Voluntary Admission Research Articles

Insertion dans les soins après une première hospitalisation dans un secteur pour psychose

First hospitalisation for a psychotic episode causes intense distress to patients and families, but offers an opportunity to make a diagnosis and start treatment. However, linkage to outpatient psychiatric care remains a notoriously difficult step for young psychotic patients, who frequently interrupt treatment after hospitalisation. Persistence of symptoms, and untreated psychosis may therefore remain a problem despite hospitalisation and proper diagnosis. With persisting psychotic symptoms, numerous complications may arise: breakdown in relationships, loss of family and social support, loss of employment or study interruption, denial of disease, depression, suicide, substance abuse and violence. Understanding mechanisms that might promote linkage to outpatient psychiatric care is therefore a critical issue, especially in early intervention in psychotic disorders. To study which factors hinder or promote linkage of young psychotic patients to outpatient psychiatric care after a first hospitalisation, in the absence of a vertically integrated program for early psychosis. Method. File audit study of all patients aged 18 to 30 who were admitted for the first time to the psychiatric University Hospital of Lausanne in the year 2000. For statistical analysis, chi2 tests were used for categorical variables and t-test for dimensional variables; p<0.05 was considered as statistically significant. 230 patients aged 18 to 30 were admitted to the Lausanne University psychiatric hospital for the first time during the year 2000, 52 of them with a diagnosis of psychosis (23%). Patients with psychosis were mostly male (83%) when compared with non-psychosis patients (49%). Furthermore, they had (1) 10 days longer mean duration of stay (24 vs 14 days), (2) a higher rate of compulsory admissions (53% vs 22%) and (3) were more often hospitalised by a psychiatrist rather than by a general practitioner (83% vs 53%). Other socio-demographic and clinical features at admission were similar in the two groups. Among the 52 psychotic patients, 10 did not stay in the catchment area for subsequent treatment. Among the 42 psychotic patients who remained in the catchment area after discharge, 20 (48%) did not attend the scheduled or rescheduled outpatient appointment. None of the socio demographic characteristics were associated with attendance to outpatient appointments. On the other hand, voluntary admission and suicidal ideation before admission were significantly related to attending the initial appointment. Moreover, some elements of treatment seemed to be associated with higher likelihood to attend outpatient treatment: (1) provision of information to the patient regarding diagnosis, (2) discussion about the treatment plan between in- and outpatient staff, (3) involvement of outpatient team during hospitalisation, and (4) elaboration of concrete strategies to face basic needs, organise daily activities or education and reach for help in case of need. As in other studies, half of the patients admitted for a first psychotic episode failed to link to outpatient psychiatric care. Our study suggests that treatment rather than patient's characteristics play a critical role in this phenomenon. Development of a partnership and involvement of patients in the decision process, provision of good information regarding the illness, clear definition of the treatment plan, development of concrete strategies to cope with the illness and its potential complications, and involvement of the outpatient treating team already during hospitalisation, all came out as critical strategies to facilitate adherence to outpatient care. While the current rate of disengagement after admission is highly concerning, our finding are encouraging since they constitute strategies that can easily be implemented. An open approach to psychosis, the development of partnership with patients and a better coordination between inpatient and outpatient teams should therefore be among the targets of early intervention programs. These observations might help setting up priorities when conceptualising new programs and facilitate the implementation of services that facilitate engagement of patients in treatment during the critical initial phase of psychotic disorders.

Voluntary vs. involuntary hospital admission in acute mania of bipolar disorder: Results from the Swiss sample of the EMBLEM study

Background Patients with acute mania in bipolar disorder require pharmacological treatment to reduce symptoms. In addition, it is recognised that admission status is a clinically relevant aspect of bipolar disorder. There is, however, a lack of published data assessing the association of admission status with clinical or functional outcomes. The European-Mania-in-Bipolar-Longitudinal-Evaluation-of-Medication (EMBLEM) study has been designed to describe outcomes associated with medication therapies. Baseline data from this study are now available and we used these data to examine the characteristics of patients with acute mania in the Swiss EMBLEM cohort who were admitted involuntary and voluntary, respectively, and their functional and clinical status. Methods Ninety-five patients with an acutely manic or mixed episode of bipolar disorder were included in the Swiss cohort of the study. Patients' history, psychosocial functioning, clinical measures of mania and depression, pharmacological and compliance variables were assessed. Statistical methods comprised univariate analyses of variance and logistic regression analyses to elucidate associations between variables of interest. Results Patients with involuntary hospital admission ( n = 55) were more aggressive and had less insight. They had a more frequent history of substance abuse and were less likely to take anticonvulsants or lithium. Furthermore, these patients showed lower compliance, which also guided physicians' decision on pharmacotherapy. Limitation The EMBLEM study had an observational and non-interventional design; therefore it was not possible to compare treatment groups by means of stringent between-group analyses. However, a main target of this study was to gather clinically relevant information on outcomes of acute mania associated with currently available medication therapies. Conclusions Involuntary admission status was significantly associated with clinical status, especially aggression and also compliance. Admission status in bipolar patients plays a clinically important role.

