Contemplation of Legal Status of the Committee for the Appropriateness of Hospitalization Related to Involuntary Admission / 신경정신의학

The revised Mental Health Act, in which the legal status and role of “the committee for the appropriateness of hospitalization” as an administrative committee, which has been launched since June 2017, is discussed. The German and British laws were reviewed in comparison with the Korean laws, focusing on the similarities and differences among the laws and which parts require revision. This study reported that patient care should be considered not only from a constitutional point of view, but also from a health care point of view. Self-determination and medical paternalism are both important but generally incompatible values. In recent days, objective and fair diagnosis from medical experts have been challenging. The current Mental Health Act was inevitably revised to actively accept the decisions of the Constitutional Court and apparently guarantee the basic rights of people in the future. The pros and cons of “the committee for the appropriateness of hospitalization” and which parts need to be revised to perform its role properly as a guardian of the admission procedure are assessed. This should reflect the current reality of the mental health medical community. In addition, a face-to-face examination should be made in principle. Nevertheless, the basic rights of the mentally ill are not guaranteed based on current law because of the shortage of budget and human resources. The final option maybe the introduction of a judicial system on involuntary admission. Legitimacy and professionalism are engagements that should be adhered to when treating psychiatric patients.

The United Nations Convention on the Rights of Persons with Disabilities and Compulsory Admission of Persons with Mental Illness: A Critique of Prohibition of Compulsory Admission / 신경정신의학

The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) has often been cited as the basis for the abolition of involuntary hospitalization for persons with mental illness. Although the UNCRPD itself does not refer explicitly to the abolition of involuntary hospitalization, the General Comment prohibited all compulsory admission without adequate explanation. While the disability status alone may not justify the denial of legal capacity, the existence of impaired decision-making ability can raise issues regarding whether involuntary admission can be justified in the best interest of persons with mental illness. The General Comment, however, argues that involuntary admission does not comply with the CRPD which prohibits discrimination on the basis of disabilities. This statement defies logic since the issue is whether the existence of impaired decision-making ability may be an exceptional case. It is also against the principles of beneficence to withhold treatment for persons with mental illness just for self-determination when poor outcomes are anticipated if left untreated. The concept of supported decision making suggested by the General Comment is also ambiguous, and not clearly distinguishable from substitute decision making. Another reason for the prohibition of involuntary admission relates to doubt concerning the accuracy of assessment of mental capacity, which implies adequate assessment may justify involuntary admission. In practice, it is not always complicated to assess mental capacity in order to make treatment-related decisions. The third reason concerns the argument that psychiatric treatments lack empirical evidence concerning effectiveness. Scientific evidence supporting the effectiveness of psychiatric treatment is abundant. The rights of persons with mental illness are important ethical issues. However, it is doubtful whether the blanket prohibition of compulsory admission is appropriate and ethical. Critical review of the UNCRPD and the General Comment is urgent for timely treatment and for the well-being of persons with mental illness.

Critical Review on Amendment Bill of Mental Health Act / 신경정신의학

The Korean Mental Health Act, enacted in 1995, was entirely amended 20 years later and the amendment was passed by the National Assembly plenary session on May 19. 2015. The amended Mental Health Act reflects the recent rapid changes in the mental health environment and contributes one more step toward securing human rights for people with mental illness. However, after review of some major issues, it is doubtful whether there was sufficient discussion on the national mental health policy and whether a national consensus was obtained. This paper describes some problems within the amended Act and discusses several ways to improve the Act. Patients' autonomy and medical paternalism are typical major concerns in the field of medical ethics. Especially for patients with mental illness, it is difficult to maintain a balance between those two concerns because there is often an inability to assign responsibility for those concerns. Therefore, a revised Act should take into account these two concerns. When creating subordinate legislation ahead of the enactment of the amendments on May 30, 2016, establishment of a more reasonable and efficient system is expected ; if there has been sufficient discussion with related organizations and professionals and sufficient consideration of the realities of various medical fields. Such expectations should improve public mental health welfare.

A Study of Effectiveness of Outpatient Treatment Orders and Compliance with Outpatient Treatment / 정신신체의학

