Involuntary Psychiatric Treatment Research Articles

Chronic, Disruptive, or Resistant? Target Ecologies and the Medicalization of Homelessness in California

Abstract How do place and social context shape how policymakers construct the targets of state interventions? This paper analyzes recent proposals in California to subject people experiencing homelessness to involuntary psychiatric treatment. Using newspaper articles, legislative hearings, government reports, and interviews, we show how policymakers frame “the homeless mentally ill” in distinctive ways: Chronic and contained people who require extended institutionalization, disruptive and visible individuals who need a period of forced sobriety, and a service-resisting and underserved population whom mental health agencies have overlooked, but who could comply with treatment with a coercive incentive. We argue these constructions reflect how policymakers represent specific target ecologies: concentrated but confined homelessness on LA’s Skid Row, frequent and expensive use of emergency services in San Francisco’s Tenderloin, and expanding homelessness in jurisdictions traditionally reticent to provide care, as in San Diego County. This paper shows the value of disaggregating broad population categories to show how they are differentially problematized, as policymakers seek to gain support and justify intervention in specific places. We also illustrate a broader policy trend of reframing involuntary treatment as a progressive and compassionate response to substance use, homelessness, and urban disorder.

Debate: The experience of involuntary psychiatric hospitalisation for children and young people.

Involuntary treatment has been reported to be traumatic, stigmatising and frightening, as well as sometimes lifesaving. However, there has been little research into the experiences of people who have been hospitalised involuntarily prior to the age of 18. A greater understanding of this may help us to make changes which could improve the experience of involuntary psychiatric treatment for children and young people. Lizzie Mitchell is an expert by experience who was admitted to a psychiatric hospital in England under the Mental Health Act (MHA) when she was 16 years old. Here, in discussion with Susan Walker, a child and adolescent psychiatrist, Lizzie reflects on her own experiences alongside wider reflections around the involuntary hospitalisation of young people, including the potential short and long-term impact on mental health, education, friendships, family and identity.

Debate: Involuntary treatment and detention are a necessary part of mental health care for children and young people.

People of all ages are subject to involuntary psychiatric detention and treatment worldwide but there is current discussion about whether this complies with modern human rights law. The use of involuntary psychiatric hospitalisation among children and young people has largely eschewed research and policy interest to date. In this debate section, we hear from people with experience of child mental health services in the UK, USA and low- and middle-income countries about their views on the use of involuntary treatment in young people.

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review.

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.

A country report: impact of COVID-19 lockdowns on involuntary psychiatric treatment in Austria.

Coercive measures such as involuntary psychiatric admission are considered a last resort in the treatment of people with psychiatric disorders. So far, numerous factors have been identified that influence their use. However, the link between a pandemic - in particular, restrictions such as lockdowns - and the use of involuntary psychiatric admission is unclear. To examine the association between COVID-19 lockdowns and involuntary psychiatric admissions in Austria. This retrospective exploratory study assessed all involuntary psychiatric admissions and use of mechanical restraint in Austria, except for the federal state of Vorarlberg, between 1 January 2018 and 31 December 2020. Descriptive statistics and regression models were used. During the 3-year study period, 40 012 individuals (45.9% females, mean age 51.3 years) had 66 124 involuntary psychiatric admissions for an average of 10.9 days. Mechanical restraint was used during 33.9% of these admissions. In weeks of nationwide COVID-19 lockdowns (2020 v. 2018/2019), involuntary psychiatric admissions were significantly fewer (odds ratio = 0.93, P = 0.0001) but longer (11.6 (s.d.: 16) v. 10.9 (s.d.: 15.8) days). The likelihood of involuntary admission during lockdowns was associated with year (2020 v. 2018-2019; adjusted odds ratio = 0.92; P = 0.0002) but not with sex (P = 0.814), age (P = 0.310), use of mechanical restraint (P = 0.653) or type of ward (P = 0.843). Restrictions such as lockdowns affect coercive measures and resulted in fewer but longer involuntary psychiatric admissions during weeks of lockdown in Austria. These results strengthen previous findings that showed the dependence of coercive measures on external factors, highlighting the need to further clarify causality and desired prevention effects when using coercive measures.

Involuntary psychiatric treatment during the COVID-19 pandemic. An international qualitative study.

