coercion and involuntary psychiatric care: a study of involuntary and voluntary psychiatry inpatients in Dublin

Objectives There is a paucity of research about psychiatric inpatients’ experience of dignity. Most of the limited literature on this topic is qualitative. Our study provides quantitative data about self-rated dignity among involuntary and voluntary psychiatry inpatients. We explore relationships between perceived dignity and legal status, coercion, level of insight, diagnosis, and therapeutic alliance, among other parameters. Methods We recruited 107 participants aged 18 years or over from two inpatient psychiatric units in Dublin, Ireland over a 30-month period. Interviews consisted of structured, validated assessment tools. Demographic and clinical data were obtained from patient charts. Results Patient Dignity Inventory (PDI) score was non-normally distributed (skewed to the right), with a median score of 63.0 out of 125 (inter-quartile range: 40.0–80.0). On multi-variable testing, lower self-rated dignity was associated with higher perceived coercion, better insight and more negative symptoms. There was no association between dignity and gender, employment status, marital status, ethnicity, age, admission status, diagnosis, working alliance, positive symptoms or cognition. Conclusions Lack of dignity is linked with perceived coercion and negative symptoms, and is seen in patients with better insight. These links merit further study if we are to understand patient dignity in a more nuanced and useful way. KEYPOINTS We interviewed psychiatric inpatients using the Patient Dignity Inventory and other structured assessment tools. There was no significant difference between voluntary and involuntary patient groups’ self-rated dignity. Less self-rated dignity was seen in patients with higher levels of perceived coercion. Patients with better insight reported lower dignity. Dignity scores were not significantly associated with age, gender, ethnicity, diagnosis or length of stay in hospital.

Grave Disability in U.S. Jails and Prisons.

Many states authorize involuntary psychiatric care on the basis of grave disability, a legal standard often defined as a person's inability to provide for basic needs because of mental illness. Mental illness is prevalent in U.S. jails and prisons, and although correctional facilities must generally provide incarcerated people with basic necessities (e.g., food, clothing, and shelter), incarcerated people may still meet criteria for grave disability. This Open Forum examines the assessment and treatment implications of grave disability in correctional contexts and ways to support the well-being of incarcerated people who may meet criteria for grave disability.

Maintaining subjectivity under coercion: Former patients’ experiences of being transformed into an object in psychiatric care

Coercion in psychiatric care may cause long-term negative effects such as trauma, reluctance to seek later treatment, as well as erosion of self-confidence and trust in one’s own feelings and thoughts. Based on data from a previous study and the theoretical framework developed by Hans Skjervheim, this article discusses how experiences with coercion may appear as a result of how the patients are approached and defined when involuntarily admitted. If patients admitted to involuntary psychiatric care are treated as objects they might respond by objectifying the professionals back or succumbing to the descriptions of themselves as sick. The latter may ultimately cause them to question their own sanity. In light of this, this paper argues that there is a need for an ongoing ethical discussion on how to find common ground between patients and health care workers, where both are viewed as subjects with knowledge and opinions worthy of respect.

