Sectioned Research Articles

Examining legal challenges in involuntary hospitalisation proceedings: insights from judicial analysis in China

Since the implementation of China’s Mental Health Law, there has been a notable increase in involuntary hospitalisation cases involving individuals with mental health conditions across many provinces, leading to significant social controversy. Moreover, in the process of involuntary hospitalisation litigation, patients with mental health conditions have experienced difficulty initiating legal proceedings, presenting their cases effectively, and prevailing in court, to name a few of the many challenges they face. These obstacles, by impeding them in safeguarding their lawful rights and interests against this legal measure, substantially restrict their personal freedom. To establish a more accessible judicial relief mechanism, a number of steps need to be taken: enhancing the relevant provisions governing the acceptance of involuntary hospitalisation cases, ensuring a balanced distribution of the burden of proof between both parties, and strengthening judicial scrutiny of the legality of involuntary hospitalisation.

The effect of legal representation on clinical measures in involuntarily admitted psychiatric patients: a retrospective study

BackgroundMost western countries provide funded legal representation (LR) for involuntarily admitted psychiatric patients appearing before judicial committees. In 2004, an amendment to the Israeli Mental Health Act granted this right to involuntarily committed psychiatric patients. Psychiatrists then voiced concerns that LR may increase rates of premature discharge and compromise patients’ safety and well-being. These worries have not been sufficiently addressed to date. This study aimed to provide answers to their concerns.MethodsThis study included 3124 and 3434 inpatients involuntarily admitted to psychiatric facilities in 2000 and in 2010 (respectively), prior to and after the introduction of LR in Israel. Data were acquired from the Israeli National Psychiatric Hospitalization Registry. Clinical measures included percentage of discharges by the District Psychiatric Board (DPB), duration of involuntary hospitalization and rates of readmissions within thirty days and six months of discharge by treating psychiatrists (TP) or DPB.ResultsThe odds ratio (OR) of discharge by a DPB in 2010 (n = 221) compared to 2000 (n = 93) was 2.2 [95%CI 1.72–2.82]. The OR was similar for readmissions within thirty days or six months among patients discharged by TP and a DPB (OR = 1.08, p = 0.697 and OR = 0.92, p = 0.603, respectively) as well as between the two time points (p = 0.486 and p = 0.618). The duration of hospitalizations terminated by a DPB was significantly shorter than those terminated by TP, with no difference between the study time points. The mean hospitalization duration in 2010 was 21% shorter compared to 2000 among patients discharged by TP.ConclusionsThe number of DPB proceedings and the number of involuntarily hospitalized psychiatric patients discharged by DPBs increased considerably after the advent of state-funded legal representation in 2004. We found that this did not compromise beneficence and non-malfeasance of patient care. Our results emphasize the feasibility of affording even the most severely mentally ill patients the rights to due process. These findings may relieve concerns about state-funded LR procedures in involuntary psychiatric hospitalizations.

The perspectives of Māori on community treatment orders: A thematic analysis.

To understand the themes for Māori subjected to compulsory community treatment orders. The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms. Thematic analysis of a purposive sample of Māori in Hawke's Bay, New Zealand. Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant. Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially 'slippery slope' towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective.

Advancing readiness for change in substance use for people with substance use disorders using the Kawa model based intervention program: A quasi-experimental study.

Substance use disorders (SUDs) may cause severe social and health problems. Therefore, providing adequate treatments for people with SUDs to change their drug use behaviors is important. This study examined the effectiveness of Kawa Model based therapy among people with SUDs in Taiwan. Participants were recruited from people with SUDs who violated the Controlled Drugs Act in Taiwan were mandated to abstinence services by law from January 2016 through October 2021 in Southern Taiwan. Each participant selected a 2-hour for 4 times or 8-hour for one day compulsory treatments and received either the Kawa model based treatment (n = 55; 9 women; mean ± SD age = 36.73 ± 10.42years) or psychoeducation courses (n = 42; 8 women; mean ± SD age = 27.57 ± 5.78years), respectively. Stages of change was assessed using the University of Rhode Island Change Assessment before and after treatments. There were no significant differences in the stages of change scores at baselines between the 2 groups (p = .06-0.20). After treatments, participants who received the Kawa Model based treatment had higher scores in specific stages of change than did those who received the psychoeducation course in the domains of 'contemplation' (p = .001), 'action' (p = .001), and 'readiness' (p = .002). The present study demonstrated initial and preliminary findings that the Kawa Model based therapy may improve readiness for changing drug use behaviors in people with SUDs.

