Effect of Community Treatment Orders on Mental Health Service Usage, Emergency Visits, and Violence: a Systematic Review and Meta-Analysis.

INTRODUCTION: Community treatment orders (CTOs) enable patients to actively engage in mental health services while being supervised in the community outside the hospital setting. However, the efficacy of CTOs remains controversial in terms of mental health services usage or service contacts, emergency visits, and violence. METHODS: The databases PsychINFO, Embase, and Medline were searched on 11 March 2022 by 2 independent reviewers through the Covidence website (www.covidence.org). Randomised or non-randomised case-control studies and pre-post studies were included if they examine the effect of CTOs on service contacts, emergency visits, and violence in individuals with mental illnesses by comparing with control groups or pre-CTO conditions. Conflicts were resolved by consultation of the third independent reviewer. RESULTS: Sixteen studies provided sufficient data in the target outcome measures and were included in analysis. Variability in the risk of bias was high among studies. Meta-analyses were conducted separately for case-control studies and pre-post studies. For service contacts, a total of 11 studies with 66,192 patients reported changes in the number of service contacts under CTOs. In 6 case-control studies, a small non-significant increase in service contacts was observed in those under CTOs (Hedge's g = 0.241, z = 1.535, p = 0.13). In 5 pre-post studies, a large and significant increase in service contacts was noted after CTOs (Hedge's g = 0.830, z = 5.056, p < 0.001). For emergency visits, a total of 6 studies with 930 patients reported changes in the number of emergency visits under CTOs. In 2 case-control studies, a small non-significant increase in emergency visits was noted in those under CTOs (Hedge's g = -0.196, z = -1.567, p = 0.117). In 4 pre-post studies, a small significant decrease in emergency visits was noted after CTOs (Hedge's g = 0.553, z = 3.101, p = 0.002). For violence, a total of 2 pre-post studies reported a moderate significant reduction in violence after CTOs (Hedge's g = 0.482, z = 5.173, p < 0.001). CONCLUSION: Case-control studies showed inconclusive evidence, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence. Future studies on cost-effectiveness analysis and qualitative analysis for specific populations with various cultures and backgrounds are warranted.

Reasonable or Random: 72-Hour Limits to Psychiatric Holds.

Across the United States, state laws most commonly limit the duration of emergency psychiatric holds to 72 hours. Estimates suggest that more than 1 million emergency psychiatric holds are placed in the United States each year, and this 72-hour limit can shape the lives of patients, clinicians, law enforcement officials, and others in the community. Yet, from where did this time frame originate, and why is it so prevalent in psychiatric care? The author examines the evolution of 72-hour limits on psychiatric holds in the United States, as well as the evidence for or against use of this specific time frame in emergency psychiatric care. Given limited research into policies that affect millions of people, the author concludes that further study is needed to understand how these time limits influence outcomes related to psychiatric care and to strengthen the evidence base for civil commitment practices.

Psychiatric hospitalizations by the Unified Health System in Brazil between 2000 and 2014 / Internações psiquiátricas pelo Sistema Único de Saúde no Brasil ocorridas entre 2000 e 2014

ABSTRACT OBJECTIVE To characterize the profile of patients hospitalized for mental and behavioral disorders by the Unified Health System (SUS) in Brazil between 2000 and 2014, and to verify how aspects of the new mental health policy influenced the rate of hospitalized patients in that period. METHODS Non-concurrent prospective cohort study using secondary data from inpatients with a primary diagnosis of mental and behavioral disorders between 01/01/2000 and 12/31/2014. Sociodemographic, clinical, and hospital characteristics variables were selected. Overall rates of hospitalized patients were calculated according to reason for admission, type of hospital, legal nature, and number of admissions per year for each patient. The association between rates of hospitalized patients, number of psychiatric beds per year, and number of Psychosocial Care Centers per year were tested. RESULTS We selected a total of 1,549,298 patients, whose most frequent diagnoses on first admission were psychoactive substance use disorders, followed by schizophrenia and mood disorders. The median of hospitalizations per patient was 1.9 and the length of stay per patient was 29 days. The overall rate of hospitalized patients was reduced by almost half in the period. The number of beds per year was positively associated with the rates of hospitalized patients; the number of CAPS per year was negatively associated with some rates of hospitalized patients. CONCLUSION Even in the face of adversity, the National Mental Health Policy has advanced in its goal of progressively reducing hospital beds and increasing the supply of substitute services such that both strategies were associated with the reduced inpatient rates. But the changes were felt with greater intensity in the first years of the policy's implementation, becoming less pronounced in recent years.

