Effect of coercive measures on treatment outcome in involuntarily admitted patients in Amsterdam.

Objective: The prevalence of involuntary admissions rose the last forty years in European countries, including the Netherlands. Involuntary admissions result in seclusion, physical restraint and forced medication in approximately 40% of patients. We looked at whether treatment outcomes differ in patients with and without coercive measures. Methods: Using The Health of the Nation Outcome Scales (HoNOS) to measure treatment outcomes, we studied the files of 786 patients admitted involuntarily to an Amsterdam clinic. We applied Generalised Linear Models to determine whether the use, or not, of coercive measures during treatment was associated with a difference in outcomes. Results: 19% of the cohort were secluded in a High Security Room (HSR); 24% were secluded in their own room and/or received forced medication. After adjustment for the influence of diagnosis, disorder severity (initial HoNOS score) and treatment duration, the HSR group had, on average, a HoNOS difference score that was 2.4 points lower than patients without coercive measures (CI -4.0 to -0.8.; p 0.003). In the seclusion in own room group, this score was 2.6 points lower (CI -4.0 to -1.1; p 0.001), corresponding to an effect size of 0.35 and 0.40, respectively. Conclusion: Seclusion, whether or not in combination with forced medication, was applied to two-fifths of patients. The HoNOS scores of the group without coercion improved by nearly two and a half points more on average than those of the two groups with coercion. A causal relationship between coercion and treatment outcome could neither be confirmed nor excluded on the basis of our results.

[Differences in the prevalence of acute involuntary admissions between Apeldoorn, Rotterdam and Amsterdam]. / Prevalentie van acute onvrijwillige opnames in Apeldoorn, Rotterdam en Amsterdam.

BACKGROUND: There are regional differences in the Netherlands in the numbers of emergency compulsory admissions (Inbewaringstelling: IBS). We looked at three 24/7 facilities to investigate the relationships between patient and consultation characteristics on the one hand, and numbers of emergency compulsory admissions on the other, against the background of the level of urbanisation. METHOD: We compared emergency consultations in 18-64 year olds in Apeldoorn, Amsterdam and Rotterdam between 2012 and 2016 in terms of socio-demographic, procedural and clinical characteristics, and in terms of outcome. We used the Severity of Psychiatric Illness Scale (SPI) to determine disorder severity. RESULTS: Apeldoorn had as many consultations per 100,000 inhabitants as the highly urbanised city of Rotterdam. GPs there referred 68% of patients, compared with 25% in Amsterdam and 50% in Rotterdam. In Apeldoorn, 17% of the patients were psychotic, compared with 35% in the other regions. In addition, 66% of the patients there had a low SPI score, compared with 40% in the large cities. Amsterdam and Rotterdam had 3.5 times higher risk of emergency compulsory admissions as Apeldoorn. After adjustment for socio-demographic, procedural and clinical characteristics, this difference with Apeldoorn was 1.5 for Amsterdam and 2.6 for Rotterdam. SPI score and psychotic disorder were found to be the most important predictors of IBS admission. CONCLUSION: Differences in consultation numbers, referral patterns and the location of consultations indicate that there are regional differences in the position of the 24/7 facility in the mental health care system. The numbers of emergency compulsory emissions were related in part to the level of urbanisation and the associated epidemiological differences but probably also to differences in the position of the crisis facility in the mental health care system. Differences in admission numbers were primarily linked to differences in diagnostic characteristics and disorder severity and, to a lesser extent, to referral patterns and socio-demographic characteristics. However, these variables did not explain all the observed inter-regional differences.

[Suspects with mentally confused behaviour in an Amsterdam police cell; better cooperation between psychiatrist and public prosecutor]. / Verdachten met verward gedrag in Amsterdamse politiecel; betere samenwerking tussen psychiater en officier van justitie.

BACKGROUND: Over the past decade, shocking incidents have driven a debate about how to handle persons exhibiting mentally confused behaviour who commit crimes. In response, Amsterdam launched a pilot project in 2017 to improve collaboration between the judicial system and mental health services at police stations to achieve a more appropriate rapport between criminal justice and care. AIM: To describe the pilot project and it's initial results. METHOD: We describe the establishment of the pilot project, as well as the results of an initial evaluation of the characteristics of the incoming persons and the handling of the arrests. In a separate experiment we evaluated how information about the results of a psychiatric consultation affected decisions about the handling of cases by the public prosecutor's department. RESULTS: While respecting legal constraints, it proved possible to exchange information between the public prosecutor's department and the mental health care system. In one-third of the cases, the public prosecutor adapted the decision about the handling of the case after being informed about the psychiatrist's assessment. Four-fifths of the incoming persons were male and only one-third lived in Amsterdam. One-third had a psychotic disorder and more than one-third a substance-related disorder. Compulsory admissions were ordered for 15% of the suspects who were assessed. After assessment, both treatment and penalties were ordered for one-third. CONCLUSION: The professionals involved thought the new approach was positive. However, it is still too early to draw any conclusions about the effects. The unusual profile of the cohort makes it clear that the police, the judicial system, the mental health care system and municipal organisations are faced with a complex challenge in their efforts to reduce the number of incidents with confused suspects on the long term. Further research is required in order to determine the social and psychiatric characteristics that predict recurring contacts with the police.

[Social isolation, source of income and healthcare consumption for psychiatric patients with and without severe mental illness]. / Sociaal isolement en ggz-gebruik bij patiënten met een ernstige psychische aandoening.