Compulsory Community Treatment Orders and health outcomes for Ma-ori in New Zealand.

We have previously analysed outcomes for all community treatment orders commenced during a 10-year period in New Zealand. Given Te Tiriti O Waitangi obligations to scrutinise health and consider equity for Māori, we completed this analysis to consider community treatment-order outcomes according to ethnicity. Ministry of Health databases provided demographic, service use and medication dispensing data for community treatment-order recipients between 2009 and 2018. As non-Māori on community treatment orders are older, less deprived and less likely to be diagnosed with a Psychotic Disorder, data were categorised according to age (<35/⩾35 years), level of deprivation (New Zealand Dep levels ⩽3, 4-6 and ⩾7) and diagnosis (Psychotic Disorder/non-Psychotic Disorder). The incidences of key outcome measures (admissions, community care, medication dispensing) were calculated for periods on/off community treatment orders for Māori and non-Māori to consider the differential impact of community treatment orders according to ethnicity. Māori have high rates of community treatment order utilisation and are younger, more likely to be diagnosed with a Psychotic Disorder and spend longer receiving compulsory treatment than non-Māori. Non-Māori are more likely to receive more additional depot antipsychotic medication on-community treatment orders compared with periods off-community treatment order than Māori but other clear patterns of response distinguishing between Māori and non-Māori were not present. The differences between Māori and non-Māori for community treatment-order utilisation suggest the presence of structural inequity in underlying mental illness distribution and treatment provision. Māori cultural expertise at all levels of healthcare including healthcare planning and delivery is required to make advances and reduce disparity.

Impact of Comorbid Personality Disorder on the Risk of Involuntary Hospitalization in Patients Referred for Urgent Forensic Assessment: A Cross-Sectional Study.

In Belgium, involuntary psychiatric hospitalization is authorized in the presence of certain criteria governed by the law relating to the protection of the mentally ill. The number of involuntary hospitalizations has been increasing continuously in recent years. Since personality disorders are frequent comorbidities in involuntarily hospitalized patients, the aim of this study was to investigate the potential role played by comorbid personality disorders in the decisions about involuntary hospitalization made during urgent forensic assessment. A total of 565 individuals were retrospectively recruited from the database of urgent forensic assessment carried out in the Psychiatric Emergency Department. Logistic regression analyses were performed to investigate the risk of involuntary hospitalization associated with comorbid personality disorders in patients referred for urgent forensic assessment. 66.7% of urgent forensic assessments resulted in involuntary hospitalization. In addition, comorbid personality disorders (especially borderline personality disorder) were associated with a lower risk of involuntary hospitalization in patients referred for urgent forensic assessment. In this study, we demonstrated that urgent forensic assessments frequently result in involuntary hospitalizations. Furthermore, this study highlighted that comorbid personality disorders (especially borderline personality disorder) appeared to have a major impact on the decision not to involuntarily hospitalize patients referred for urgent forensic assessment. These elements therefore justify the establishment of adequate clinical reflection to avoid the stigmatization related to these frequent comorbidities in patients at risk of involuntary hospitalization.

Insights from California on Involuntary Commitment for Substance Use.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

Involuntary Commitment #3

Involuntary Commitment #3

Area-level factors associated with variation in involuntary psychiatric hospitalisation across England: a cross-sectional, ecological study.

