Involuntary Treatment Research Articles

Socio-demographic and Economic Factors Associated with Adherence to Anti-Tuberculosis Treatment

Introduction: Tuberculosis is one of the most significant health problems in Bangladesh. Adherence to TB treatment is crucial to achieving cure while avoiding the emergenceofdrug resistance. Non-adherence to anti-tuberculosis treatment may result in persistent infectiousness and a higher rate of treatment failure, relapse and drug resistance and therefore, it’sa significant barrier to the success in tuberculosis control.
 Objectives: To determine the socio-demographic and economic factors influencing adherence to anti-tuberculosis treatment among tuberculosis patients.
 Materials and Methods: This case control study was carried out among purposively selected 47 cases and 94 controls in selected DOTS centres of Dhaka city from January 2010 to July 2010. Data were collected by face to face interview using a semi-structured questionnaire.
 Results: Males were 2.5 times more likely to be non-adherent and among them day-labourer and main earning member were more commonly non-adherent (p<0.05). Low per capita income and irregularity of monthly income were significantly (p<0.01) associated with non-adherence.
 Conclusion: Non-adherence is associated with the risk factors that are modifiable by the correction of socio-demographic and economic characteristics as a whole. So the highest priority in fighting against non-adherence therefore must be to reduce poverty for its prevention especially targeting the patients of low economic status.
 Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 39-41

Post-Traumatic Stress Disorder among Burn Patients in a Tertiary Hospital

Introduction: Imbalance in multi-factorial components of human ecology plays a role in developing post-traumatic stress disorder hampering economical productivity and normal social life.
 Objectives: To find out the interplay of issues that are conducive to the outcome of the disorder among hospital admitted burn patients.
 Materials and Methods: This unobtrusive qualitative behavioral health research by in-depth interview was conducted among conveniently selected 35 burn patients in Dhaka Medical College Hospital of Bangladesh from July 2013 to June 2014. The data were analyzed to draw conclusion through etic and/or emic interpretation. All ethical issues were taken care of.
 Results: The highest 80% burn patients were married, 71% were male, and 80% were Muslim. Majority 37.14% were day laborer, 28.57% had completed primary education, 34.29% belonged to the age group 21-30 years, and 43% had monthly family income up to Tk. 10000. Of 41% burn occurring at home, majority 27% occurred during rice cooking, affecting the upper limb in 29% cases. Social dislocation was the major phenomena leading to burn injury in 22.86% of the patients. Lack of harmonious relationship and in-laws poking in conjugal life sometime led to deliberate infliction of burn.
 Conclusion: The study concluded with the suggestions for prevention of neoteric entry in the domain of post-traumatic stress disorder through social movement and psychotherapy of burn patients. Study also hinted for further probing of the phenomenon of the disorder.
 Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 27-31

Outcome of Sorafenib Therapy in Advanced Hepatocellular Carcinoma

Introduction: Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. It occurs most often in people with chronic liver diseases, such as cirrhosis caused by hepatitis B or hepatitis C infection. It is the fifth most common liver cancer globally and also a common cancer in Bangladesh. Treatment is difficult; however newer oral drug Sorafenib is available in our country which is promising.
 Objectives: To evaluate the efficacy of TKI Sorafenib on advanced and non-resect able primary HCC in Bangladeshi patients.
 Materials and Methods: This clinical trial was conducted on 38 diagnosed patients of advanced hepatocellular carcinoma (stage-3 and Child-Pugh Class-C) over a period of 3 years from May 2014 to July 2017 in the department of Oncology, CMH Dhaka. The patients receive Sorafenib 200-400 mg twice daily till disease progression ceases or increases and there are no unacceptable toxicities. Efficacy was observed in terms of overall survival, progressive free survival (PFS), drug compliance and common toxicities.
 Results: In 24 months of follow –up period from the date of Sorafenib taken, median overall survival was 7.73 months. The median overall survival was 8 months (range 8.13-27.43 months) in 42.4% patients. The median PFS is 3.5 months (range 1.2-5.8 months). Common toxicities found were anorexia, weakness, yellow colouration of skin and mucosa, HTN, rash and diarrhoea.
 Conclusion: In Sorafenib treated Bangladeshi advanced HCC patients, the median overall survival was found to be significant and compatible with some of the international publication.
 Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 16-18