RESUMO OBJETIVO Caracterizar o perfil dos pacientes que foram internados por transtornos mentais e comportamentais pelo Sistema Único de Saúde (SUS) no Brasil entre 2000 e 2014, bem como verificar como aspectos da nova política de saúde mental influenciaram a taxa de pacientes internados no referido período. MÉTODOS Estudo de coorte prospectiva não concorrente utilizando dados secundários de pacientes internados com diagnóstico primário de transtornos mentais e comportamentais entre 01/01/2000 e 31/12/2014. Foram selecionadas variáveis sociodemográficas, clínicas e de características do hospital, além disso, foram calculadas as taxas gerais de pacientes internados segundo motivo de internação, tipo de hospital, natureza jurídica e número de internações de cada paciente por ano. Foi testada a associação entre taxas de pacientes internados, número de leitos psiquiátricos por ano e número de Centros de Atenção Psicossocial por ano. RESULTADOS Foram selecionados 1.549.298 pacientes dos quais os diagnósticos mais frequentes na primeira internação foram os transtornos devidos ao uso de substâncias psicoativas, seguidos por esquizofrenia e transtornos de humor. A mediana de internações por paciente foi de 1,9 e a de tempo de internação por paciente foi de 29 dias. A taxa geral de pacientes internados foi reduzida à quase metade no período. O número de leitos por ano apresentou associação positiva com as taxas de pacientes internados, e o número de CAPS por ano teve associação negativa com algumas taxas de pacientes internados. CONCLUSÃO Verificou-se que, mesmo diante de um contexto de adversidades, a Política Nacional de Saúde Mental avançou em suas metas de reduzir progressivamente os leitos hospitalares e aumentar a oferta de serviços substitutivos de tal modo que ambas as estratégias foram associadas à redução das taxas de pacientes internados. Contudo, as mudanças foram percebidas com maior intensidade nos primeiros anos de implantação da política, tornando-se menos pujante nos últimos anos.

The frequency of references to decision-making capacity in reports to the NSW Mental Health Review Tribunal did not change after legislative reforms that promoted them.

OBJECTIVE: To assess the impact of a 2015 reform to the Mental Health Act 2007 (NSW) (MHA) that was interpreted as requiring a reference to decision-making capacity (DMC) in reports to the NSW Mental Health Review Tribunal (MHRT). METHOD: A sample of reports to the MHRT were audited for references to the MHA's treatment criteria and DMC in periods before and after the reforms, and the frequency of references between the two periods was compared. RESULTS: The frequency of references to DMC did not change significantly after the reforms. (However, references to the 'least restriction' criterion increased markedly between the two periods). CONCLUSION: Despite legislative reforms and a supporting education campaign promoting the importance of consideration of DMC, references to DMC did not increase after the reforms.

Institucionalização prolongada, transtornos mentais e violência: uma revisão científica sobre o tema / Prolonged institutionalization, mental disorders and violence: a scientific review on the topic

Resumo Trata-se de uma revisão de literatura sobre institucionalização prolongada, transtornos mentais e violência. Uma busca sistematizada foi realizada nos principais bancos de dados e foram analisados trabalhos dos últimos 22 anos. Os resultados foram divididos em dois grupos: "Estudos relacionando fatores ligados à predição/risco de violência e institucionalização" e "Estudos relacionando risco de violência e desassistência/desinstitucionalização". Verificou-se que a doença mental isoladamente não é fator diretamente associado ao maior risco de violência, que fatores relacionados à própria institucionalização e à assistência com privação de liberdade influenciam a predição de violência. Conclui-se que abordagens humanizadas, multiprofissionais e com equipe treinada, aliadas ao gerenciamento dos reais fatores de risco de violência, contribuirão para uma melhor assistência e menor necessidade de institucionalização.

Abstract This study is a review of institutionalization, mental disorders and violence. A systematic search was performed in major databases, focusing on studies from the last twenty-two years. The results were divided into two groups: 'studies on factors related to the risk of violence/prediction and institutionalization' and 'studies on the risk of violence and deinstitutionalization/inadequate mental treatment'. We found that mental illness is not directly associated with high risk of violence. Specific details of the institutionalization and assistance with deprivation of liberty are related to violent behavior. We concluded that humanized, multiprofessional approaches and trained staff, combined with the management of real risk factors of violence can contribute to a better health assistance and reduce the need for institutionalization.