Involuntary hospitalisations for mental health care are rising in many high income countries, including England. Looking at variation between areas can help us understand why rates are rising and how this might be reversed. This cross-sectional, ecological study aimed to better understand variation in involuntary hospitalisations across England. The unit of analysis was Clinical Commissioning Groups (CCGs), NHS bodies responsible for delivering healthcare to local areas in England. 205 CCGs were included in the analysis. Demographic, clinical, and socioeconomic variables at CCG-level were extracted from national, open access data bases. The outcome variable was the rate of involuntary hospitalisation for psychiatric care under the 1983 Mental Health Act in 2021/22. There was a four-fold difference between the CCGs with the highest and lowest involuntary hospitalisations. In an adjusted analysis, CCGs with a higher percentage of severe mental illness in the population, higher percentage of male population, and higher community and outpatient mental health care use showed a higher rate of involuntary hospitalisation. Depression, urbanicity, deprivation, ethnicity, and age were not strongly associated with involuntary hospitalisation after adjustment. These variables explained 10.68% of the variation in involuntary hospitalisations across CCGs. Some demographic and clinical variables explained variation in involuntary hospitalisation between areas in England, however, most of the variance was unexplained. Complex relationships between urbanicity, deprivation, age, and ethnicity need to be further explored. The role of other influences, such as variation in service organisation or clinical practice, also need to be better understood.

Development of a Vignette-Based Instrument to Assess Psychiatric Involuntary Hospitalization Decision-Making

The decision to hospitalize a psychiatric patient against their will is an ethically and clinically complex problem. While there is variation in rates of involuntary hospitalization (IH) across different settings, we lack a tool to measure individual differences in IH decision-making. This study used a mixed-methods approach to develop and validate a vignette-based instrument designed to assess the decision to hospitalize psychiatric cases and confidence in IH decision-making. The instrument was tested locally inn= 31 psychiatrists, and the results were replicated in a national sample (n= 238). The results showed variation in IH rates across the eight vignettes. Mixed-effects models found significant variability in confidence ratings across both vignettes and participants, supporting the validity of this instrument to assess IH decision-making.

Views and experiences of involuntary civil commitment of people who use drugs in Massachusetts (Section 35)

BackgroundInvoluntary civil commitment (ICC) is a court-mandated process to place people who use drugs (PWUD) into substance use treatment. Research on ICC effectiveness is mixed, but suggests that coercive drug treatment like ICC is harmful and can produce a number of adverse outcomes. We qualitatively examined the experiences and outcomes of ICC among PWUD in Massachusetts. MethodsData for this analysis were collected between 2017 and 2023 as part of a mixed-methods study of Massachusetts residents who disclosed illicit drug use in the past 30-days. We examined the transcripts of 42 participants who completed in-depth interviews and self-reported ICC. Transcripts were coded and thematically analysed using inductive and deductive approaches to understand the diversity of ICC experiences. ResultsParticipants were predominantly male (57 %), white (71 %), age 31–40 (50 %), and stably housed (67 %). All participants experienced ICC at least once; half reported multiple ICCs. Participants highlighted perceptions of ICC for substance use treatment in Massachusetts. Themes surrounding ICC experience included: positive and negative treatment experience’s, strategies for evading ICC, disrupting access to medications for opioid use disorder (MOUD), and contributing to continued substance use and risk following release. ConclusionsPWUD experience farther-reaching health and social consequences beyond the immediate outcomes of an ICC. Findings suggest opportunities to amend ICC to facilitate more positive outcomes and experiences, such as providing sufficient access to MOUD and de-criminalizing the ICC processes. Policymakers, public health, and criminal justice professionals should consider possible unintended consequences of ICC on PWUD.

Involuntary Commitment: Opinions Regarding Patient Autonomy, Legal Parameters, and Behavioral Services Care Delivery.

Involuntary Commitment: Opinions Regarding Patient Autonomy, Legal Parameters, and Behavioral Services Care Delivery.

Involuntary Commitment: A Humanitarian Treatment.

Involuntary Commitment: A Humanitarian Treatment.

Ending Involuntary Commitment for People With Treatment-Resistant Mental Illness and Grave Disability.