Efficacy of Burst Mode Torsional Phacoemulsification in Age-Related Cataract

Introduction: Torsional ultrasound energy and burst mode interrupted energy delivery system are recent advancementsin the technique of phacoemulsification surgery. It has been reported that both these advancementshelpto reduce corneal wound burn and thermal induced endothelial cell loss and thereby helps to achieve excellent early postoperative visual outcome
 Objectives: To evaluate the efficacy of burst mode torsional phacoemulsification surgery in age-related cataract.
 Materials and Methods: Prospective observational study of 120 cases that underwent phacoemulsificationcataract surgery in which torsional energy was used in burst mode. Phacoemulsification was performed by “vertical –chop” technique. Intraoperatively corneal wound burn, Descemet’s membrane detachment, posterior capsule ruptureetc.were evaluated. Postoperatively corneal oedema, best corrected visual acuity, cystoid macular oedema were evaluated. Postoperatively eyes were examined at day 1, 1 week, 6 weeks and 3 months.
 Results: Mean age of the patients was 57.28± 8.20 years. Most of the patients 81(67.5%) had nuclear sclerosis grade-II cataract.Intraoperatively, moderate wound burn occurred in 02(1.6%) eyes, localized Descemet’s membrane detachmentin 03(2.5%) eyes and posterior capsule rupture occurred in 03(2.5%) cases. Postoperatively, moderate and severe corneal edema was found in 06(5.0%) and 04(3.3%) eyes respectively at day 1. At the end of 3 months follow-up, 114(95%) eyes maintained a best corrected visual acuity of ≥ 6/18, of which 109(90.8%) eyes achieved ≥ 6/9.
 Conclusion: Burst mode torsional phacoemulsfication is a very effective and advanced technique of cataract surgery. Intraoperative complications are very less and visual outcome is excellent.
 Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 94-97

Audit of forced care in California fuels discussion of flaws in law

An audit examining implementation of California's law governing the provision of involuntary mental health treatment has found several flaws in the system of care for persons with serious mental illness. However, the audit itself is coming under some criticism as well, for not taking a deep enough dive into contributing issues such as inadequate state funding and outdated standards to determine the need for involuntary treatment.

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.

Clinical application of negative-pressure wound therapy in split-thickness skin grafting at hard-to-fix sites