[Characteristics of patients who received an indication of involuntary admission, with or without the involvement of a third party, in a Parisian psychiatric emergency unit]. / Caractérisation d'une population de patients hospitalisés sous contrainte en ASPDT/u et ASPPI à partir d'un service d'urgence psychiatrique parisien.

BACKGROUND: The French mental health law, first enacted on July 5, 2011, introduced the possibility of psychiatric commitment in case of extreme urgency (imminent peril - ASPPI). The decision of involuntary admission can then be made by the hospital director based on a medical certificate, without the need of a third party request. This procedure was intended to be applied on an exceptional basis, but its use is steadily increasing against the other types of involuntary care. Our study aimed at comparing the characteristics of patients who had received an indication for involuntary admission due to imminent peril (ASPPI) or at the request of a third party (ASPDT/u) in a psychiatric emergency ward, according to sociodemographic and clinical characteristics and regarding the potential implication of a third party. METHODS: An observational study was conducted among patients from the Centre Psychiatrique d'Orientation et d'Accueil (CPOA), located at Sainte-Anne hospital in Paris, from August 1st to 31st, 2016. RESULTS: One hundred and fifty patients with an indication for involuntary commitment were included, 101 of whom for ASPDT/u (67 %) and 49 for ASPPI (33 %). For more than half of the patients from the ASPPI group, a third party had been identified with (39 %) or without (17 %) contact information. Compared to ASPDT/u patients, ASPPI individuals were more socially vulnerable, showed more negligence, and had a lower mean functioning score. The indication for ASPPI status was also associated with behavioural quirks, prior psychiatric hospitalization (especially as an ASPPI patient) and with the diagnosis of chronic psychosis instead of mood disorder. CONCLUSION: Our exploratory results help to better understand how the ASPPI procedure is used in psychiatric emergency wards six years after enactment of the law. They highlight the differences between ASPPI patients and ASPDT/u and raise ethical issues regarding involuntary psychiatric care.

A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm.

BACKGROUND: The use of involuntary psychiatric holds (IPH) to detain patients who lack the capacity to make health care decisions due to nonpsychiatric conditions is common. While this practice prevents patient harm, it also deprives civil liberties, risks liability for false imprisonment, and may hinder disposition. Medical incapacity hold (MIH) policies, which establish institutional criteria and processes for detaining patients who lack capacity but do not meet criteria for an IPH, provide a potential solution. METHODS: A retrospective chart review was conducted on adult medical/surgical inpatients placed on an IPH or MIH over the 1-year periods before and after implementation of a MIH policy at an academic medical center. The primary outcome was frequency of IPH utilization in patients who did not qualify for an IPH as determined by 2 independent physician reviewers. A Cohen's kappa was calculated to determine inter-rater reliability. Differences in patient demographics and outcomes were compared using a Student's t-test, Wilcoxon rank-sum test, and Pearson chi-square test (α = 0.05). RESULTS: The Cohen's kappa was 0.72 indicating substantial agreement. Seventy MIHs were placed after implementation (mean duration 4.3 days). Before MIH implementation, 17.6% of IPHs were placed on non-qualifying patients, which decreased to 3.9% following MIH implementation (p < 0.01). The average length of stay for patients on an IPH or MIH did not change following MIH implementation. No instances of patient elopement, grievances, or litigation were found. CONCLUSION: MIH policies benefit both patients lacking capacity and the health care systems seeking to protect them while avoiding inappropriate use of IPHs.

Sexually Violent Predator Law in the United States.

Sexually violent predator (SVP) laws in the United States are controversial. They tend to be opposed by academics, libertarians, and professional organisations but are supported by states and the Supreme Court. This study reviews the history of SVP legislation, compares features of SVP laws among states, and summarise requirements by the Supreme Court that shaped these laws. Features of SVP laws include identification of sexual offenders with mental abnormality that predisposes them to sexually offending behaviours in the future, and standards of proof for conditional or unconditional release. A comprehensive understanding of all statutes can inform policymakers about SVP laws, whether supportive or restrictive of such legislation.