Ending Involuntary Commitment for People With Treatment-Resistant Mental Illness and Grave Disability.

Civil Commitment for People With Substance Use Disorders: Balancing Benefits and Harms.

Civil Commitment for People With Substance Use Disorders: Balancing Benefits and Harms.

Other Specified Paraphilic Disorder: Patterns of Use in Sexually Violent Predator Evaluations.

"Sexually violent predator" (SVP) legislation requires, in part, that an individual has a mental abnormality that causes difficulty in controlling sexual behavior. Previous research has found paraphilia not otherwise specified (NOS) as one of the most prevalent diagnoses proffered in SVP evaluations. However, the fifth edition of the Diagnostic and Statistical Manual (DSM-5) modified paraphilia NOS diagnosis in two ways. First, this diagnosis was divided into two new diagnostic categories: other specified paraphilic disorder (OSPD) and unspecified paraphilic disorder. Second, OSPD required an added specifier to indicate the individual's source of sexual arousal. To date, no study has systematically explored how the revision to paraphilia NOS has affected diagnoses within SVP evaluations. The current study explored the frequency and diagnostic reliability of paraphilic disorders in a sample of 190 adult men evaluated for SVP civil commitment using the DSM-5. Results indicated that OSPD was the second most common paraphilic disorder, next to pedophilic disorder. However, there was poor to fair agreement (kappa= 0.21,p< .01) between independent evaluators in providing this diagnosis. Additionally, the two most common OSPD specifiers were non-consent and hebephilia, despite recent debate and rejection of these constructs from the DSM-5. While these constructs were the most prevalent, the specifiers contained quite varied terminology, suggesting vague diagnostic tendencies within these evaluations. Given that the presence of a mental abnormality is the cornerstone to the constitutionality of SVP commitment, diagnostic practices should be based in reliable and valid techniques.

Police officers’ perception of mentally disordered people: a national survey in Japan

ABSTRACT The treatment of offenders with mental disorders is an important issue in forensic mental health. In most countries, police officers working in the community are the first to deal with patients at risk of harming themselves or others. However, police officers’ perceptions and opinions of their practice in dealing with such patients have not been adequately investigated in Japan. We conducted a national survey to gather police officers’ opinions regarding their diversion practice for people with mental disorders and interorganizational collaboration. A total of 241 police officers participated in the study. Many participants were aware of the national mental health care scheme of administrative involuntary hospitalization in their daily work. However, many participants complained about public health centers and psychiatrists. These complaints seem to stem partly from the differences between organizational structures, lack of resources, and communication gaps. Many participants felt they lacked the opportunity to learn more about mental health literacy. Better collaborative care for people with mental disorders requires mutual relationships between the police, public health centers, and psychiatrists to promote a deeper understanding of community mental health.

Nochmals Odysseus. Zum normativen Status vorausschauender Autorisierungen von Zwangsbehandlungen für Situationen einer temporären Kompetenzbeeinträchtigung

ZusammenfassungMit dem Ausdruck „Odysseus-Anweisung“ werden dokumentierte Behandlungswünsche kompetenter Personen für Phasen einer vorübergehenden Kompetenzbeeinträchtigung bezeichnet, mittels derer diese Personen ein Handeln gegen ihre Präferenzen in der vorausgesehenen Situation der Kompetenzbeeinträchtigung autorisieren. Im Zentrum der ethischen Diskussion der Odysseus-Anweisungen steht im Allgemeinen die Frage nach ihrer „moralischen Autorität“ oder „Respektabilität“. Es wird gefragt, ob Odysseus-Anweisungen moralische Autorität in dem Sinne besitzen, dass sie bei Einschlägigkeit und Anwendbarkeit in der Akutsituation ein Handeln gegen den Patientenwillen moralisch geboten machen. Im vorliegenden Beitrag wird argumentiert, dass es in der Akutsituation Gründe geben kann, gegen eine einschlägige und anwendbare Odysseus-Anweisung zu handeln, da ein Handeln entsprechend einer Odysseus-Anweisung gerechtfertigt, aber gleichwohl falsch sein kann. Dazu wird nach einer einleitenden Darstellung des Problems und einigen terminologischen Präzisierungen zunächst die Unterscheidung zwischen Gerechtfertigt Sein und Richtig Sein auf einer allgemeinen Ebene erläutert und dann auf Odysseus-Anweisungen übertragen und zwischen der Anwendung dieser Unterscheidung auf der Einzelfallebene und der Prinzipienebene differenziert. Abschließend wird dafür plädiert, dass, da ein Handeln entsprechend einer Odysseus-Anweisung gerechtfertigt, aber falsch sein kann, Odysseus-Anweisungen die von ihnen autorisierten Zwangsbehandlungen auch bei vorhandener Einschlägigkeit und Anwendbarkeit nicht zu moralisch gebotenen machen und deren Befolgung nicht rechtlich bindend gemacht werden sollte. Sie sind nicht als normativ gleichrangig mit anderen Patientenverfügungen, die sich z. B. auf Zustände der Demenz beziehen, anzusehen.