Objective: To compare the clinical effects of continuous negative-pressure wound therapy (NPWT) and conventional pressure dressing at at hard-to-fix sites after split-thickness skin grafting. Methods: From September 2017 to August 2019, 129 patients who met the inclusion criteria and had spilt-thickness skin grafting at hard-to-fix sites were admitted to the First Affiliated Hospital of Air Force Medical University and included in this retrospective cohort study. The patients were divided into NPWT group (67 patients, 41 males and 26 females, aged (32±6) years) and conventional pressure dressing group (62 patients, 37 males and 25 females, aged (30±5) years) according to whether the hard-to-fix sites were applied with NPWT after spilt-thickness skin grafting. After debridement and spilt-thickness skin grafting at hard-to-fix sites in patients of 2 groups, the wounds of patients in conventional pressure dressing group were applied with conventional pressure bandaging after being filled with dry gauze; for the wounds of patients in NPWT group, the semi-permeable membrane was pasted and sealed for continuous negative pressure suction after filled with dry gauze and placed the drainage foam or drainage tube, with the negative pressure ranging from -16.6 to -9.9 kPa. The bandage was opened during the first dressing change on the 5th day after surgery in NPWT group and on the 7th day after surgery in conventional pressure dressing group. The skin graft surviving area and proportion, the area and proportion of hematoma, the incidence of common complications of skin graft were observed and calculated. The times of postoperative dressing change and the length of hospital stay were counted. Data were statistically analyzed with two independent sample t test, Cochran & Cox approximate t test, chi-square test, and Fisher's exact probability test. Results: (1) At the first dressing change, the skin graft surviving area of patients in NPWT group was (420±94) cm(2), which was significantly larger than (322±97) cm(2) in conventional pressure dressing group (t'=12.33, P<0.01); the skin graft surviving area proportion of patients in NPWT group was (97.0±2.3)%, which was significantly higher than (74.4±4.8)% in conventional pressure dressing group (t'=50.11, P<0.01). (2) At the first dressing change, the skin hematoma area of patients in conventional pressure dressing group was (31.7±10.1) cm(2), which was significantly larger than (3.2±0.7) cm(2) in NPWT group (t'=23.04, P<0.01); the skin hematoma area proportion of patients in conventional pressure dressing group was (7.3±2.3)%, which was significantly higher than (0.7±0.3)% in NPWT group (t'=76.21, P<0.01). (3) At the first dressing change, there was 1 case of skin movement and no case of skin graft edge tear in NPWT group with an incidence of 1.5% (1/67). In the conventional pressure dressing group, there were 4 cases of skin movement and 2 cases of skin graft edge tear with an incidence of 9.7% (6/62), P<0.05. The incidence of complication of skin graft of patients in NPWT group was significantly lower than that in conventional pressure dressing group (P<0.05). (4) The times of postoperative dressing change of patients in NPWT group was significantly less than that in conventional pressure dressing group (t=7.93, P<0.01). The postoperative length of hospital stay in NPWT group was significantly less than that in conventional pressure dressing group (t=11.71, P<0.01). Conclusions: Continuous NPWT can effectively promote wound healing, improve the survival rate of skin graft, reduce the incidence of complications after skin grafting, and shorten the length of hospital stay in split-thickness skin grafting at hard-to-fix sites.

The Connecticut Experience with Sell Legislation.

Since 2004, Connecticut has had two different mechanisms for involuntary medication of defendants hospitalized for restoration of competence to stand trial. In this article, we first describe the development of these two mechanisms and compare their procedural elements. The first procedure required a hearing in criminal court, in a process parallel to the subsequent U.S. Supreme Court holding in Sell v. United States; the later procedure uses a civil mechanism in probate court and was enacted in response to the dicta in Sell regarding the preferential use of alternate mechanisms for involuntary medication orders. To compare the effectiveness and efficiency of the two mechanisms, we examined 1,455 admissions to the state's secure forensic hospital for competency restoration for the calendar years 2005 through 2011. Petitions for involuntary medication of defendants were filed in five cases in criminal court (0.3%) and in 177 cases (12.2%) in probate court. The probate mechanism resulted in a significantly shorter duration of the resolution of the competence matter. Both mechanisms were effective at restoring defendants' competency (i.e., two thirds were restored by the criminal court process, and nearly 74% were restored in the civil process).

Uwagi do wyroku Sądu Apelacyjnego w Katowicach z 27.06.2013 r., I ACa 361/13, LEX nr 1342253

The paper aims to describe and evaluate state of art which led to the verdict of the Appellate Court in Katowice of z 27.06.2013 r., I ACa 361/13, at the same time pointing at major inconsistencies in understanding compulsory psychiatric health care. The latter may touch numerous rights and freedoms and interests touched upon in the above case. Thus a presentation of involuntary treatment was presented, underpinning a vaster notion of autonomy in psychiatry, which was a subject here.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care

Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients. Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables. Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001). These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

The Current Status of Involuntary Treatment in Canada and Implication for Korea: Focusing on Ontario

The Current Status of Involuntary Treatment in Canada and Implication for Korea: Focusing on Ontario

Treatment Efficiency in Gaucher Patients Can Reliably Be Monitored by Quantification of Lyso-Gb1 Concentrations in Dried Blood Spots.