Perceções, atitudes e emoções dos doentes submetidos a internamento psiquiátrico compulsivo: Revisão integrativa / Perceptions, attitudes and emotions of the patients subjected to involuntary psychiatric hospitalization: Integrative review / Percepciones, actitudes y emociones de los enfermos sometidos a ingreso compulsivo: Revisión integrativa

CONTEXTO: O internamento compulsivo em Psiquiatria é um dos temas mais desafiantes desta área da saúde devido às questões éticas envolvidas. A experiência de estar sob cuidados involuntários, nomeadamente em internamento compulsivo, caracteriza-se por sentimentos negativos face à perda de liberdade e autonomia. OBJETIVOS: Conhecer perceções, atitudes e emoções dos doentes submetidos a internamento compulsivo. MÉTODOS: Revisão integrativa da literatura através de pesquisa nas bases de dados EBSCO e Trip Database nas duas primeiras semanas de janeiro de 2018, cujos critérios de inclusão foram: estarem disponíveis em full text, de abordagem quantitativa, qualitativa e/ou revisões de literatura, nos idiomas Português, Inglês e Espanhol e terem como tema de pesquisa as perceções, atitudes e emoções de doentes internados compulsivamente em psiquiatria. RESULTADOS: Foram encontrados 8 artigos que dão resposta ao objetivo do estudo, incluem uma revisão de literatura, quatro estudos observacionais, um ensaio controlado, um estudo qualitativo e um estudo de validação de escala. CONCLUSÕES: Face à experiência de internamento compulsivo, foram identificadas perceções, atitudes e emoções maioritariamente negativas, mas também positivas e ambivalentes. Conclui-se que estas vivências podem ter consequências para além do internamento e que há práticas que devem ser aperfeiçoadas no sentido de melhorar a experiência do doente sujeito a internamento compulsivo.

BACKGROUND: Involuntary hospitalization in Psychiatry is one of the most challenging themes in this specialty due to the ethical issues involved. The experience of being under involuntary care, namely in compulsory hospitalization, is characterized by negative feelings in the face of loss of freedom and autonomy. AIM: To investigate the perceptions, attitudes and emotions of the patients that are admitted into involuntary hospitalization. METHODS: Integrative literature review through data search on the EBSCO database and on the Trip Database, in the first two weeks of January 2018, whose inclusion criteria were: to be available in full text, quantitative, qualitative and / or literature reviews, in the Portuguese, English and Spanish languages, attitudes and emotions of patients hospitalized compulsively in psychiatry. RESULTS: We found eight articles that met the study's objective, including a literature review, four observational studies, a controlled trial, a qualitative study and a scale validation study. CONCLUSIONS: Perceptions, attitudes and emotions that were mostly negative, but also positive and ambivalent, were identified in view of the experience of compulsive hospitalization. It is concluded that these experiences can have consequences beyond hospitalization and that there are practices that must be improved in order to improve the experience of the patient subject to compulsory hospitalization.

CONTEXTO: El ingreso compulsivo en Psiquiatría es uno de los temas más desafiantes de esta área de salud debido a las cuestiones éticas envueltas. La experiencia de estar bajo cuidados involuntarios, en un régimen de ingreso compulsivo, se caracteriza por sentimientos negativos en relación a la pérdida de libertad y autonomía. OBJETIVOS: Conocer las percepciones, actitudes y emociones de los enfermos sometidos al ingreso compulsivo. MÉTODOS: Revisión integrativa de la literatura a través de la búsqueda en las bases de datos EBSCO eTrip Database, en las dos primeras semanas de enero de 2018, cuyos criterios de inclusión fueron: estar disponibles en texto completo, cuantitativa, cualitativa y / o revisiones de la literatura, en portugués, inglés y español y tienen como tema de investigación de las percepciones, actitudes y emociones de pacientes internados compulsivamente en psiquiatría. RESULTADOS: Se encontraron ocho artículos que dan respuesta al objetivo del estudio, incluyen una revisión de literatura, cuatro estudios observacionales, un ensayo controlado, un estudio cualitativo y un estudio de validación de escala. CONCLUSIONES: Frente a la experiencia de internamiento compulsivo, se identificaron percepciones, actitudes y emociones mayoritariamente negativas, pero también, positivas y ambivalentes. Se concluye que estas vivencias pueden tener consecuencias más allá del internamiento y que hay prácticas que deben ser perfeccionadas en el sentido de mejorar la experiencia del paciente sujeto a internamiento compulsivo.

Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression.