OBJECTIVES: Outpatient treatment orders refer to a mandatory social program in which mentally ill persons are ordered by the court to participate in specified outpatient treatment programs. This study aimed to investigate the factors that affect outpatient treatment orders and adherence to outpatient treatment in mental health patients. METHODS: A survey on outpatient treatment orders and adherence to outpatient treatment was conducted on 60 psychiatrists between October and November 2016. The questionnaire items were drafted based on a literature review, and they were then evaluated by 3 psychiatrists and 1 law school professor before being finalized. Answers from the respondents were analyzed using descriptive statistics, and the median, maximum, and minimum values of the effectiveness scores of outpatient treatment orders were calculated. RESULTS: Among the 60 psychiatrists, 45(75.0%) were aware of outpatient treatment orders; however, only 2 out of the 45(4.0%) had actually used the program in the last 12 months. The subjective effectiveness was very low, with only 40 points out of 100. Furthermore, of the readmitted patients, 37.7% had received continued outpatient treatment, whereas 53.1% chose to quit the outpatient treatment programs, meaning that the number of dropouts was higher. Among the discharged patients, approximately two-thirds were receiving continued treatment. With regard to follow-up for dropouts, majority of the responses were either “Not taking any action”(n=27) or “Not following up”(n=15). Only two respondents answered “Contact the community mental health promotion center,” meaning that this response was very rare. Meanwhile, when asked about efficient measures to be implemented for dropouts, a vast majority of the respondents(n=30) selected the answer “Work with the community mental health promotion center.” CONCLUSIONS: The outpatient treatment orders currently being administered were found to be ineffective, and the associated adherence to outpatient treatment was also found to be extremely poor. Hence, the effectiveness of the therapeutic interventions could benefit from institutional as well as administrative improvements. Community mental health promotion centers are expected to have an important role in the future.

La ley de salud mental en Inglaterra / The mental health act in England

Introduction: People can become extremely vulnerable during episodes of severe mental ill health. Their ability to protect themselves can become impaired. They can also pose significant risks to the safety of others through their erratic or hostile behaviour. It could be actually argued that it is precisely during a mental health crisis when explicit legal safeguards are of critical importance for the protection of people's rights, including their dignity and autonomy. Method: An outline is provided of how the Mental Health Act operates in England, with particular reference to involuntary admissions to hospital as well as the right of appeal through the Mental Health Review Tribunal. Results: The roles of medical professionals, Approved Mental Health Professionals, the Nearest Relative as well as the type of evidence that professionals must submit to the Mental Health Review Tribunal and how this evidence is challenged are discussed. Conclusions: The independent legal review of the involuntary detention of a person in hospital is discussed both regarding the protection of human rights it provides as well as in terms of its impact on promoting higher standards of care.

Introducción: Las personas afectadas de un episodio severo de enfermedad mental pueden encontrarse en un estado de alta vulnerabilidad, incluyendo el ser incapaces de protegerse. Durante estos episodios, dichas personas pueden también suponer un riesgo significativo para otros debido, por ejemplo, a una conducta errática u hostil. En este artículo se arguye que es durante estos períodos de crisis cuando se requiere de disposiciones legales explícitas que protejan los derechos, la dignidad, y la autonomía de dichas personas. Métodos: Se provee de un resumen de cómo funciona la Ley de Salud Mental en Inglaterra, con particular referencia a la hospitalización involuntaria así como al derecho de apelación que los pacientes tienen contra dicha hospitalización, la que es vista por el Tribunal de Salud Mental. Resultados: Se discuten los roles de los médicos, de los denominados Profesionales Aprobados de Salud Mental (AMHP) y del Familiar Más Cercano (Nearest Relative), así como el tipo de evidencia que todos los profesionales deben presentar ante el Tribunal de Salud Mental y cómo dicha evidencia es cuestionada en detalle tanto por el abogado del paciente como por los miembros del Tribunal de Salud Mental. Conclusión: Se discute la importancia del hecho de que la hospitalización involuntaria es sometida a una revisión legal independiente de la profesión médica. En particular, se hace referencia al efecto de dicho derecho de apelación en términos tanto de la protección de los derechos humanos de los pacientes así como de la mejoría de los estándares de la calidad de los servicios de psiquiatría.

Current Human Rights Education for Psychiatrists Leaves Much to Be Desired / 신경정신의학

OBJECTIVES: Human rights education programs have been implemented annually since Korea enacted human rights legislation in 2009. The purpose of this study was to investigate attitudes of Korean psychiatrists toward human rights education and assess the relevance of the provided education materials. METHODS: Questionnaires comprised of 8 items were provided to 274 psychiatrists attending the April 2015 Korean Neuropsychiatric Association seminar. In addition, 12 cases related to education material developed by the Korean National Human Rights Commission were examined to determine whether the material's content was relevant and appropriate for human rights education. RESULTS: Data from 267 psychiatrists that answered all requested questions were included in the analysis. Although respondents in general accepted the beneficial intent of human rights education, the majority of respondents (71.5%) disagreed with the mandatory 4 h of annual human rights education. Approximately half of respondents (49.4%) believed that frequency of such education should be decreased. A substantial percentage of respondents (38.7%) expressed overall dissatisfaction with the education program, and more than half of respondents (55.6%) were skeptical that the current education program could produce a real difference in attitudes toward human rights. The case reviews highlighted several problems. First, all education materials were heavily weighted toward psychiatric hospitalization legal proceedings rather than human rights. Among the 12 cases examined, four were considered inappropriate for human rights education because they were presented as if human rights abuse was synonymous with violation of a law, even if the law was ambiguous. CONCLUSION: The current human rights education program does not meet psychiatrists' expectations. The results of this study suggest there is a need to reconsider the purpose and means of providing human rights education to psychiatrists.