Gaucher disease (GD) is a lysosomal storage disorder that responds well to enzyme replacement therapy (ERT). Certain laboratory parameters, including blood concentration of glucosylsphingosine (Lyso-Gb1), the lyso-derivate of the common glycolipid glucocerebroside, correlate with clinical improvement and are therefore considered candidate-monitoring biomarkers. Whether they can indicate a reduction or loss of treatment efficiency, however, has not been systematically addressed for obvious reasons. We established and validated measurement of Lyso-Gb1 from dried blood spots (DBSs) by mass spectrometry. We then characterized the assay’s longitudinal performance in 19 stably ERT-treated GD patients by dense monitoring over a 3-year period. The observed level of fluctuation was accounted for in the subsequent development of a unifying data normalization concept. The resulting approach was eventually applied to data from Lyso-Gb1 measurements after an involuntary treatment break for all 19 patients. It enabled separation of the “under treatment” versus “not under treatment” conditions with high sensitivity and specificity. We conclude that Lyso-Gb1 determination from DBSs indicates treatment issues already at an early stage before clinical consequences arise. In addition to its previously shown diagnostic utility, Lyso-Gb1 thereby qualifies as a monitoring biomarker in GD patients.

Problematic issues of Criminal and Criminal Procedural Legislation in Applying Coercive Medical Measures

The author of the article proves that the possibility for a court to apply coercive medical measures to an insane person who has committed a socially dangerous act is regulated by the norms of the law on criminal liability and the provisions of the criminal procedural legislation of Ukraine. Their implementation is carried out in the interaction of substantive and procedural law, in particular in certain forms of criminal liability and in measures that are not covered by criminal liability, but are called criminal coercion, and is resolved through individual procedural institutions. The scientific positions of certain scholars and representatives of scientific schools on these issues were studied. On their basis the author expressed a number of own conclusions on problematic and debatable areas and issues raised in the article. Based on the results, the author of the article made some conclusions about the application of coercive medical measures: establishing the fact of committing a criminal offense by a specific person; after a forensic psychiatric examination to determine that such a person is mentally ill and according to its results cannot be sane; such a person is socially dangerous to society and must be isolated for the period of involuntary treatment. In the absence of at least one of the elements of the specified structure, coercive medical measures cannot be applied. The author made generalization, based on the initial provision that the main component of criminal liability is the conviction of a person, the adoption of a court conviction, which provides a legal assessment of the act and the specific person who committed it. Comparison of the current criminal and criminal procedural legislation provides an opportunity to assess coercive medical measures by coercive measures of a criminal law nature, as those used in criminal law relations against persons who committed a socially dangerous act, are ill with certain types of mental illness at the moment of the commission of a crime. The tendency of modern development of the direction in criminal law about delimitation of concepts and essence of "release of the person from criminal liability" and "punishment" from "exclusion of such responsibility" and existence and allocation at the same time of other direction - "criminal coercion" is distinguished. At the same time, the conclusions concerning persons who fell ill with a mental illness after the commission of a crime or while serving a sentence in places of imprisonment that relate to the procedural mechanism of temporary suspension of the imposed criminal punishment, were singled out. The results of the study of criminal and criminal procedural legislation on the application of coercive medical measures confirm and present the mechanism of interaction and implementation of substantive and procedural legislation to ensure the objectives of criminal proceedings under the Art. 1 of the Criminal Code and the Art. 2 of the Criminal Procedural Code of Ukraine.

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

Is higher psychotropic medication burden associated with involuntary treatment under the Mental Health Act? A four-year Australian cohort study