The current study investigates the relationship between involuntary hospitalization, severity of psychopathology, and aggression. Adult psychiatric inpatients hospitalized from August, 2012 to January, 2013 were evaluated via the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Individuals were compared regarding voluntariness of hospitalization. Of the 137 hospitalizations in the period, 71 were involuntary (INV). The variables associated with involuntariness were being brought to hospital by ambulance or police, and aggression in the first 24 h of admission. Risk of suicide at admission, and having personal income were associated with voluntariness. The dimensions of the BPRS associated with involuntary hospitalization were activation, resistance, and positive symptoms. Involuntary psychiatric hospitalization was associated with agitation, psychosis and aggression. The data support the indication of involuntary hospitalization for treatment of patients with severe mental illness.

The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act.

OBJECTIVES: The Mental Health Act 2007 (NSW) ( MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice. CONCLUSIONS: The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients' decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.

Caracterização de usuários de substâncias psicoativas e motivos para a internação compulsória / PSYCHOACTIVE SUBSTANCES USERS' DESCRIPTION FOR COMPULSORY TREATMENT

O estudo teve por objetivo avaliar as características de usuários de substâncias psicoativas internados por ordem judicial. Trata-se de um estudo transversal retrospectivo, baseado em dados secundários, realizado na Defensoria Pública do Estado de São Paulo, unidade Araraquara. A amostra foi composta por 217 processos judiciais de indivíduos internados por mandato judicial em função do uso de substâncias psicoativas. Utilizou-se um questionário estruturado, contendo perguntas fechadas, obtidas no formulário de informações da internação compulsória na Defensoria Pública. As informações referem-se a informações sociodemográficas, substância psicoativa utilizada, à internação e sobre o tratamento, bem como aspectos concernentes a própria internação. A amostra caracterizou-se predominantemente por indivíduos do sexo masculino, com faixa etária de 21 a 40 anos, solteiros e desempregados. Em relação ao uso de substâncias psicoativas, 78 (35,9%) usavam álcool e/ou maconha e 139 (64%) faziam uso de cocaína (inalada ou fumada). A amostra diferenciou-se em relação à faixa etária, estado civil e ocupação. Usuários de álcool e/ou maconha se caracterizaram por serem adultos, separados/divorciados e exercerem trabalho informal. Os usuários de cocaína/crack são jovens, solteiros e desempregados. Observa-se associações estatisticamente significativas entre uso de droga, solicitante da internação e a presença de agressividade. A presença de situações de agressividade foi predominante entre usuários de cocaína/crack, quando comparado aos usuários de álcool/ maconha. Os resultados podem auxiliar no entendimento do perfil do usuário de substâncias psicoativas internado compulsoriamente, trazendo luz a questões que relacionam-se ao processo de internação e ao fenômeno do uso de drogas, bem como podem levantar discussões sobre estratégias de cuidado atualmente oferecidas aos usuários de substâncias psicoativas em processo de judicialização

The study has as objective evaluate psychoactive substances users' characteristics hospitalised by court order. This is a cross-sectional retrospective study, based on secondary data, held in the Public Defender's Office of the State of São Paulo, Araraquara's unit. A sample composed by 217 court lawsuits of hospitalized individuals by court orders due to abuse of psychoactive substances. A structured questionnaire was used, containing closed questions, obtained from the data of compulsory hospitalization in the Public Defender's Office. The data refers to sociodemographic information, drug used, hospitalization and treatment. The sample was predominantly male, aged between 21 and 40 years old, single and unemployed. Regarding the use of psychoactive substances, 78 (35.9%) used alcohol and / or marijuana and 139 (64%) used cocaine (inhaled or smoked). The sample was differentiated in relation to age, marital status and occupation. Alcohol and / or marijuana users were characterized as adults, separated / divorced, and engaged in informal work. Cocaine / crack users are young, single and unemployed. Statistically significant associations between drug use, hospitalization requestor and the presence of aggressiveness are observed. The presence of aggressive situations was predominant among cocaine / crack users when compared to alcohol / marijuana users. The results can help to understand the profile of compulsory hospitalized drug user's, bringing light to issues that relate to the hospitalization process and the phenomenon of drug use, as well as to raise discussions about care strategies currently offered to users of psychoactive substances in court orders

O exame de Verificação de Cessação de Periculosidade: a importância da avaliação ampliada em um caso com conclusão contrária ao parecer da equipe assistente / The cessation of dangerousness verification exam: the importance of extended evaluation in a case with conclusion contrary to the opinion of the health care team / L’examen de la vérification de la cessation de la dangerosité: l’importance de l’évaluation prolongée dans un boîtier avec une conclusion contrairement à l’opinion de l’équipe de soins de santé / El examen de verificación del cese de la peligrosidad: la importancia de la evaluación extendida en un caso con la conclusión contraria a la opinión del equipo de salud / Gutachten zur gegenwärtigen Gefährlichkeitsprognose: die Bedeutung einer erweiterten Untersuchung in einem Fall dessen Gutachten im Gegensatz zur Meinung der Betreuungsgruppe steht / 鉴定精神病人社会危险性的终止：专家鉴定与卫生保健人员的意见相反的一个病例

