Real world evidence in involuntary psychiatric hospitalizations: 64,685 cases

Objective: We explored hospitalization patterns and the clinical and individual characteristics of a large cohort of patients who underwent involuntary psychiatric hospitalization in Brazil (n=64,685). Methods: Data were collected from the District Attorney's Office of the State of São Paulo (Ministério Público do Estado de São Paulo) on all involuntary psychiatric hospitalizations in the city of São Paulo between January 2003 and February 2020. The annual involuntary psychiatric hospitalization rate was calculated and descriptive statistics of the characteristics were produced. Results: Involuntary psychiatric hospitalizations increased from 5.8 to 25.5 per 100,000 population, with an eight-folder increase in the first 10-year period (2003-2013). The majority of admissions were to public institutions (86.6%), involved a psychotic disorder in the primary diagnosis (26.1%), involved more than one diagnosis (83.7%), and lasted less than 7 days (52.4%). The majority of the patients were aged 18 to 39 years and were single, and readmission was relatively common (13%). Although the reason for admission was missing in many reports (44%), the risk of harm to self or others was the most common (68.5%). Conclusion: This is one of the largest cohorts of involuntary psychiatric hospitalization records ever explored. These findings build upon existing international evidence about involuntary psychiatric hospitalizations and show recent trends in admission rates in the largest city in Brazil.

Involuntary Hospitalization System: An Ethical Analysis Based on Mental Health Law of the People’s Republic of China / 中国医学伦理学

Involuntary hospitalization system is a controversial issue in international mental health legislation. During the legislation and implementation process of Mental Health Law of the People’s Republic of China, the substantive and procedural elements of the involuntary hospitalization system have always been under dispute and discussion. These disputes have profound ethical implications, highlighting the phenomenon of the coexistence of "insufficient" and "excessive" regarding China’s involuntary hospitalization system in protecting individual autonomy. From the perspective of public health ethics, the values of respect, justice, and care can provide ethical guidance for improving the involuntary hospitalization system and promoting the construction of mental health law.

Internações compulsórias por processos judiciais para usuários de um Centro de Atenção Psicossocial álcool e drogas / Compulsory hospitalization by legal proceedings for users of a psychosocial Care Center - alcohol and drugs

O estudo teve por objetivo avaliar as características sociodemográficos e clínicas de 218 usuários de substâncias psicoativas, em um Centro de Atenção Psicossocial para Álcool e Drogas (CAPS-ad), de Ribeirão Preto, que chegaram por mandado judicial para avaliação médica e internação compulsória. Trata-se de um estudo retrospectivo, baseado em dados secundários do tipo transversal da abordagem quantitativa. O período avaliado se deu entre os anos de 2008 e 2019. Foram avaliadas as informações sociodemográficas, tipos de internações, diagnósticos, tipos de substâncias psicoativas usadas, requerentes no processo judicial e motivações para a abertura do processo judicial. Os resultados demonstraram que os usuários encaminhados por demanda judicial se caracterizam por serem adultos, com média de idade de 30,5 anos, variando entre 15 e 69 anos, do sexo masculino 182 (83,5%), raça/ etnia branca 146 (67,0%), viviam sem um companheiro 177 (81,2%), possuíam baixo nível de escolaridade 146 (66,1%), desempregados 140 (64,2%) e eram residentes de Ribeirão Preto 215 (98,6%). Quanto aos tipos de internações: 126 (58%) foram Internações Compulsórias, 66 (30,3%) internações voluntárias em Comunidades Terapêuticas, 69 (31,7%) internações voluntárias em hospital e 36 (16,6%) internações involuntárias. Considerando que o estudo se deu a partir da análise dos prontuários ao longo de um período de tempo, o mesmo paciente pode ter tido mais de uma internação em qualquer uma das modalidades. Em relação aos tipos de substâncias psicoativas as mais usadas foram: crack 104 (48,4%), cocaína 59 (27,4%), álcool 33 (15,3%) e a maconha 19 (8,8%). Um pouco mais da metade, 113 (54,6%) dos usuários, possuía outro transtorno mental associado ao uso de substâncias, dentre eles, a Esquizofrenia 40 (18,1%) e o Transtorno de Personalidade 25 (11,5%) foram os mais prevalecentes, seguidos de Outros Transtornos Psicóticos 20 (9,2%) e Transtorno Afetivo Bipolar 18 (8,3%). Não apresentaram outro transtorno mental associado ao uso de substâncias 99 (45,4%). O estudo aponta principalmente a dificuldade das famílias dos usuários de álcool ou de outras drogas para lidar com situações de conflito, bem como a necessidade de políticas públicas de saúde que entendam a realidade na qual esses indivíduos estão inseridos