BackgroundInvoluntary treatment for individuals who lack sufficient capacity to make informed decisions regarding treatment has been associated with increased rates of injectable antipsychotics, antipsychotic polytherapy, and/or high doses. However, little is known about non-antipsychotic psychotropic prescription, or psychotropic medication burden as a more encompassing approach for people treated involuntarily. The aim of this study was to examine the relationship between Mental Health Act (MHA) status and psychotropic polypharmacy and/or high-dose medication prescribing practices in an Australian inpatient mental health unit.MethodsA retrospective cohort study of 800 adults discharged from a large metropolitan Queensland mental health unit was undertaken. Data was collected for 200 individuals, discharged on at least one psychotropic medicine, at four time periods; Cohort 1 (on or before 31st January 2014), Cohort 2 (2015), Cohort 3 (2016) and Cohort 4 (2017). The number of prescribed medicines and total daily doses were recorded and reviewed for alignment with current clinical guidelines. Participant demographics and clinical characteristics were compared by individual MHA status using chi-square test for categorical variables and analysis of variance for continuous variables. Associations between MHA status and prescribing practices (psychotropic polypharmacy and/or high-dose prescribing) were assessed using bivariate and multivariate binomial logistic regression models. Age, gender, birth country, year of admission, admissions in previous 12 months, primary diagnosis, ECT/clozapine treatment, and other psychotropic medications were adjusted as covariates.ResultsRegression analysis found that compared to their voluntary counterparts, individuals treated involuntarily were 2.7 times more likely to be prescribed an antipsychotic at discharge, 8.8 times more likely to be prescribed more than one antipsychotic at discharge and 1.65 times more likely to be prescribed high-dose antipsychotic treatment at discharge. The adjusted model also found that they were half as likely to be prescribed an antidepressant at discharge.ConclusionImplicit review of justifications for increased psychotropic medication burden (antipsychotic polypharmacy and high-doses) in those treated involuntarily is required to ensure clinical outcomes and overall quality of life are improved in this vulnerable group. Clearly documented medication histories, reconciliation at discharge and directions for medication management after discharge are necessary to ensure quality use of medicines.

It’s All About the Beds: Geller to Focus on Inpatient Bed Shortage as Discrimination

Back to table of contents Previous article Next article APA & MeetingsFull AccessIt’s All About the Beds: Geller to Focus on Inpatient Bed Shortage as DiscriminationMark MoranMark MoranSearch for more papers by this authorPublished Online:28 May 2020https://doi.org/10.1176/appi.pn.2020.6a13AbstractThe new APA president said the crisis in public mental health—most glaring in the shortage of inpatient beds—should be regarded as a form of discrimination and prejudice.APA President Jeffrey Geller, M.D., M.P.H., says that APA’s most significant progress in the 21st century is the diversity of the membership.At the heart of the mental health crisis in the United States is the dramatic shortfall of inpatient psychiatric beds, according to incoming APA President Jeffrey Geller, M.D., M.P.H.In his address at the Opening Session of the virtual APA Spring Highlights Meeting in late April, Geller spoke of the interrelated problems in the nation’s public mental health system that predated the global COVID-19 pandemic and will remain in its aftermath: health inequities, social marginalization of people with serious mental illness, and inadequate resources to treat psychiatric patients.He recounted the dismal realities of America’s public mental health in the 21st century:At least 20% of inmates in jails and prisons have a serious mental illness.People with untreated serious mental illness make up one-third of the total homeless population in the United States.Suicide rates in the United States increased by 33% between 1999 and 2017, with an increase in some states as high as 59%.Between 2000 and 2017, unintentional deaths and suicides related to opioid use increased substantially. From 2012 through 2018, the rate of drug overdose deaths involving cocaine more than tripled, and the rate of deaths involving psychostimulants with abuse potential (such as methamphetamine) increased nearly fivefold.But Geller said addressing the psychiatric bed shortage is key. “Fundamental to extricating ourselves from the current quagmire of services for persons with mental illness is getting to the right number of psychiatric beds,” he said. “Too few, and we have the conditions I’ve described; too many, and we pull resources away unnecessarily from alternatives to hospitalization.”In addition, Geller said that psychiatry and the mental health community need to move past “stigma” as a talking point to a discussion of prejudice and discrimination. “Discrimination against those with serious mental illness is no different from prejudice against other groups deprived of equal opportunity due to their genetics, infections, or accidents,” he said.“But we cannot focus only on what we have yet to do,” Geller said. “The spring of 2020 has seen more than its share of despair. Where are we succeeding?” Among the strides in psychiatry that Geller cited were these:Telepsychiatry, blossoming even before COVID-19, is quickly becoming commonplace.Enhanced understanding of the impairments that render patients with serious mental illness unable to acknowledge their own illness are lending support to the judicious use of involuntary treatment in inpatient and outpatient settings.Significant strides are being made in assisting people with serious mental illness to become employed, particularly through clubhouses.The success of long-acting injectable medications is helping to “make a significant dent in the prevalence of nonadherence to psychiatric medications.”Innovative integrated care strategies are extending psychiatric expertise to more people in need.Advocacy is steadily chipping away at the arcane institutions for mental disease (IMD) exclusion, a requirement that excludes most Medicaid beneficiaries with mental illness from coverage in psychiatric hospitals.Regulatory changes are allowing expansion of the number of buprenorphine prescribers, and Narcan is being made more widely available for emergency treatment of overdoses.”Geller said the most significant progress in the 21st century is the diversity of the body that is the APA membership. “Just think how different we are from our predecessors,” he said. In 1890 APA had 175 members, 139 of whom were still living (at that time, members did not lose membership status upon death). All were Caucasian men, 90% had a beard and/or a mustache.“Now APA is an organization of enviable heterogeneity,” Geller said. “And we shall continue to progress with more and more underrepresented group members having more and more of a presence in APA.”Returning to the crisis that has upended life around the globe, Geller offered a tribute to psychiatrists everywhere doing their part to meet the challenge of COVID-19.“In the APA Annual Meetings of 1918 and 1919, no mention of the raging influenza epidemic was made,” said Geller. “We shall not commit the same oversight. Together we thank our fellow psychiatrists who have been on the front lines every day and our trainees who have been pinch-hitting wherever they’ve been needed. And in quiet moments, each in our own way, we can remember our colleagues whose work with COVID patients ceased with the end of the doctor’s life.” ■ ISSUES NewArchived