Trata-se de uma discussão a respeito de um caso em que um indivíduo sob medida de segurança, devido a tentativa de homicídio, foi submetido à avaliação de sua periculosidade por peritos psiquiatras. A conclusão foi de que sua periculosidade não havia cessado, divergindo da opinião de sua equipe assistente. Foram identificados relevantes fatores que implicam um maior risco de violência e reincidência criminal, demonstrados no laudo. O resultado mostra que uma avaliação criteriosa e independente é fundamental para a elaboração de um bom laudo psiquiátrico.

This paper discusses a case in which a man under security measures – due to attempted murder – was referred to assessment of dangerousness by expert psychiatrists. The conclusion was that his dangerousness had not ceased, diverging from the opinion of his health care team. Relevant factors were identified that implied greater risk of violence and criminal recidivism, both stated in the report. The result shows that careful and independent assessment is crucial to a good psychiatric report.

Il s’agit d’un débat sur un cas dans lequel une personne sous mesure de sécurité en raison de la tentative de meurtre a été renvoyée à l’évaluation de sa dangerosité par psychiatres. La conclusion était que son danger n’avait pas cessé, diverge de l’opinion de votre équipe soignante. Facteurs pertinents ont été identifiés qui impliquent un risque plus élevé de violence et de la récidive criminelle, indiqué le rapport. Le résultat montre qu’un examen attentif et indépendant est fondamental pour le développement d’un bon rapport psychiatrique.

Esta es una discusión sobre un caso en que un individuo cumplió la medida de seguridad por intento de asesinato y después fue referido a la evaluación de su peligrosidad por peritos psiquiatras. La conclusión fue que su peligrosidad no había cesado, opinión diferente de su equipo de atención médica. Se han identificado los factores relevantes que implican un mayor riesgo de violencia y reincidencia criminal. El resultado muestra que una revisión cuidadosa e independiente es fundamental para el desarrollo de un buen informe psiquiátrico.

Dieser Artikel diskutiert einen Fall, in dem ein Mann wegen versuchten Mordes von psychiatrischen Experten begutachtet wurde, um eine Gefährlichkeitsprognose zu erstellen. Das Gutachten bestätigte die Gefährlichkeit des Mannes, was im Gegensatz zur Stellungnahme seiner Betruungsgruppe stand. Dem Gutachten zufolge wurden relevante Faktoren identifiziert, die auf ein erhöhtes Risiko von Gewalt und Rückfall hindeuten. Dieses Ergebnis zeigt, wie wichtig eine gründliche und unabhängige Bewertung für die Erstellung eines psychiatrischen Gutachtens ist.

这是关于一个被采取安全措施的有谋杀倾向的病人的危险性的案例。由于谋杀未遂，病人被送到精神分析专家那里做评估。专家的结论是，这个病人的危险性没有终止，这个结论和心理健康中心的治疗小组的意见相反。鉴定专家书中指出病人一系列的重要因素，确认病人有更强的暴力倾向和再次犯罪的危险。结果表明，只有通过高水平的独立的鉴定，才能做出精神分析的最好的鉴定书。.

Exploring and explaining involuntary care: The relationship between psychiatric admission status, gender and other demographic and clinical variables.

Involuntary admission and treatment are features of psychiatric care in many countries, but the relationship between involuntary status and gender (among other factors) is not clear. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in a deprived area of Dublin's north inner-city over a 7-year period (2008 to 2014 inclusive). Over this period, there were 1099 admissions, yielding an annual admission rate of 504.8 admissions per 100,000 population per year. When adjusted for deprivation, this rate (387.7) was lower than the national rate (413.9). Consistent with other inner-city areas in Dublin, 14.1% of admissions were involuntary, yielding an involuntary admission rate of 71.2 per 100,000 population per year (deprivation-adjusted rate: 54.8), which is higher than the national rate (39.4). After controlling for age, occupation, marital status and diagnosis, the only independent predictors of admission status were place of origin (p<0.001) and male gender (p=0.001). These findings are consistent with studies showing associations between male gender and involuntary status in the United States, New Zealand, Netherlands, Norway, Belgium, France, and Luxembourg. In contrast, female gender is associated with involuntary status in Switzerland, Brazil, and China. These cross-national differences are likely related to differing legal traditions and different criteria for involuntary admission, possibly related to varying emphases placed on "dangerousness" as a mandatory criterion for involuntary hospitalization. This merits further, cross-national study.