Latest findings highlight the continuing uncertainty over the utility of compulsory psychiatric treatment in the community.

Community treatment orders (CTOs) have been introduced in many jurisdictions with evidence of increasing use over time as well as a disproportionate use in marginalised populations. Rates of CTOs also vary widely, both internationally and within the same country, for reasons that are poorly understood. This is despite evidence for effectiveness being mixed and, as a result, there have been calls for a reappraisal of this type of legislation. In the UK, a parliamentary committee on reforming the existing Mental Health Act recommended abolishing CTOs other than for people in the criminal justice system. Two recent Australian papers based on large state-wide administrative data-sets give conflicting results and came to markedly different conclusions regarding the desirability of reducing CTO rates. The debate about the effectiveness of CTOs therefore remains unresolved. This is of concern beyond Australia, as other jurisdictions such as England, Scotland and Canada have similar clinician-initiated orders.

Comparative analysis of the clinical and social characteristics of persons with organic mental disorders suffering from mental retardation who have repeatedly committed socially dangerous acts

BACKGROUND: The study of various characteristics of mentally ill persons suffering from mental disorders that influence the possibility of committing a repeated socially dangerous act. This has been one of the most urgent tasks of forensic psychiatry in recent years. The identification of such factors will significantly improve the secondary prevention of crime among the mentally ill. AIM: The purpose of the study — a comparative analysis of clinical and social characteristics in patients with mental retardation and organic psychological disorders (hereinafter referred to as DIS) who have repeatedly committed socially dangerous acts (hereafter referred to as DIS) and the identification of factors specific to patients with mental retardation that contribute to the commission of repeated DIS. Design: comparative study. MATERIALS AND METHODS: The comparative study included 65 patients diagnosed with mild and moderate mental retardation (who made up the main group A) and 45 patients with organic mental disorders (who made up the comparative group B) had repeatedly committed socially dangerous acts (OOD), who had been recognised as insane and who had undergone two or more periods of court-ordered compulsory medical treatment (hereafter referred to as MMMT) of various types. The study was carried out both in the form of a personal questionnaire and through a retrospective study of the patients' medical records. Correlation and comparative analysis were the main research methods used in the thesis. RESULTS: A number of clinical and social characteristics such as: hereditary burden of exogenous diseases (r +0.58, pi 0.05); single lifestyle (r +0.33, pi 0.05); urban place of residence (r +0.21, pi 0.05) increase the risk of repeated OOD, and are specific predictors for patients with mental retardation. A number of characteristics had a negative impact on the possibility of repeated OOD and negative correlations: the absence of any hereditary burden (r –0.44, pi 0.05), the presence of severe endogenous heredity (r –0.35, pi 0.05), living in rural areas (r –0.21, pi 0.05), concomitant alcohol dependence (r –0.29, pi 0.05). CONCLUSION: The data obtained will form the basis for the development of practical recommendations for secondary forensic psychiatric prevention, specifically for this nosological group, as well as methods for predicting and preventing recurrent DIS.