The problem of medical-psychiatric illness in the homeless and its occurrence in the midst of a viral pandemic: A commentary

This article has the purpose of examining the problem of getting help for the medical-psychiatric-substance use group of “homeless” people on the streets of our cities, who refuse treatment. The problem has gradually worsened since closure of state hospitals and subsequent lack of community resources. It has been stalemated, in part, by advocates, who argue for personal autonomy and freedom rather than involuntary diagnosis and treatment over the life of these people. It has reached a crisis situation secondary to such potential patients being imprisoned and/or sick with COVID-19 being potential health and legal threats. We review A) the nature of the problem, B) the current social-legal availability of treatment and long-term management (or lack of one) in the context of societal rejection of these potential patients, and C) suggest what might be done, locally and nationally. Mandating scientifically-based medical orders to citizens regardless of personal freedom – are now being implemented to manage the COVID-19 pandemic. We argue for creating a similar med-psych short- and long-term system as a new approach to help this group. They are now mostly being ignored “to die on the streets.”

The impact of Crisis Intervention Team Training for police

Policing persons with mental illness and/or emotional/behavioral issues is complex and difficult. Police interactions and encounters of this nature are expected to increase due to dwindling budgets and the resulting deficiencies of local mental health systems. Police departments are responding to this growing need by requiring officers to attend Crisis Intervention Team (CIT) Training. CIT Training is designed to teach officers about mental illness and effective strategies and techniques for engaging and de-escalating potentially volatile interactions and encounters. This study was conducted in a large, Midwestern, municipal police department. The data were triangulated and included: (a) CIT Training pre- and post-tests administered to officers ( N=323) prior to and upon completion of the required 40-hour CIT Training held during the months of October through December 2016 and February through May 2017; (b) participant observation with police patrol officers in three of the seven police districts ( N=127 hours; April 2017 through May 2017); (c) semi-structured interviews with police patrol officers assigned to three of the seven police districts who had completed the CIT Training ( N=32 patrol officers; intensive interviews were conducted during participant observation); (d) in-person semi-structured interviews with service providers/practitioners who interact with officers in the context of their working roles and responsibilities ( N=27; July 2017 through January 2018); and (e) interviews with Urbantown Police Department (UPD) executive command staff, CIT coordinators and UPD telecommunications personnel ( N=10; September 2017 through January 2018). The assessment finds that the CIT Training administered in a large, municipal police department changed officers’ perceptions, as well as their street-level practices with persons with mental illness and/or emotional/behavioral issues. This assessment also finds that police officers are taking fewer persons into custody for involuntary treatment, and are instead transporting more persons for voluntary treatment.