The study aimed to evaluate the sociodemographic and clinical characteristics of 218 users of psychoactive substances, in a Psychosocial Care Center for Alcohol and Drugs (CAPS-ad) in Ribeirão Preto who arrived by court order for medical evaluation and compulsory hospitalization. This is a retrospective study based on secondary data of the transversal type of the quantitative approach. The evaluated period took place between the years 2008 to 2019. Sociodemographic information, type of hospitalizations, diagnosis, type of psychoactive substances used; applicant in the judicial process and reasons for opening the judicial process. The results showed that the users referred by judicial demand were characterized by being adults, with an average age of 30.5 years, ranging from 15 to 69 years old, male 182 (83.5%), white race / ethnicity 146 (67.0%), lived without a partner 177 (81.2%), had a low level of education 146 (66.1%), unemployed 140 (64.2%) and were residents of Ribeirão Preto 215 (98, 6%). Regarding the types of hospitalizations: 126 (58%) were Compulsory Hospitalizations, 66 (30.3%) voluntary hospitalizations in Therapeutic Communities, 69 (31.7%) voluntary hospitalizations and 36 (16.6%) involuntary hospitalizations. Considering that the study was based on the analysis of medical records over a period of time, the same patient may have had more than one hospitalization in any of the modalities. Regarding the type of psychoactive substance most used were: crack 104 (48.4%), cocaine 59 (27.4%), alcohol 33 (15.3%) and marijuana 19 (8.8%). A little more than half, 113 (54.6%) of users had another mental disorder associated with substance use; among them, Schizophrenia 40 (18.1%) and Personality Disorder 25 (11.5%) were the most prevalent, followed by Other Psychotic Disorders 20 (9.2%) and Bipolar Affective Disorder 18 (8.3%). There was no other mental disorder associated with substance use 99 (45.4%). The study mainly points out the difficulty of the family of users of alcohol or other drugs to deal with conflict situations, as well as the need for public health policies that understand the reality in which these individuals are inserted

Critique of Mental Health Welfare Law in Korea : Focusing on Involuntary Hospitalization Criteria / 신경정신의학

Under new mental health and welfare law, involuntary admission is allowed only for persons with mental illness based on the narrowed criteria of mental illness when they meet both need for treatment and danger to themselves and others. These stringent danger criteria along with narrowed definition of mental illness may prevent timely intervention for people with acute psychosis. It is claimed that the danger criteria is essential to keep up with international (UN, WHO) principles for legislation of mental health acts and laws of advanced countries. The international principles, however, do not necessarily call for stringent danger criteria for involuntary hospitalization. Danger criteria are not also prerequisites for involuntary hospitalization in many advanced countries. In countries with strict danger criteria, complementary measures seem to be taken for the drawback of danger criteria. As for the involuntary hospitalization by legal guardians, the complicated qualification for legal guardians may hinder prompt admission. The required number of legal guardians also needs to be changed from two to one person. Even in the situation where involuntary hospitalization is deemed urgent, there is no way to transport the patients to the hospital for assessment or temporary admission unless the police judges the patients to be dangerous to themselves or others. Outpatient treatment order can be an alternative to involuntary admission. However, it is rarely used since the order cannot be applied to those who do not have history of admission due to danger. For voluntary admission, status conversion to involuntary admission needs to be allowed in case of aggravation of symptoms to meet involuntary admission criteria. In addition, informal admission needs to be introduced to avoid unnecessary formal procedures for patients admitting voluntarily to open ward. In view of all these issues with new mental health and welfare law, entire revision of new mental health law is urgent to balance the rights to proper treatments and protection of human rights of persons with mental disorder.

Poder e exclusão - a internação involuntária à luz dos direitos humanos e a percepção do usuário de drogas como sujeito de direitos / Power and Exclusion. The Involuntary Hospitalization in the light of human rights and the perception of the drug user as a subject of rights (master's degree)