Troubles dépressifs majeurs et urgences psychiatriques: Une étude naturaliste concernant la place des interventions de crise

This retrospective study aimed to evaluate the impact of introducing crisis intervention patterns in the emergency unit of a general hospital on the number of admissions and outpatient follow-ups for patients with major depressive disorder. The study included all patients with major depressive disorder (DSM-IV criteria) who visited the psychiatric emergency unit in a general hospital during two 8-month periods: before (425 patients) and after (436 patients) crisis interventions were introduced. After crisis interventions were introduced, the voluntary admission rate decreased significantly (from 17.9% to 12.4%), while the number of outpatient follow-ups increased (from 82.1% to 86.2%). Borderline personality disorder was associated with a significant reduction of the admission rate (27.8% against 38.2%), while the admission rate for patients with depressive disorder with psychotic features did not decline after crisis interventions. Crisis interventions were more effective on women. These outcomes suggest the relevance of crisis intervention in psychiatric emergency settings to improve the management of patients with major depressive disorder. Crisis intervention fosters outpatient multimodal follow-up rather than admission in a psychiatric setting.

High School Exit Examinations: When Do Learning Effects Generalize?

This paper reviews international and domestic evidence on the effects of three types of high school exit exam systems: voluntary curriculum-based external exit exams, universal curriculum-based external exit exam systems and minimum competency tests that must be passed to receive a regular high school diploma. The nations and provinces that use Universal CBEEES (and typically teacher grades as well) to signal student achievement have significantly higher achievement levels and smaller differentials by family background than otherwise comparable jurisdictions that base high stakes decisions on voluntary college admissions tests and/ or teacher grades. The introduction of Universal CBEEES in New York and North Carolina during the 1990s was associated with large increases in math achievement on NAEP tests. Research on MCTs and high school accountability tests is less conclusive because these systems are new and have only been implemented in one country. Cross-section studies using a comprehensive set of controls for family background have not found that students in MCT states score higher on audit tests like the NAEP that carry no stakes for the test taker. The analysis reported in table 1 tells us that the five states that introduced MCTs during the 1990s had significantly larger improvements on NAEP tests than states that made no change in their student accountability regime. The gains, however, are smaller than for the states introducing Universal CBEEES. New York and North Carolina. The most positive finding about MCTs is that students in MCT states earn significantly more during the first eight years after graduation than comparable students in other states suggesting that MCTs improve employer perceptions of the quality of the recent graduates of local high schools.

Special Section on the GAF: Determinants of Indicated Versus Actual Level of Care in Psychiatric Emergency Services

This study was undertaken to improve understanding of the admission decision process by distinguishing between the clinically indicated level of care and actual level-of-care decisions in emergency psychiatry. Clinicians in emergency psychiatric services in Rotterdam, The Netherlands, prospectively rated 720 patients by using the Severity of Psychiatric Illness Scale and collected information on demographic, clinical, and contextual parameters. The clinically indicated level of care and actual level-of-care decisions were studied independently, by using multivariate logistic regression analyses. The decision-making process was divided into three consecutive steps: evaluation of clinically indicated inpatient or outpatient level of care (step 1), voluntary or involuntary admission (step 2), and actual admission of patients for whom voluntary admission was indicated (step 3). Each step was determined by separate factors. Specifically, clinically indicated admission (step 1) was associated with family or friends' desire for admission (odds ratio [OR]=3.7), previous admissions (OR=2.9), symptom severity (OR=2.7), and personality disorder (OR=.4). Involuntary admission (step 2) was associated with lack of motivation (OR=5.7), symptom severity (OR=3.7), time of referral (OR=3.5) and danger to self or others (OR=2.7). Actual voluntary admission (step 3) was associated mainly with bed availability (OR=8.7). The overall percentage of correctly predicted cases was 82 percent for all steps in the decision process. This study showed that each step in the admission decision process is determined by a unique set of variables and provided evidence that contextual factors influence decision making. Guidelines for voluntary admission and civil commitment need to be based on the results of studies that distinguish between the clinical needs of patients and contextual factors.