During the COVID-19 pandemic, studies report that in the first few months of the lockdown there was a decrease in requests for mandatory psychiatric treatment, while, in contrast, following the second wave, the number of cases increased. This study investigates the use of compulsory psychiatric treatments internationally in the first and subsequent phases of the pandemic. Sixteen key people were interviewed: eight mental health care professionals and eight scholars in Italy, Greece, China and Chile. Participants were asked to discuss their experience of the motivations, diagnoses and management of patients undergoing an involuntary psychiatric hospitalization. The analysis through Grounded Theory highlighted four themes: (a) the culture of psychiatric care services, (b) the effect of the pandemic on involuntary hospitalizations, (c) exceptional management of hospitalization, and (d) policies and suggestions for more inclusive mental health treatments. During the first wave, respondents reported a decrease in the use of involuntary treatments, while a gradual increase was seen in the following months. Italy extended compulsory psychiatric treatment to a group of new users, including young people and adolescents with acute crises; in other contexts, the main users are chronic psychiatric patients.

Racial and Ethnic Inequities in Inpatient Psychiatric Civil Commitment.

Involuntary psychiatric treatment may parallel ethnoracial inequities present in the larger society. Prior studies have focused on restraint and seclusion, but less attention has been paid to the civil commitment system because of its diversity across jurisdictions. Using a generalizable framework, this study investigated inequities in psychiatric commitment. A prospective cohort was assembled of all patients admitted to an inpatient psychiatric unit over 6 years (2012-2018). Patients were followed longitudinally throughout their admission; raters recorded legal status each day. Sociodemographic and clinical data were collected to adjust for confounding variables by using multivariate logistic regression. Of the 4,393 patients with an initial admission during the study period, 73% self-identified as White, 11% as Black, 10% as primarily Hispanic or Latinx, 4% as Asian, and 3% as another race or multiracial. In the sample, 28% were involuntarily admitted, and court commitment petitions were filed for 7%. Compared with White patients, all non-White groups were more likely to be involuntarily admitted, and Black and Asian patients were more likely to have court commitment petitions filed. After adjustment for confounding variables, Black patients remained more likely than White patients to be admitted involuntarily (adjusted odds ratio [aOR]=1.57, 95% confidence interval [CI]=1.26-1.95), as were patients who identified as other race or multiracial (aOR=2.12, 95% CI=1.44-3.11). Patients of color were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalization, and Black patients and patients who identified as other race or multiracial were particularly vulnerable, even after adjustment for confounding variables.

Algorithmic Assessments in Deciding on Voluntary, Assisted or Involuntary Psychiatric Treatment.

The challenges in assessing whether psychiatric treatment should be provided on voluntary, assisted or involuntary legal bases prompted the development of an assessment algorithm that may aid clinicians. It comprises a part that assesses the incapacity to provide informed consent to treatment, care or rehabilitation. It also captures the patient’s willingness to receive these treatments, the risk posed to the patient’s health or safety, financial interests or reputation and risks of serious harm to self or others. By following various decision paths, the algorithm yields one of four legal states: a voluntary, assisted, or involuntary state or that the proposed intervention should be declined. This study examined the predictive validity and the reliability of this algorithm. It was applied 4052 times to 135 clinical case narratives by 294 research participants. The legal states yielded by the algorithm had high statistical significance when matched with the gold standard (Chi-squared = 6963; df = 12; p < 0.001). It was accurate in yielding the correct legal state for the voluntary, assisted, involuntary and decline categories in 94%, 92%, 88% and 86% of the clinical case narratives, respectively. For internal reliability, a correspondence model accounted for 99.8% of the variance by which the decision paths clustered together fittingly with each of the legal states. Inter-rater reliability testing showed a moderate degree of agreement among participants on the suitable legal state (Krippendorff’s alpha = 0.66). These results suggest the algorithm is valid and reliable, which warrant a subsequent randomised controlled study to investigate whether it is more effective in clinical practice than standard assessments.

Totalitarian approaches to risk and the banality of harm in secure and forensic psychiatric settings in England and Wales

The secure and forensic mental health system sustains its legitimacy predominantly by acting to assuage public fear of the perceived risk posed by people with mental disorders. In this paper we aim to consider the totalising nature of the policies and practices which govern the care and treatment of mentally disordered offenders. A discursive exploration of the restrictive nature of policies and practices which govern the care and treatment of mentally disordered offenders. We further draw parallels between the potential for harm due to disproportionately risk averse ways of working with patients in secure settings and Arendt's conceptualisations of the nature of totalitarian regimes and the harms they incur. Although secure and forensic psychiatric settings are ostensibly hospitals and not prisons, given the potential for harm associated with involuntary psychiatric treatment within closed institutions, it is crucial that risk related practices are scrutinised and challenged.

Involuntary psychiatric treatment and the erosion of consent: A critical discourse analysis of mental health legislation in British Columbia, Canada.