O presente trabalho se localiza entre os saberes da saúde, jurídicos e criminológicos no âmbito das internações involuntárias de usuários de drogas, com foco na lei 10.216 de 2001 e sua funcionalidade frente a uma engrenagem celular de controle social. Nesta perspectiva, a inter-relação entre o Direito e a Saúde Mental se intensifica em vários aspectos, seja no âmbito do respaldo legal para tais condutas, no contexto dos direitos e garantias constitucionais atingidos com a restrição de liberdade de um cidadão ou na esfera ideológica, com a limitação e exclusão de sujeitos sendo uma das ferramentas do controle social de determinada parcela da sociedade, concretizada por meio de políticas por vezes profiláticas e higienistas. O objetivo geral desta investigação foi compreender a percepção dos usuários de drogas internados involuntariamente em uma clínica terapêutica sobre a vivência de seus direitos humanos, com foco em situações de exclusão favorecidas pela evolução legislativa, políticas públicas e práticas dos serviços de saúde para usuários de drogas. Trata-se de pesquisa qualitativa com referência à abordagem dialética que utilizou-se da entrevista semiestruturada e observação participante para a coleta de dados. Os dados foram analisados por meio de análise de conteúdo. Os sujeitos participantes do estudo foram pacientes de uma Clínica Terapêutica, usuários de drogas e internados involuntariamente. Os resultados identificaram a exclusão dos usuários de drogas e a consolidação intramuros de um caráter segregador e repressor, sem o compromisso com a ressocialização e reinserção dos sujeitos vulneráveis na sociedade. As entrevistas demonstraram a ausência da percepção por parte dos usuários de drogas de seus direitos e garantias fundamentais. Ademais verificou-se um desamparo em relação aos direitos humanos e a ausência de possibilidades de reabilitação e empoderamento. Foi observado nas falas a ausência das garantias e direitos fundamentais, por vezes suspensos frente a uma instituição total consolidada. A observação participante evidenciou a Clínica Terapêutica como um espaço de exclusão referendado por um aparato legal com uma intersecção com a política criminal excludente de drogas no Brasil. Conclui-se que os usuários de drogas são pertencentes a uma parcela da sociedade excluída e fragilizada pelo objeto de consumo que acaba por mitigar e descontruir seus direitos. Desta forma, há necessidade de deixar falar o usuário de drogas, sujeito de direitos, e a dependência ao uso de drogas não deve ser vista apenas como uma enfermidade, mas também como um reflexo das políticas públicas de controle social segregacionistas que devem ser contrapostas à dignidade humana e os direitos do indivíduo. Por fim, o usuário de drogas necessita ser considerado como um sujeito de direitos e assim ter potencializada a consciência de suas garantias como cidadão e dos propósitos de qualquer cerceamento de liberdade

This work is located between health knowledge, juridical and criminological in the context of involuntary admissions of drug users, focusing on the Act 10.216 of 2001, and your functionality front of a gear of social control. In this perspective, the interrelationship between the Law and Mental Health intensifies in many aspects, either under the legal support for such conduct in the context of constitutional rights and guarantees achieved with the restriction of freedom of a citizen, or in the ideological sphere with the limitation and exclusion of subjects being one of the tools of social control in a certain part of society, sometimes concretized by prophylactic and hygienists policies. The general objective of this research was to understand the perception of drug users admitted involuntarily in a therapeutic clinic about your experience of their human rights, focusing on exclusion situations favored by legislative developments, public policies and practices of the health services for drug users. It is a qualitative research with reference to the dialectical approach that we used semi-structured interviews and participant observation. The data were analyzed by content analysis. The participants in the study were patients of one therapy clinic, drug users and hospitalized involuntarily. The results identified the exclusion of drug users and the consolidation of an internal segregating and repressive character, without the commitment to the rehabilitation and reintegration of vulnerable individuals in society. The interviews showed the lack of awareness on the part of drug users of your rights and guarantees. In addition there was a dereliction in relation to the human rights and the absence of rehabilitation and empowerment possibilities. In the speeches was observed the default of guarantees and fundamental rights, sometimes suspended against a consolidated total institution. The participant observation showed the Therapy Clinic as an exclusion space countersigned by a legal apparatus with an intersection with the exclusionary criminal drug policy in Brazil. It is concluded that drug users are belonging to a part of the excluded and weakened society by consumer object that ultimately mitigate and deconstructing your rights. Thus, there's a need to stop talking about the drug user, a subject of rights, and the addiction to drug use should not be seen only as a disease, but also as a reflection of public policy segregationist of social control against the human dignity and the rights of the individual. Finally, the drug user needs to be considered as a subject of rights and so have a awareness potentiated of their guarantees as a citizen and of the purposes of any retrenchment of freedom

Related factors to the competence of informed consent in new admitted patients with schizophrenia / 中国心理卫生杂志