Factors associated with disallowance of compulsory mental healthcare referrals.

OBJECTIVE: Norwegian studies report that a substantial amount of referrals for compulsory mental health care are disallowed at specialist assessment, at a rate that varies with referring agent. Knowledge on factors associated with disallowance could improve the practice of compulsory mental health care. This study aims to examine such factors, placing particular emphasis on the impact of referring agents. METHOD: This study utilized data from the prospective, longitudinal cohort study 'Suicidality in Psychiatric Emergency Admissions' conducted at a Norwegian psychiatric emergency unit which served approximately 400 000 inhabitants. Data on referral, admission and patient characteristics were retrieved on compulsory admissions conducted between 1 May 2005 and 30 April 2008. Bivariate and logistic regression analyses and structural multilevel modelling were performed. RESULTS: Among 2813 compulsory admissions, 764 were disallowed. Low competence in the referring agent, high GAF S score, observed alcohol or drug intoxication, reported suicide risk, and the presence of neurotic, stress-related and somatoform disorders, personality disorders and other non-specified diagnoses were associated with above average disallowance frequency. Non-Norwegian ethnicity and schizophrenia spectrum disorders were associated with below average disallowance rates. CONCLUSION: Among several factors associated with disallowance, low symptom load was the strongest, whilst referring agent competence modestly affected disallowance rate.

Comentarios de la psiquiatría forense al concepto de inimputabilidad en Colombia / Comments forensic psychiatry the concept of criminal responsibility in Colombia

Este artículo de reflexión presenta los aspectos relevantes de la figura jurídica de la inimputabilidad, desde el punto de vista de la psiquiatría forense con base en el análisis de la legislación penal colombiana al respecto. Se define el concepto de imputabilidad, se muestran las asociaciones jurídicas psiquiátricas forenses que se correlacionan con los hallazgos psicopatológicos más frecuentes, que determinan la defensa por insania mental, a la luz del nuevo sistema penal acusatorio en Colombia. Luego se discuten las medidas de seguridad asignadas a los enfermos mentales nominados insanos mentales e inimputables.

This reflection paper presents relevant aspects of the legal concept of Mental Insanity Defense, from the viewpoint of forensic psychiatry, based on the analysis of the Colombian criminal legislation in this regard. As an introduction examples of the concept of criminal responsibility in regulation of some countries and legal aspects are showed and discussed. The concept of liability is defined; forensic psychiatric legal associations correlated to the most frequent psychopathological findings are showed and it is explained that they determine the mental insanity defense in light of the new accusatory penal system in Colombia. Then, we discuss the security measures assigned to mentally ills, named mentally ills or insanes.

Custody, care and country of origin: demographic and diagnostic admission statistics at an inner-city adult psychiatry unit.

Involuntary detention is a feature of psychiatric care in many countries. We previously reported an involuntary admission rate of 67.7 per 100,000 population per year in inner-city Dublin (January 2008-December 2010), which was higher than Ireland's national rate (38.5). We also found that the proportion of admissions that was involuntary was higher among individuals born outside Ireland (33.9%) compared to those from Ireland (12.0%), apparently owing to increased diagnoses of schizophrenia in the former group. In the present study (January 2011-June 2013) we again found that the proportion of admissions that was involuntary was higher among individuals from outside Ireland (32.5%) compared to individuals from Ireland (9.9%) (p<0.001), but this is primarily attributable to a lower rate of voluntary admission among individuals born outside Ireland (206.1 voluntary admissions per 100,000 population per year; deprivation-adjusted rate: 158.5) compared to individuals from Ireland (775.1; deprivation-adjusted rate: 596.2). Overall, admission rates in our deprived, inner-city catchment area remain higher than national rates and this may be attributable to differential effects of Ireland's recent economic problems on different areas within Ireland. The relatively low rate of voluntary admission among individuals born outside Ireland may be attributable to different patterns of help-seeking which mental health services in Ireland need to take into account in future service-planning. Other jurisdictions could also usefully focus attention not just on rates on involuntary admission among individuals born elsewhere, but also rates of voluntary admission which may provide useful insights for service-planning and delivery.