Black and minority ethnic groups and forensic mental health

AimsTo review the existent literature base regarding Black and Minority Ethnic (BAME) groups care pathway into and experience of care and treatment within secure services. This includes any differences (between BAME and majority ethnic groups) in rates of sentencing, sectioning, length of stay, received treatment and use of restrictive practice. Our overarching aim is to highlight the severe lack of research in this area and the corresponding need for increased research to both consolidate and progress the existing evidence base in order to inform and improve culturally competent service provision.BackgroundResearch suggests that BAME groups have an increased risk of involuntary psychiatric care, longer-stays within services and higher rates of re-admission. Several explanations have been proposed for this observed disparity, however few of these proposed explanations have provided sufficient or consistent supporting evidence.MethodA review of both quantitative and qualitative research regarding BAME groups within secure services was conducted. Approximately twenty journal articles, literature reviews and meta-analysis published between 1988 and 2019 were included. The current study should be considered a snapshot and not reflective of the full extent of published literature on the subject. For inclusion, studies should have been conducted in either a forensic mental health setting or a prison and differentiate a minimum of two ethnic groupsConclusionResearch suggest that BAME individuals continue to experience an increased risk of involuntary psychiatric care, longer stays within secure services and higher rates of re-admission. Whilst many explanations for this disparity have been proposed, few have provided adequate supporting evidence. The ongoing lack of research within this field has led to a limited evidence base from which to inform culturally competent practice. The research which has been conducted has tended to produce inconsistent findings, in part due to the reliance on small scale studies with limited generalisability. Research within this area has been further complicated by varying definitions of culture and ethnicity across studies, leading to some suggestion that the issue of ethnic inequalities and pathways to care, has been misconceptualised. This highlights a critical need for increased research efforts to:Understand why BAME individuals are at increased risk of involuntary psychiatric care, and how this disproportionate risk can be addressedExplore potential disparities in the care and treatment of BAME individuals within services and how this might impact upon higher rates of re-admissionAscertain how best to improve culturally competent service provision.

Comparison of accredited person and medical officer discharge decisions under the Mental Health Act of NSW: A cohort study of deliberate self-poisoning patients.

The Accredited Persons Programme was introduced in 2003. The relevant Mental Health Acts (NSW) authorised reviews by appropriately credentialed non-medical health professionals as part of the process of detaining and treating a person without consent: an authority previously held by medical officers. Evaluations of the Programme are needed. To compare discharge decisions for hospital-treated deliberate self-poisoning patients made by an Accredited Person and Medical Officers. For a 10-year cohort (2003-2012) of index hospital-treated deliberate self-poisoning admissions at the Calvary Mater Newcastle, we compared Accredited Person and Medical Officer discharge decisions from the general hospital. We specifically examined discharges to the psychiatric hospital under a Mental Health Act certificate (used as an index of the Accredited Person's use of the authority under the Accredited Persons Programme) compared to any other discharge destination. Unadjusted and adjusted logistic regression models and a propensity score analysis were used to explore the relationship between clinician type and discharge destination. There were 2237 index assessments (Accredited Person = 884; Medical Officer = 1443). One-quarter (27%) were referred for assessment under the Act at the psychiatric hospital, with the Accredited Person significantly more likely (32%) to require this compared to the Medical Officers (24%); Risk Difference: 8.3% (4.5 to 12.1). However, after adjusting for patient characteristics; Risk Difference: -3.0% (-5.9 to -0.1) and for propensity score, Risk Difference: -3.3% (-6.7 to 0.1), the Accredited Person and Medical Officer likelihood of discharging for an assessment under the Act was similar. The Accredited Person assessed more clinically complex patients than the Medical Officers. After adjusting for clinical complexity and propensity score, the likelihood of referral for involuntary psychiatric hospital care was similar for Accredited Person and Medical Officers. Our evaluation of the Accredited Person programme in the general hospital was favourable, and wider implementation and evaluation is warranted.

Involuntary Commitments: Billing Patients for Forced Psychiatric Care

Involuntary Commitments: Billing Patients for Forced Psychiatric Care

Involuntary Hospitalization During the COVID-19 Pandemic

Civil commitment statutes authorize involuntary psychiatric hospitalization in many countries. However, a pandemic disrupts the balance of ethical principles for involuntary hospitalization. Some patients will continue to require and to benefit from involuntary psychiatric care during a pandemic, but involuntary hospitalization also brings unique risks of infectious disease transmission that warrant consideration. In addition, changes to inpatient policies geared toward mitigating transmission risks may shape the effectiveness of involuntary care. Using a framework of four ethical principles—autonomy, nonmaleficence, beneficence, and justice—this article examines the shifting ethics of involuntary psychiatric hospitalization during the COVID-19 pandemic and offers suggestions for clinicians navigating these ethical dilemmas.