Objective:To investigate the competency of informed consent in new admitted schizophrenia pa-tients.Methods:Fifty-three patients who were consecutively admitted to the hospital and diagnosed as schizophrenia according to the International Statistical Classification of Diseases and Related Health Problems,Tenth Revision (ICD-10)were recruited and assessed in seventy-two hours.The competence of informed consent was assessed by the MacArthur Competence Assessment Tool-Treatment (MacCAT-T).The insight was assessed by the Insight and Treatment Attitude Questionnaire.The severity of illness was assessed by the Brief Psychiatric Rating Scale (BPRS).Correlations between the competence of informed consent and the factors mentioned above were discussed.Results:Forty-five (84.9%)patients had lower MacCAT-T scores,especially the scores of understand-ing dimension (1.58 ±1.85)and appreciation dimension (2.40 ±1.47).The competence of informed consent was significantly correlated with insight (r =0.73,P <0.01)but not correlated with age,education,duration of illness and BPRS scores.Logistic regression demonstrated that insight (OR =0.69)was a protective factor of competence of informed consent while thought disturbance (OR =1.39)was a risk factor.As to the involuntary admitted pa-tients,34.1% of them had competence of informed consent.Conclusion:The competence of informed consent in new admitted schizophrenia patients is widely impaired especially in understanding and appreciation dimension.The competence of informed consent is correlated with insight and thought disturbance.Voluntary or involuntary hospi-talization does not reflect the level of competence of informed consent.

Improvement of legal institutions of hospitalization of mentally disabled patients / 中国卫生政策研究

The institution of voluntary hospitalization should be improved by establishing the concept of prece-dent autonomy and surrogate decision-making. The institution of advance directives should also be established to pro-tect rights of autonomy for mentally disabled patients. The decision by the guardian provided by China’s Mental Health Law is one situation of surrogate decision-making rather than involuntary hospitalization. The provision of in-voluntary hospitalization, especially“damage”,“safety”, and“danger”, should be properly interpreted on the basis of balancing patient autonomy and social security. Serious mental disorders shall return to the essence of pure medical problems, and the determination of decision-making capacity should be a separate question. Unified criteria for the judgment of decision-making capacity should be established.

O tratamento da dependência química e o ordenamento jurídico brasileiro / Treatment for chemical dependence and the brazilian legal system / Le traitement de la dépendance chimique et le système juridique brésilien / El tratamiento de la dependencia química y el sistema jurídico brasileño

Este artigo procura relembrar a trajetória de exclusão provocada pelos tratamentos de dependência química no Brasil e apresenta as formas atuais de tratamentos que objetivam a reinserção social do usuário. Ademais, demonstra que o não cumprimento da política pública sobre o assunto, crenças irreais da população sobre uma forma milagrosa de cura e desconhecimento sobre a legislação e formas alternativas de tratamento, retomam, com novas roupagens, a segregação das pessoas que sofrem com a dependência química, permitindo internações desnecessárias, por ordem judicial e sem o devido processo legal.

This article seeks to re-discuss the process of exclusion caused by drug addiction treatments in Brazil and describes current forms of treatment that focus on the social integration of users. Furthermore, the authors show that failure to comply with public policies in the area, unrealistic beliefs of the population in miraculous cures and their unfamiliarity with alternative forms of treatment and the legislation, are repeating, in new garb, the age-old segregation of persons suffering from such dependence. Among other realities are frequent and unnecessary hospitalization, sometimes by court order and without due process of law.

Cet article vise à rappeler le cheminement vers l'exclusion provoquée par les types de traitement des toxicomanes au Brésil et présente les traitements actuels qui ont comme but l'intégration sociale de l'utilisateur. En outre, il démontre que la non-conformité avec les réglementations, les croyances irréalistes de la population sur une façon miraculeuse de guérison, la méconnaissance des lois et d'autres formes de traitement, reprennent, sous autre forme, la ségrégation des toxicomanes. Ces phénomènes finissent par légitimer des hospitalisations inutiles par ordonnance du tribunal et sans actions judiciaire correcte.

Este artículo busca recordar la trayectoria de exclusión causada por los tratamientos de dependencia química en Brasil y presenta las formas actuales de tratamientos que tienen como objetivo la reinserción social del usuario. Además, demuestra que el incumplimiento de la legislación sobre el tema, creencias irreales de la población en una forma milagrosa de cura y desconocimiento sobre la legislación y las formas alternativas de tratamiento, retoman con una nueva apariencia, la segregación de las personas que sufren de dependencia química, permitiendo internaciones desnecesarias, por orden judicial y sin el debido proceso jurídico.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Ethical Problems of Involuntary Hospitalization of Psychiatric Patients / 中国医学伦理学

There are some differences between psychiatric patients and others in the informed consent right. The article discussed some basic problems on the ethics of involuntary hospitalization of psychiatric patients.