BACKGROUND: The more severe the psychiatric illness the more patients are dependent on social support and informal care. However, research showed that patients with severe mental illness (smi) have smaller networks than healthy controls.
AIM: To examine the relationship between network size and perceived social support on the one hand and healthcare consumption on the other.
METHOD: A group of 252 patients who got a crisis consultation in Amsterdam, was divided into patients with and without smi on the basis of two years of observation. Mental healthcare consumption was then measured over a period of three years. Bi- and multivariate analyses were used to determine which variables predict levels of mental healthcare consumption.
RESULTS: Both patient groups did not show any change in level of care consumption during the three follow-up years. In both smi patients and other patients, mental healthcare consumption increased with smaller network size (or 0,85; 95% ci 0,75-0,96). Patients with smi showed a more than threefold higher care consumption compared to non-smi patients (or 3.19; 95% ci 1.82-5.61) independent of network size and living situation.
CONCLUSION: smi patients live in conditions that undermine self-reliance: they have a small social network, they often live alone and they usually depend on welfare benefits. They also consume considerably more care than patients with milder disorders and this level of consumption did not decline during the three years of follow-up. A development of new social interventions will be needed to make this patient group more self-reliant and less dependent on care.

[Intensive follow-on care does not prevent a repeat compulsory admission; a prospective cohort study with a 5-year follow-up]. / Intensieve nazorg voorkomt BOPZ-heropname niet.

OBJECTIVE: To explore the relationship between psychiatric care consumption after a compulsory admission and the probability of a repeat compulsory admission. DESIGN: Prospective cohort study with a 5-year follow-up. METHOD: Mental health care consumption was registered for 460 patients admitted compulsorily under the Dutch Psychiatric Care (Compulsory Admissions) Act by the Amsterdam Emergency Psychiatry service between 15 September 2004 and 14 September 2006, with socio-demographic and clinical data as independent variables. RESULTS: There was no repeat compulsory admission in 63% of the cohort. The odds ratio for repeat compulsory admission only decreased in the fourth year (odds ratio (OR) 0.64; 95% CI 0.45-0.92). Repeat compulsory admission was associated with high treatment continuity (χ2 p ≤ 0.001) and a high level of care consumption during the follow-up period (χ2 p ≤ 0.001). Compulsory admission was predicted on the basis of: high care consumption in the five years prior to inclusion (OR 2.61; 1.44-4.73), aged younger than 35 years at outset (OR 1.65; 1.08-2.52), living alone at the time of inclusion (OR 1.68; 1.22-2.33), and a history of compulsory admission (OR 1.56; 1.03-2.35). CONCLUSION: Two-thirds of the patients were not re-admitted compulsorily. The probability of a repeat admission of this kind fell only after four years. Patients who underwent a repeat compulsory admission proved to be the ones who had been treated most intensively, yet this intense treatment did not prevent a higher probability of readmission. When not taking the quality and nature of care and social integration of patients into account, attempts to reduce treatment dropout on the one hand and more intense treatments on the other may not have an effect on reducing the probability of a repeat compulsory admission.

[Emergency compulsory admission in crisis situations; the Amsterdam Study of Acute Psychiatry]. / Inbewaringstelling als uitkomst; de Amsterdam Study of Acute Psychiatry.

BACKGROUND: This article presents initial data from the Amsterdam Study of Acute Psychiatry (ASAP) which investigated the factors that play a role in the decision to admit a patient compulsorily to a psychiatric clinic in the Amsterdam area. AIM: To find out how socio-demographic factors, a patient's psychiatric history and pathway to care influence a patient's chance of being served with an emergency compulsory admission order during emergency consultation. METHODS: We conducted a prospective cohort study of 1970 consecutive patients who consecutively came into contact with the Psychiatric Emergency Service Amsterdam (PESA) in the period September 2004 to September 2006. RESULTS: A patient who had been admitted compulsorily once in the previous five years ran an increased risk of compulsorily admission (or 3.9). Referral by the police or by the mental health services also implied a high risk of a compulsorily admission (or 2.2 and or 2.6 respectively). CONCLUSION: A previous compulsorily admission and referral by the police or mental health services were found to be predictors of emergency compulsory admission, irrespective of possible danger to the patient himself and others and irrespective of the patient's lack of motivation for treatment.

Crisis intervention and acute psychiatry in Amsterdam, 20 years of change: a historical comparison of consultations in 1983 and 2004-2005.

AIM: There has been a striking increase in the number of compulsory admission proceedings in the Netherlands since 1992, to such an extent that treatment in Amsterdam's psychiatric clinics is in danger of being dominated by coercive treatment. Our aim was to establish a picture of the changes in emergency psychiatry that have contributed to the increase in the number of acute compulsory admissions. METHODS: A cohort (N = 460) of psychiatric emergency consultations with the city crisis service in 1983 was compared with a similar cohort (N = 436) in 2004-2005. The study focused on the following variables: patient characteristics, crisis-service procedures and consultation outcomes. RESULTS: Compared with 1983, there are now more services involved in crisis support in the public domain for psychiatric patients. The number of patients referred by the police has risen from 29% to 63%. In 1983, all consultations took place where the patients were located; at present, 60% take place at the crisis service premises. The number of psychotic patients in the cohort has increased from 52.0% and 63.3 %. There has been an increase in the proportion of compulsory admissions and a sharp decrease in the proportion of voluntary admissions from 61% to 28% of all admissions. Overall, the percentage of consultations leading to a psychiatric admission has fallen from 42% to 27%. CONCLUSION: The front-line outreach service of 1983 has changed into a specialist psychiatric emergency department with a less pronounced outreach component. Voluntary admissions to psychiatric hospitals have almost disappeared as a feature of the crisis service.

[Changes in crisis intervention and emergency psychiatry, Amsterdam emergency consultations in 1983 and 2005]. / Veranderingen in crisisinterventie en acute psychiatrie; Amsterdamse consulten in 1983 en 2005.

BACKGROUND: Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics. AIM: To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions. METHOD: A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes. RESULTS: In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%. CONCLUSIONS: The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.