Discharge of patients with mental illness back into the community following involuntary admission versus voluntary admission: factor analysis

Background: At times, there is even a need for community involuntary treatment which may help in reducing the hospital admissions of patients with mentally illness. In India, there are very few State run psychiatric hospitals where patients get admitted and treated under section 20 of MHA 1987. There should be provisions for treating mentally ill in the community, if needed involuntarily. Detention of mentally ill for treatment during the time of florid psychosis is not a permanent solution for mental illness treatment. With the existing medicines these illnesses cannot be cured but can be controlled. So it leaves us with the option of using such detention only when no other method to treat is practicable. Such detention should best in the interest of the patient and the community. Aims: This study was an attempt to explore the practical problems in reintegrating the mentally ill back in to the community after their involuntary admission in comparison with the voluntary admission. Methods: This is a cross sectional study and data was collected from the medical records of 113 patients who were admitted in this hospital during the period of January 2010 to June 2010. Nearly 470 voluntary patients’ records were analysed during the above said period but by randomization they were limited to nearly 113 to equate with the involuntary admission. Results: Median duration of total hospitalization period in involuntary admission group of patients is 108 days with a minimum of 15 days and maximum of 460 days of admission. Median duration of involuntary stay at hospital is 91 days in some patients in whose reception orders there was a clear mention of what should be done after their treatment and recovery. In comparison to this group median duration of involuntary stay in others is 113 days as there was no clear mention in their reception orders about what should be done after their treatment and recovery. Conclusion: Most of the hospitals do not have any community social worker who can liaise with the family members to address their fears and to facilitate their early reintegration back in to home. There is a need for a review board consisting judiciary and medical personnel which can revoke the reception order at any point of time to minimize through duration of involuntary hospitalization in closed wards. Key message: Mentally ill patient rights need to be protected.

A cross sectional descriptive study to assess the factors determining involuntary admissions in a psychiatric hospital

Back ground: In our day to day work, especially in government hospitals we come across involuntary admissions where it is difficult to discharge them. Aim: To study the 1)socio demographic factors, 2)symptom profile during admission, 3)referral mode, 4) previous admissions, 5)diagnosis, and 6)co morbidity; of the patients admitted in the open and closed wards of a tertiary level psychiatry hospital. Methods: Collecting the information on socio-demographic profile, presentation, diagnosis and management details of the patients from the case sheets in a semi structured proforma. The data so collected is analyzed statistically to determine any significance. Results: Involuntary (closed ward) admissions were determined by various factors, such as education, marital status, caste, economic status, family structure, social support, referral mode, first consultation, duration of untreated illness, substance abuse and symptom profile. Conclusions: Involuntary admission in India is determined by factors which are not similar to other countries. Policies should be made based on large scale Indian studies.

History of the Korean Mental Health Act / 신경정신의학

The aim of this study was to review the history of the Korean Mental Health Act. The Korean Mental Health Act was enacted in 1995 and revised over the next 15 years. We analyzed these changes over time from the viewpoint of the mental health system. Social systems influenced the Mental Health Act through the mental health system. The first Korean Mental Health Act in 1995 was enacted under the industrial age model and as such, supported long-term hospitalization. This was despite the introduction of a preliminary community mental health model. Subsequently, the Korean Mental Health Act has evolved into one which fully supports a community mental health model. Despite the fact that the Korean Mental Health Act plays an important role in Korea, more research is required to improve and thus, ensure a more effective Korean mental health system.

A Study on the Policy Making Process of the Mental Health Act (1995) in Korea : A Comparative Analysis of Two Different Legislation Periods / 신경정신의학

The purpose of this paper is to produce a policy decision making model most appropriate for formulating mental health policy in Korea. This research will also illuminate the legislation process and make accurate predictions about the revision process of the Mental Health Act. Using the Allison Models, we analyzed the legislation process of for the Korean Mental Health Act from the 1980s to 1995, which was largely divided into two periods. We applied the three types of model to each of these two periods. The results of the comparative analysis show that the process of the Mental Health Act enactment can be explained through by each of the three types of Allison models and that there is no dominant model. However, the analysis shows that, compared with the 'Rational Actor' model, the 'Organizational Behavior' model and the 'Governmental Politics' model are better able to explain the decision making process compared to the 'Rational Actor' model.