The Mental Health Act (1996) is legislation that directs voluntary and involuntary psychiatric treatment for people experiencing mental health issues in British Columbia (BC), Canada. This critical discursive analysis explores how BC's Mental Health Act (1996) and the Guide to the Mental Health Act (2005) structure involuntary psychiatric treatment and illustrates how the discourses within these texts constitute people experiencing mental health issues as passive recipients of care. Understandings of people experiencing mental health issues as pathological, incapable, vulnerable and dangerous justify their need for protection and the protection of others. Protection is identified as a central legitimising discourse in the use of involuntary psychiatric treatment. Further, these texts define the roles and responsibilities of police, physicians and nurses in authorising and implementing involuntary psychiatric treatment. This analysis describes how this legislation erodes consent and entrenches social marginalisation. Alternatively, discourses of equity have potential to transform health care practices and structures that reproduce discourses of deficit, vulnerability and dangerousness, shifting towards promotion of the rights and safety of people experiencing mental health issues and crises.

FUQARONING LAYOQATI (HUQUQ VA MUOMALA) BILAN BOG‘LIQ ISHLAR: NAZARIY TAHLIL VA AMALIY NATIJALAR

The legal capacity and its procedural peculiarities, the issues connected with the rights and legal capacity of citizens, the procedure of considering those cases in courts, opinions about characteristics of the cases in these categories as well as proposals and recommendations were explained in this article. The article discusses the material and procedural legal capacity, legal capacity, procedural legal capacity, procedural capacity, emancipation, limitation of civil capacity, incapacity, involuntary or involuntary psychiatric treatment of a person.), the need for inclusion in legislation and procedural features, as well as legal consequences. Citizenship (legal capacity and procedural capacity) is one of the most important institutions in medicine and jurisprudence. The legal capacity of a citizen is divided into legal capacity and procedural capacity. At the same time, it seems important to study this concept on the basis of the norms of the Civil Code, the Code of Civil Procedure, the Family Code, its medical, psychological and legal basis. At the same time, a scientific and practical study of the legal criteria for the concepts of legal capacity and procedural capacity. The article also contains proposals and theoretical conclusions for improving the material and procedural legislation based on the analysis of the subject.

Patients' Rights and the Texas Mental Health Law.

A series of court cases between the 1960s and the 1980s focusing on patient autonomy changed the approach to mental health treatment in the United States. The process of involuntary psychiatric treatment can vary greatly between states; thus, all mental health practitioners need to have a strong grasp of their respective state and institutional policies. In this article, we examine the Texas mental health law regarding consent to psychoactive medications and involuntary medications. The Texas Health and Safety Code requires the use of a legally authorized representative to consent to psychoactive medications when patients lack capacity due to a mental illness. We argue that the use of a legally authorized representative is ethical and improves psychosocial outcomes. Using a case example, we explore the interplay among patient rights to treatment, autonomy, ethics, and the law. Consistent application of this process will facilitate treatment according to the current standard of practice.

SIDMA as a criterion for psychiatric compulsion: An analysis of compulsory treatment orders in Scotland

Scottish mental health legislation includes a unique criterion for the use of compulsion in the delivery of mental health care and treatment. Under the Mental Health (Care and Treatment) (Scotland) Act, 2003, patients must exhibit ‘significantly impaired decision-making ability’ (SIDMA) in order to be eligible for psychiatric detention or involuntary psychiatric treatment outside the forensic context. The SIDMA requirement represents a distinctive strategy in ongoing international efforts to rethink the conditions under which psychiatric compulsion is permissible. We reconstruct the history of the Scottish SIDMA requirement, analyse its differences from so-called ‘fusion law,’ and then examine how the SIDMA standard actually functions in practice. We analyse 100 reports that accompany applications for Compulsory Treatment Orders (CTOs). Based on this analysis, we provide a profile of the patient population that is found to exhibit SIDMA, identify the grounds upon which SIDMA is attributed to individual patients, and offer an assessment of the quality of the documentation of SIDMA. We demonstrate that there are systemic areas of poor practice in the reporting of SIDMA, with only 12% of CTOs satisfying the minimum standard of formal completeness endorsed by the Mental Welfare Commission. We consider what lessons might be drawn both for the ongoing review of mental health legislation in Scotland, and for law reform initiatives in other jurisdictions.

Compulsory Treatment as Task of Public Governance or What Thyphoid Mary and Mad King Ludwig Had in Common (Abstract)

The article concerns involuntary treatment of infectious and mental diseases. Development of the legal regulation since the 19th century has been described here. Quality of the existing legal regulation has also been evaluated. Issues of involuntary psychiatric treatment have been analysed and demonstrated by the international case-law and state court practice. Significant differences between legislation in mental and infectious diseases has been detected, as well as differences have been traced between legal standards in the area of involuntary placement and involuntary treatment of mental disorders in Latvia and other countries. It has been concluded that involuntary psychiatric treatment, in line with epidemiological safety, is a task of public governance in the area of domestic security and safeguarding of human rights and it has to be reinforced by governmental authority. Thus, proposal of elaboration of the corresponding law has been made.