Chapitre 3. The present state and problems of “the Code of medical ethics” in Japan

A code of professional ethics for the physician in Japan is being prepared caused by the progress of the medical conditions. The Japan Medical Association (JMA) enacted "the guideline on professional ethics for the physician" in 2004. However, as for the substantial effect of this guideline, it may not be able to be expected. The present state of the professional group of the physician in Japan can be shown as that reason. (1) First, there is not any physician's group of the compulsory admission, but only professional ability profit group of the voluntary admission in Japan. (2) There are not ethical regulations of the profession which has legal effect to face in the physician's misconduct in Japan. (3) In addition, there is not any autonomous organizations inside the professional group which examine and impose disciplinary punishment to the physician who went through misconduct in Japan. After all, the ethics in the physician would be left to each physician's conscience. Then, how should we do to solve such various fundamental problems? In this paper, the situation in various foreign countries is surveyed as an indication of the Japanese medical profession's future conduct. Moreover, I present some solutions to the various problems in fulfilling the professional ethics for the physician in Japan.

Refusing Care: Forced Treatment and the Use of Psychiatric Advance Directives

ABSTRACT This article discusses recommendations regarding forced treatment proposed in Refusing Care: Forced Treatment and the Rights of the Mentally Ill (2002). Two of these recommendations are discussed. First, the work proposes that on a first, serious psychotic break individuals should be committable under lesser standards than ordinary civil commitment standards (likewise for involuntary medication). Each element of this recommendation is discussed: Why the break should be psychotic, why it should be a first–and only a first–break, and why it should be serious. In addition, certain counterweights are raised and answered–e.g., will this proposal discourage voluntary admissions? The second recommendation is that after a first psychotic break, patients should self-bind (i.e., give an advance directive) to care under similar circumstances as in the case of the first break–or self-bind to no treatment undertaken for the patients' own benefit. The use of self-binding in this context is discussed, in addition to some puzzles concerning its use. Most important, what we should do if a patient self-binds to no treatment, and then, when impaired, says he or she wants treatment? The last part of the article discusses practical dimensions of the recommendations proposed, e.g., how do we ensure that advance directives are truly voluntary?

Trends in the use of the Italian Mental Health Act, 1979–1997

Italian statistics on psychiatric bed availability, voluntary and compulsory admissions were examined from 1979 to 1997. Although the number of psychiatric beds dropped by 62.5%, the absolute number of compulsory admissions has remained substantially stable. The proportion of all admissions that were compulsory decreased from 17.1% to 11%. This study shows that a shift to community care was not associated with an increase in compulsory admissions in Italy.

Characteristics of teams, staff and patients: associations with outcomes of patients in assertive outreach.

Little is known about what characteristics of teams, staff and patients are associated with a favourable outcome of severe mental illness managed by assertive outreach. To identify predictors of voluntary and compulsory admissions in routine assertive outreach services in the UK. Nine features of team organisation and policy, five variables assessing staff satisfaction and burn-out and eleven patient characteristics taken from the baseline data of the Pan-London Assertive Outreach Study were tested as predictors of voluntary and compulsory admissions within a 9-month follow-up period. Weekend working, staff burn-out and lack of contact of the patient with out and lack of contact of the patient with other services were associated independently with a higher probability of both voluntary and compulsory admission. In addition, admissions in the past predicted further voluntary and compulsory admissions, and teams not working extended hours predicted compulsory admissions in the follow-up period. Characteristics of team working practice, staff burn-out and patients' history are associated independently with outcome. Patient contact with other services is a positive prognostic factor.

Antipsychotic drugs in mania: factors predicting use of antipsychotic medication following inpatient treatment of mania.

Inpatients treated for mania are frequently discharged on antipsychotics. There has been disagreement in clinical guidelines concerning their use, and there is little knowledge of the factors predicting this. The aim of the present study was to identify those factors predicting discharge on typical antipsychotic medication after hospital admission for mania. Data were collected retrospectively from the hospital notes of 74 patients who had 100 consecutive psychiatric hospital admissions for mania during the 1990s. Univariate and multivariate analyses were used to estimate odds ratios. The rate of discharge on typical antipsychotics was 71.6% (53 out of the 74 episodes included in the analyses) (95% confidence interval 61.3-81.9). Three factors were found to predict this with odds ratios significant at the P<0.05 level: (i) use of typical antipsychotics during the first week of admission [odds ratio (OR)=13.3]; (ii) voluntary admission (OR=4.2); and (iii) male gender (OR=8.4). There was no evidence that psychotic symptoms or aggressive behaviour were associated. In conclusion, the use of antipsychotics early in the episode strongly predicted discharge on antipsychotics. It appears that clinicians use antipsychotics for their anti-manic effects and patients are often thought to still need the drugs at the time of discharge.