Absence of insight as a catch-all extra-legislative factor in Swedish mental health law proceedings

Previous research indicates that insight is frequently used but rarely defined in mental health proceedings. This article examines how participants in Swedish administrative court proceedings use the concept of insight when discussing decisions regarding involuntary psychiatric care. Open-ended qualitative interviews were conducted with professional mental health court participants. The results show that lack of insight is used by the informants as an argument for all three legal criteria for involuntary psychiatric care in Sweden, as well as the criterion for release from forensic psychiatric care. It is concluded that there are troublesome legal and ethical implications of courts relying on a poorly defined concept such as insight in their rulings.

Caractérisation d’une population de patients hospitalisés sous contrainte en ASPDT/u et ASPPI à partir d’un service d’urgence psychiatrique parisien

BackgroundThe French mental health law, first enacted on July 5, 2011, introduced the possibility of psychiatric commitment in case of extreme urgency (imminent peril – ASPPI). The decision of involuntary admission can then be made by the hospital director based on a medical certificate, without the need of a third party request. This procedure was intended to be applied on an exceptional basis, but its use is steadily increasing against the other types of involuntary care. Our study aimed at comparing the characteristics of patients who had received an indication for involuntary admission due to imminent peril (ASPPI) or at the request of a third party (ASPDT/u) in a psychiatric emergency ward, according to sociodemographic and clinical characteristics and regarding the potential implication of a third party. MethodsAn observational study was conducted among patients from the Centre Psychiatrique d’Orientation et d’Accueil (CPOA), located at Sainte-Anne hospital in Paris, from August 1st to 31st, 2016. ResultsOne hundred and fifty patients with an indication for involuntary commitment were included, 101 of whom for ASPDT/u (67 %) and 49 for ASPPI (33 %). For more than half of the patients from the ASPPI group, a third party had been identified with (39 %) or without (17 %) contact information. Compared to ASPDT/u patients, ASPPI individuals were more socially vulnerable, showed more negligence, and had a lower mean functioning score. The indication for ASPPI status was also associated with behavioural quirks, prior psychiatric hospitalization (especially as an ASPPI patient) and with the diagnosis of chronic psychosis instead of mood disorder. ConclusionOur exploratory results help to better understand how the ASPPI procedure is used in psychiatric emergency wards six years after enactment of the law. They highlight the differences between ASPPI patients and ASPDT/u and raise ethical issues regarding involuntary psychiatric care.

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data

SummaryBackgroundEvidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations.MethodsFor this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137.FindingsOur search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03–3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62–3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07–1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22–4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21–1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages.InterpretationBAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention.FundingUniversity College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

System Changes Needed to Support Physicians Seeking Help

System Changes Needed to Support Physicians Seeking Help

Les soins psychiatriques sans consentement en milieu pénitentiaire sont-ils réservés aux patients « dangereux » ?

The unités hospitalières spécialement aménagées (UHSA) are full-time inpatient psychiatric units for inmates in France. Their creation has been associated with several advances in access to psychiatric care for inmates in recent years. However, there is still only one means of involuntary hospitalization for prisoners in France: care by decision of a representative of the state (les soins sur décision d’un représentant de l’état [SDRE]). Interestingly, for SDRE to be recognized as legal by the French judge, the patient must be “a danger to himself or to the others”. Thus, there is a major difference with involuntary hospitalization outside the prison, and there are specific criteria for involuntary psychiatric hospitalization for inmates in France. This situation questions the general framework of involuntary psychiatric care and is very inconsistent with French law. Indeed, the goal of the loi no 94-43 du 18 janvier 1994 relating to public health and social protection is to ensure equivalent care for all patients, incarcerated or not.