Hall of Mirrors: Toward an Open Society of Mental Health Stakeholders in Safeguarding against Psychiatric Abuse

This article explores the role of an international open society of mental health stakeholders in raising awareness of values and thereby reducing the vulnerability of psychiatry to abuse. There is evidence that hidden values play a key role in rendering psychiatry vulnerable to being used abusively for purposes of social or political control. Recent work in values-based practice aimed at raising awareness of values between people of different ethnic origins has shown the importance of what we call “values auto-blindness” – a lack of awareness of one’s own values as a key part of our background “life-world” – in driving differential rates of involuntary psychiatric treatment between ethnic groups. It is argued that the vulnerability of psychiatry to abuse stems from values auto-blindness operating on the judgments of rationality implicit in psychiatric diagnostic concepts. Acting like a “hall of mirrors,” an international open society of mental health stakeholders would counter the effects of values auto-blindness through enhanced mutual understanding of the values embedded in our respective life-worlds across and between the diverse perspectives of its constituents. The article concludes by noting that a model for the required open society is available in the contemporary interdisciplinary field of philosophy and psychiatry.

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

Held Against Our Wills: Reimagining Involuntary Commitment.

Involuntary psychiatric treatment for people with serious mental illness should focus on returning to health instead of reducing danger.

Duties toward Patients with Psychiatric Illness.

Patients with psychiatric illness feel the brunt of the intersection of many of our society's and our health care system's disparities, and the vulnerability of this population during the Covid‐19 pandemic cannot be overstated. Patients with psychiatric illness often suffer from the stigma of mental illness and receive poor medical care. Many patients with severe and persistent mental illness face additional barriers, including poverty, marginal housing, and food insecurity. Patients who require psychiatric hospitalization now face the risk of transmission of Covid‐19 due to the inherent difficulties of social distancing within a psychiatric hospital. Patients whose freedom and self‐determination have been temporarily overruled as they receive involuntary psychiatric treatment deserve a setting that maintains their health and safety. While tele‐mental health has been rapidly expanded to provide new ways to access psychiatric treatment, some patients may have limitations in technological literacy or access to devices. The social isolation, economic fallout, and potential traumatization related to the current pandemic will disproportionately affect this vulnerable population, and society's duties to them must be considered.

Impending Danger: The Meaning of Danger as a Legal Requirement for Involuntary Psychiatric Treatment in the Norwegian Criminal Justice System

A proposal for the revision of the rule regulating involuntary psychiatric treatment of criminally insane offenders has been accepted by the Norwegian parliament. As a result, greater emphasis will be placed on the requirement of ‘danger’ in future decisions on whether criminally insane offenders shall be subjected to sanctions. This paper gives an overview of the rule in question and makes a preliminary analysis of the legal contents of the danger requirement. Possible problem-areas that have not been addressed in the proposal for revision are identified. The need for future research is explained.

A retrospective analysis of determinants of involuntary psychiatric in-patient treatment

BackgroundThe purpose of our study was to identify predictors of a high risk of involuntary psychiatric in-patient treatment.MethodsWe carried out a detailed analysis of the 1773 mental health records of all the persons treated as in-patients under the PsychKG NRW (Mental Health Act for the state of North Rhine-Westphalia, Germany) in a metropolitan region of Germany (the City of Cologne) in 2011. 3991 mental health records of voluntary in-patients from the same hospitals served as a control group. We extracted medical, sociodemographic and socioeconomic data from these records. Apart from descriptive statistics, we used a prediction model employing chi-squared automatic interaction detection (CHAID).ResultsAmong involuntary patients, organic mental disorders (ICD10: F0) and schizophrenia and other psychotic disorders (ICD10: F2) were overrepresented. Patients treated as in-patients against their will were on average older, they were more often retired and had a migratory background. The Exhaustive CHAID analysis confirmed the main diagnosis to be the strongest predictor of involuntary in-patient psychiatric treatment. Other predictors were the absence of outpatient treatment prior to admission, admission outside of regular service hours and migratory background. The highest risk of involuntary treatment was associated with patients with organic mental disorders (ICD 10: F0) who were married or widowed and patients with non-organic psychotic disorders (ICD10: F2) or mental retardation (ICD10: F7) in combination with a migratory background. Also, referrals from general hospitals were frequently encountered.ConclusionsWe identified modifiable risk factors for involuntary psychiatric in-patient treatment. This implies that preventive measures may be feasible and should be implemented to reduce the rate of involuntary psychiatric in-patient treatment. This may include efforts to establish crisis resolution teams to improve out-patient treatment, train general hospital staff in deescalation techniques, and develop special programs for patients with a migratory background.