Psychiatric emergencies after the terrorist attacks of September 11, 2001.

Population surveys suggest that the events of September 11, 2001, resulted in psychiatric emergencies in U.S. communities. This study tested the extent of such emergencies in San Francisco. S: Interrupted time-series designs were applied to counts of emergency calls to the police during the 424-day period beginning January 1, 2001, and of voluntary and coerced admissions to psychiatric emergency services during the 1620-day period beginning July 1, 1997. The number of men and women who were coerced into treatment increased significantly on Thursday, September 13, but the number of voluntary admissions was as expected. The number of telephone calls from citizens that police dispatchers judged to be mental health related increased significantly on Wednesday, September 12, and remained elevated through September 13. Several additional analyses were conducted to test the stability of the findings, and the results were essentially unchanged. The events of September 11 may not have induced emergent mental illness in U.S. communities at relatively great distance from the attacks. However, it is possible that persons with severe mental illness were either more evident to or less tolerated by the community.

Patients' Rights and Psychiatrists' Duties: Discharging Patients against Medical Advice

Every psychiatrist who treats voluntary inpatients has had or will have patients who leave the hospital against medical advice (AMA). Studies reveal that between 6 and 35 percent of voluntary psychiatric inpatients are discharged AMA. These patients often are acutely ill and have severe symptoms at discharge. They also, as a group, have high rehospitalization rates and worse outcomes than patients who do not leave AMA. When a mentally ill patient demands to leave the hospital AMA, a tension arises between the patient's rights and the psychiatrist's duties. These duties include those to the patient and, in many cases, to third parties. Patients discharged AMA may remain dangerous and can expose health care providers to a heightened liability risk. More importantly, because of such factors, decisions about handling the AMA discharge are more difficult than decisions about admission. This article analyzes the sources of increased liability risk posed by AMA discharges. It includes discussions of patients' rights, including the different types of voluntary admissions, and psychiatrists' duties. Malpractice litigation in this area is reviewed. The article concludes by suggesting risk-management techniques that can aid in protecting the psychiatrist while also respecting patients' rights and delivering good clinical care.

Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review.

Inequalities of service use across ethnic groups are important to policy makers, service providers and service users. To identify ethnic variations in pathways to specialist mental health care, continuity of contact, voluntary and compulsory psychiatric in-patient admissions; to assess the methodological strength of the findings. A systematic review of all quantitative studies comparing use of mental health services by more than one ethnic group in the UK. Narrative analysis supplemented by meta-analysis, where appropriate. Most studies compared Black and White patients, finding higher rates of in-patient admission among Black patients. The pooled odds ratio for compulsory admission, Black patients compared with White patients, was 4.31 (95% CI 3.33-5.58). Black patients had more complex pathways to specialist care, with some evidence of ethnic variations in primary care assessments. There is strong evidence of variation between ethnic groups for voluntary and compulsory admissions, and some evidence of variation in pathways to specialist care.

Stigma by association: psychological factors in relatives of people with mental illness.

Stigma affects not only people with mental illnesses, but their families as well. Understanding how stigma affects family members in terms of both their psychological response to the ill person and their contacts with psychiatric services will improve interactions with the family. To investigate factors of psychological significance related to stigma of the relatives. In a Swedish multi-centre study, 162 relatives of patients in acute psychiatric wards following both voluntary and compulsory admissions were interviewed concerning psychological factors related to stigma. A majority of relatives experienced psychological factors of stigma by association. Eighteen per cent of the relatives had at times thought that the patient would be better off dead, and 10% had experienced suicidal thoughts. Stigma by association was greater in relatives experiencing mental health problems of their own, and was unaffected by patient background characteristics. Interventions are needed to reduce the negative effects of psychological factors related to stigma by association in relatives of people with mental illness.

Involuntary Treatment Within a Prison Setting

Given the high proportion of criminal justice treatment clients in the United States, a major policy and program issue in drug treatment is the appropriateness and effectiveness of coercing offenders to enter and remain in treatment. As part of a comprehensive evaluation of a large treatment facility in California, the authors conducted an analysis of during-treatment psychosocial changes of inmates admitted voluntarily and those admitted involuntarily. The main focus was on psychological functioning (self-esteem, depression, anxiety, decision making, and selfefficacy) and social functioning (hostility, risk taking, and social conformity). Regardless of voluntary or involuntary admission status, treatment participants exhibited significant during-treatment change on most measures of psychosocial functioning, although significant change was more likely on measures of psychological than on social functioning. In addition, similar percentages of both groups were paroled from treatment (as opposed to being discharged from the program prior to parole) and agreed to attend community treatment.