Hospitalisation en unité hospitalière spécialement aménagée : enquête de satisfaction auprès des patients

BackgroundIn France, special full-time inpatient hospital units (UHSA) have been created for inmates with psychiatric disorders. Since they were established in 2010, the quality of care in such units has not been studied. Particularly, no patient satisfaction survey has been conducted yet. The main objective of this study was to assess the patients’ satisfaction about their hospitalization in UHSA. MethodsA descriptive study has been performed in two hospitals (UHSA of Villejuif and UHSA of Lille-Seclin). From February to May 2015, 125 adult patients were included, at the end of their hospitalization (voluntary or involuntary psychiatric care) in UHSA. The patient's satisfaction was assessed by a psychiatrist who did not participate in patient care with a 16-item scale exploring three areas (quality of care, quality of information provided and UHSA functioning and organization). The items were evaluated with a visual numeric scale (1 to 10). ResultsThe average score of overall satisfaction was 7.3±1.9 (average±standard deviation) for this sample. For the care area, the average score was 7.6±2; for the quality of information provided, it was 7.5±2.5 and for UHSA functioning and organization, 7.0±2. Furthermore, 84.8 % of patients reported their wish to continue psychiatric care in prison and 77.6 % after release. ConclusionThis study demonstrates that patients hospitalized in UHSA are satisfied. Given the relationship between patient satisfaction and compliance, these structures could therefore have an important medical interest for inmates with psychiatric disorders. However, these results need to be replicated in a study involving all the UHSA of France.

Committed: The Battle Over Involuntary Psychiatric Care Miller Dinah and Johns Annette Hanson Committed: The Battle Over Involuntary Psychiatric Care 328pp US£22.95/£15.99 Hopkins University Press 9781421420783 1421420783 hardback edition

Committed: The Battle Over Involuntary Psychiatric Care Miller Dinah and Johns Annette Hanson Committed: The Battle Over Involuntary Psychiatric Care 328pp US£22.95/£15.99 Hopkins University Press 9781421420783 1421420783 hardback edition

A Review of Treatment Failures Presented inCommitted: The Battle Over Involuntary Psychiatric Care

Committed: The Battle Over Involuntary Psychiatric Careexplores the complex battle over involuntary hospitalization for mental illness. This article aims to explore the flaws of involuntary commitment as the authors presented in their book and seeks to foster a discussion that will improve the lives of the mentally ill. This discussion includes the negative experiences of patients, some of the legal issues surrounding involuntary care, and some issues with the process of commitment that were presented in the book.

Critères de soins psychiatriques sans consentement. Revue de littérature et synthèse des différentes recommandations

Though the carrying out of involuntary psychiatric care (IPC) mainly follows from a subjective appraisal of the patient's state, some specific clinical criteria have been proposed on regards to the underlying disorder. French national recommendations are synthesized hereby, and completed by a literature review. In psychotic disorders, the level of insight and the impact of delusion(s) are the essential criteria that should recommend to carry out IPC. In mood disorders, the appraisal is different depending on the underlying clinical state. In depressive or mixed states, IPC should be considered mainly in case of suicidal risk or jeopardizing physical consequences. In mania, IPC should result from a poor level of insight, or from the onset of significant social or occupational aftermaths. For suicidal states, it is necessary to appreciate suicidal risk and underlying psychiatric disorder. In addictive disorders, repeated risk-taking and denial should be the main criteria for considering IPC. In eating disorders, the occurring of both danger of death and denial of care should lead to possible IPC. Personality disorders are severity factors of emergency psychiatric states which can result in IPC. They are not criteria for IPC by themselves. For patients with dementia, mostly behavioural disturbances can require IPC.

Recovery in involuntary psychiatric care: Is there a gender difference?

Background: Research on recovery from mental illness and the influence of compulsory psychiatric institutional care has revealed the complexity of this concept. There is also limited knowledge regarding the impact of gender-role expectations in these contexts, and how such expectations may influence both the care and individuals' recovery processes.Aim: To explore women's and men's perceptions of the impact of compulsory inpatient care on recovery from severe mental illness.Method: Grounded theory was used to analyse 30 first-person accounts of recovery from mental illness, elicited via interviews with individuals who had been compulsorily treated in hospital and diagnosed with a severe mental illness.Results: Inpatient care at an early stage was crucial for the informants' recovery. However, there was ambivalence in their perceptions of the impact of compulsory inpatient care. The narratives confirmed gender differences as well as gender stereotypes.Conclusions: The results have implications for recovery research, in that they emphasise the importance of understanding recovery as a gender-influenced process.