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).

Influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage

Objective: To explore the influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage. Methods: A total of 74 massive burn patients (65 males and 9 females, aged 21 to 65 years) admitted to the Second Affiliated Hospital of Air Force Medical University (n=57) and Yan'an University Affiliated Hospital (n=17) from May 2009 to December 2019 were enrolled in this retrospective cohort study. Patients were divided into inhalation injury group (n=56) and non-inhalation injury group (n=18) based on clinical symptoms, vital signs, and results of bronchofibroscopy. Then 26 patients in inhalation injury group and 13 patients in non-inhalation injury group were 1∶2 matched by case-control matching based on the difference of total burn surface area. The total fluid replacement coefficient, crystalloid replacement coefficient, colloid replacement coefficient, glucose input volume, ratio of crystalloid to colloid, urine volume, and cumulative ratio of input to output volume during the first 24 h post injury, the second 24 h post injury, and the third 24 h post injury, heart rate, respiratory rate, mean arterial pressure (MAP), and hematocrit (HCT) at post injury hour (PIH) 24, 48, and 72 were recorded and compared between the two groups. Data were statistically analyzed with analysis of variance for repeated measurement and Bonferroni correction, t test, Fisher's exact probability test, and Mann-Whitney U test. Results: (1) After matching, during the first to third 24 h post injury, the total fluid replacement coefficient and glucose input volume of patients in inhalation injury group were significantly higher than those in non-inhalation injury group (F=4.202, 10.671, P<0.05 or P<0.01). During the first, second, and third 24 h post injury, the total fluid replacement coefficient, crystalloid replacement coefficient, colloid replacement coefficient, and ratio of crystalloid to colloid were similar between the patients in two groups(t=-1.336, -1.452, -1.998; -0.148, 0.141, 0.561; 0.916, -0.046, -0.509; -1.024, 0.208, 0.081, P>0.05). During the first, second, and third 24 h post injury, the glucose input volume of patients in inhalation injury group were respectively (2 996±1 176), (2 659±1 030), and (2 680±1 509) mL, which were significantly higher than (2 125±898), (1 790±828), and (1 632±932) mL in non-inhalation injury group (t=-2.334, -2.639, -2.297, P<0.05). (2) After matching, in overall comparison between groups, during the first to third 24 h post injury, the urinary output volumes and cumulative ratios of input to output volume of patients in inhalation injury group were significantly lower or higher than those in non-inhalation injury group, respectively (F=12.158, 9.111, P<0.01). At PIH 24, 48, and 72, heart rate of patients in inhalation injury group were significantly higher than those in non-inhalation injury group (F=4.675, P<0.05). There were no statistically significant differences in heart rate, respiratory rate, MAP, and HCT between patients in the two groups at PIH 24 and 48 (t=-0.039, -1.688, 1.399, 1.299, -1.741, 0.754, -0.677, 0.037, P>0.05). During the first and second 24 h post injury, the urine volume and cumulative ratio of input to output volume of patients in inhalation injury group were respectively significantly lower and higher than those in non-inhalation injury group (t(urine volume)=2.421, 2.876, t(cumulative ratio of input to output volume)=-2.687、-2.943, P<0.05 or P<0.01). At PIH 72, the heart rate and HCT of patients in inhalation injury group ( (114±13) times/min, 0.42±0.06) were significantly higher than those in non-inhalation injury group ( (98±18) times/min, 0.38±0.06, t=-3.182, -2.123, P<0.05 or P<0.01), there were no statistically significant differences in respiratory rate and MAP between the patients in two groups (t=0.359, 1.722, P>0.05). During the third 24 h post injury, there were no statistically significant differences in urine volume and cumulative ratio of input to output volume between the patients in two groups (t=1.664, -1.895, P>0.05). Conclusions: The presence of inhalation injury can lead to increased fluid requirement in massive burn patients during shock stage. An appropriate increase of fluid volume in the fluid resuscitation of burn patients combined with inhalation injury would be beneficial for maintaining ideal urine output.