Comparison of Major Procedures of Korean Mental Health Law with Other Developed Countries / 신경정신의학

OBJECTIVES : The Mental Health Act is an initiative aimed at changing and shaping mental health services and protecting human rights of persons with mental disorders. Since the Mental Health Act was legislated in 1995, four amendments have been made according to the issues that arose from public concerns. However, there are still many debates about the human rights protection of the mentally ill. This study aimed to provide information regarding major aspects of the Mental Health Act by comparing them among several developed countries. METHODS : Current Mental Health Acts of the state of Michigan in the United States, Scotland in England, the state of Victoria in Australia, and Japan were reviewed. Issues regarding the Korean Mental Health Act were collected from seminar materials, news media contents, and mental health professionals. RESULTS : The definition of subjects in Korean Mental Health Act was more inclusive than other countries and was derived from a medical classification of mental illness. Family members or guardians were granted important responsibilities for deciding the involuntary admission of mentally ill patients in Korea and Japan. In Western countries, Mental Health Review Tribunals or courts have the primary responsibility for important decisions about mentally ill patients. The regulation of immediate discharge after request by voluntarily admitted patients was not enacted in all countries except Korea. The mandatory procedure for involuntary admission in Western countries includes an individual case review with personal interview by a Mental Health Review Tribunal or court. CONCLUSION : The Korean Mental Health Act appears to meet the basic standards of Guidelines from international organizations. Our traditional culture and inherent health systems seem to influence the legal regulation of mental health service and might be related to the problems of human rights protection of mentally ill patients in Korea.

Mental health act, 1987: An analysis.

Health is defined as "the state of complete physical, mental and social well being and not merely an absence of disease or infirmity." 1 Out of three, the mental status is tricky to evaluate and is the one which actually determines other two health parameters. In our country plenty of legal orders interact with mental disorders in order to protect the interests of mentally ill, society and the state. These legislations are enacted to protect the society from dangerous manifestations of mental illness. There are guidelines regarding restrain, admission and discharge, procedures of civil and criminal action with regard to mentally ill. But do these laws discuss about proper care and treatment? Are there provisions for post discharge care and rehabilitation? In present study, an attempt has been made to discuss Mental Health Act, 1987 and suggestions to make them more fundamental.

A Survey on The Current Status of Mental Health Act Application / 신경정신의학

OBJECTIVES: The purpose of this study is to find out how the Mental Health Act(MHA) which was enacted in 1995 has been practiced in reality since it was enforced. This study focuses on the following provisions of this law; admission procedures in relation to the protection of patients' rights, discharge procedures in view of the human rights, and the conditions of the restriction of the patients' rights in hospital. METHODS: The questionnaire on "the current state of the application of the MHA" was designed by the authors and was distributed by mail to 213 psychiatric hospitals and general hospitals which operate psychiatric closed wards as of 1999. RESULTS: One hundred ten hospitals responded to the survey(51.6%) and 92.5% of the total admission to the closed ward were by 'admission by agreement of guardian'(article 24 of MHA). It was reported that a written agreement paper of guardian was filed in 98% and the official document(for the article 14 of rule for enforcement of MHA) for legal guardianship was filed in 85 % of these ad-missions respectively. However, the rate of filling the official document is actually below 85% accor-ding to the direct telephone confirmation. Other kind of admissions such as 'admission by the order of head of prefecture(article 25 of MHA) and 'emergency admission'(article 26 of MHA) were not performed except in several psychiatric hospitals. There cases no report regarding the patient's or guardian's appeal for the improvement of patient's right and better treatment and/or disagreement to involuntary admission. Sixty three percent of hospitals reported that the patients were free to use telephone, and 18.1% reported that the official forms to appeal human right violation of the institute were accessible to patients. However, the actual rates are suspected to be lower than the reports by the institutes. Petition for extension of hospital stay requested by the doctor in charge(article 24-3 of MHA) was submitted mostly by psychiatric hospitals, and its rejection rate was 3.7%. CONCLUSION: In case of 'admissions by agreement of guardian', the required qualification for guardianship and the accompanying document to prove the legal guardianship should be amended to make it more realistic. For other kinds of admissions, such as 'emergency admission' and 'admission by order of head of prefecture', admission procedure should be modified to make it more efficient and practical. The rules and regulations for the human rights of psychiatric patients are not observed properly, which needs much improvement. As this study was done by a survey, it has limitation in understanding how the MHA is actually applied and therefore msufficient as data for the use of revising the Act. However, it appears that MHA is not properly observed with problems in applying MHA in practice. The information obtained from this study suggests that extensive study on national level should be done to find out how the MHA is practiced in reality with much discussion on improving the MHA on the basis of its finding.