Compulsory admissions to psychiatric hospitals in Norway - international comparisons and regional variations

Internationally there has been a long debate regarding the use, and potential misuse, of coercion in psychiatry. One of the topics that has gained most attention is compulsory admissions. Only a few studies have published cross-country comparisons on the magnitude of compulsory admissions. This study presents data on voluntary and compulsory admissions to psychiatric hospitals in Norway in 1996. Approx 47% of all admissions were compulsory, and the rates were 147 per 100 000 inhabitants. These are both high figures compared to other countries. Regarding patient characteristics, our study confirms the international findings in most fields, except for a higher proportion of women and nonpsychotic patients admitted compulsory. The observed substantial regional differences in compulsory admission are primarily explained by variations in diagnoses. Whether the recent changes in the Norwegian Mental Health Act will reduce these figures are discussed.

Gold award: A community-based program providing a successful alternative to acute psychiatric hospitalization.

Gold award: A community-based program providing a successful alternative to acute psychiatric hospitalization.

Use of the Mental Health Act criteria in the decision-making process for compulsory admissions: a study of psychiatrists in South London.

This study investigates the decision-making process for admitting patients compulsorily under the Mental Health Act 1983 of England and Wales. We used three case-vignettes describing different clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. The vignettes were administered to a group of psychiatrists working at the Bethlem Royal and Maudsley Hospitals in South London. The psychiatrists were asked to rate 11 factors from the most to the least important in their decision to admit the individual compulsorily. Three factors resembled the criteria considered in the Mental Health Act 1983 for compulsory admission: current mental state; severity of the disease; and dangerousness to self or others. Three were other clinical features of the patient: diagnosis; psychiatric history; and likely response of the mental state to the medical treatment. The remaining five were sociodemographic features of the patient: age and gender; owning a home; occupational status; and social support available. The psychiatrists were not given the option that the patient would accept a voluntary admission to hospital. We obtained responses from 42 psychiatrists (25 males and 17 females). The most important factor for deciding to detain a patient compulsorily was perceived dangerousness to self and others. The current mental state of the patient and the severity of the illness were the next two important factors. Our results confirm that the criteria recommended by the Mental Health Act 1983 of England and Wales were applied consistently in three different hypothetical situations. The need for protection of the patient or others may take precedence over the current mental state of the patient or the severity of the illness, a finding that warrants further investigation in view of the current debate on the responsibility of psychiatrists in deciding to detain subjects affected by personality disorder.

The informal patient in England and Wales.

The informal status of a patient is a very important topic because the vast majority of mental patients in hospital are informal. The origins of the status are traced to the Royal Commissions of 1924-6 and 1954-7 which recommended voluntary admissions and informal admissions, respectively. It is pointed out, inter alia, that it is only generally true to say the informal patient has consented to admission and cannot be treated without his or her consent because exceptionally he or she can be given such treatment, e.g. on the grounds of necessity, as held by the House of Lords in R v Bournewood Community and Mental Health Trust (1998) and that today there are two types of informal patients: those who can, and do, consent to admission, and those who cannot consent to admission, but do not show willingness to leave hospital. It is argued that there is only a power under the Mental Health Act 1983 to admit patients informally. Finally, the informal patient's consent to admission, consent to treatment, other rights, leaving hospital, and how his or her position can be improved are looked at.

Informed consent for short-stay surgery.

This study in the context of short-stay surgery is based on a definition according to which informed consent consists of five elements: consent, voluntariness, disclosure of information, understanding and competence. The data were collected in four district hospitals in southern Finland by using a structured questionnaire. The population consisted of short-stay and one-day surgery patients (n = 107). Data analysis was based on statistical methods. The results indicated some problems in the realization of informed consent. Most commonly, consent was expressed by voluntary admission. Most patients had indicated their voluntary consent by making their decision independently. There were also certain problems with information. The respondents were least well informed about the drawbacks of anaesthesia and about alternative forms of treatment. The patients had not understood all the information they had received; problems of understanding were greatest with information about the advantages and disadvantages of anaesthesia. Problems were also reported with competence. These patients had the most difficulty in assessing the advantages and drawbacks of different treatments and anaesthesia.