Internação compulsória e crack: um desserviço à saúde pública / Compulsory treatment and crack: a harmful service to public health

O objetivo deste ensaio é o de discutir a interpretação inconstitucional que vem sendo conferida à Lei nº 10.216/01, que prevê a internação compulsória de doentes mentais, mas que está servindo de fundamento para a internação de dependentes químicos. Trata-se de absoluta afronta aos princípios constitucionais da dignidade da pessoa humana e do direito à saúde. Aborda-se usuário de drogas, maior de 18 anos que tem sua internação requerida judicialmente. Partindo-se da premissa que os dependentes químicos não são doentes mentais, a internação compulsória, além de ser agressiva e uma forma de tratamento ineficaz, constitui um modo de eliminação dos indesejados, constituindo-se em prática higienista violadora de direitos humanos.

This essay aims to discuss the unconstitutional interpretation conferred to Law nº 10.216/01, which provides for compulsory hospitalization of the mentally ill but also grounds the hospitalization of drug addicts. This is an absolute outrage to the constitutional principles of human dignity and to the right to health. The essay encompasses drug users of 18 years or above who have their hospitalization required by law. Starting from the premise that the addicts are not mentally ill, compulsory hospitalization, in addition to being aggressive and an ineffective form of treatment, shall constitute a means of eliminating the unwanteds, in a hygienist practice that violates human rights.

[Decision of emergency involuntary hospitalization: categorical or dimensional approach?]. / La décision d'hospitalisation sans consentement aux urgences: approche dimensionnelle ou catégorielle?

BACKGROUND: In 2005, in its recommendations on the modalities of decision making for compulsory hospitalization, the French Health High Authority (HAS) had already stressed the need for rapid implementation of studies and epidemiological analyses on the subject to compensate the lack of adequate data in France. The new French law of July 5, 2011, on the rights and protection of persons under psychiatric care, establishes a judicial review of decisions for compulsory hospitalization. Therefore, healthcare professionals need to better define and characterize the criteria for such decisions, especially in their relation to psychopathology. The concept of capacity to consent to treatment includes the ability to understand (to receive information about the disease), the ability to appreciate (to weigh the risks and benefits of treatment), the ability to reason (determining the best choice rationally) and the ability to freely express a decision. However, assessment tools of capacity to consent to treatment seem to fail to predict the modality of hospitalization. OBJECTIVE: This study examined the impact of clinical and contextual characteristics on the decision in emergency services to admit patients to compulsory inpatient psychiatric units. METHOD: Data was collected from 442 successive patients admitted to hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent course of care, clinical diagnosis, Global Assessment of Functioning scale (GAF) and Insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the HAS for the severity of mental disorders and the necessity of emergency care. RESULTS: Multivariable logistic regression shows that diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being married as well as being referred by a doctor or family are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for compulsory admission. CONCLUSION: Our study shows a dimensional rather than categorical assessment of patients by clinicians. Assessment of insight is the main operational criterion used by clinicians in our study. This supports using insight and GAF evaluation in clinical practice to clarify assessment and decision-making in an emergency setting regarding compulsory hospitalization.

Clinical and demographic differences between voluntary and involuntary psychiatric admissions in a university hospital in Brazil / Diferenças clínicas e demográficas entre internações psiquiátricas voluntárias e involuntárias em um hospital universitário no Brasil / Las diferencias clínicas y demográficas entre los ingresos psiquiátricos involuntarios y voluntarios en un hospital universitario en Brasil

To assess the frequency of involuntary psychiatric hospitalizations from 2001 to 2008 and to determine associated clinical and socio-demographic characteristics, a retrospective cohort study was conducted. Adult admission data were collected from a university hospital in Brazil. Hospitalizations were classified as voluntary (VH) or involuntary (IH). Groups were compared using chi-square test for categorical variables and Mann-Whitney test for continuous non-parametric variables. The relative risk of certain events was estimated by the odds ratio statistic. Of 2,289 admissions, 13.3% were IH. The proportion of IH increased from 2.5% to 21.2% during the eight year period. IH were more frequently associated with female gender, unmarried status, unemployment, and more than 9 years of schooling. Psychotic symptoms were more common among IH. There were no differences in age, duration of hospitalization, or rate of attendance at first appointment after hospital discharge. Understanding of the characteristics associated with IH is necessary to improve the treatment of psychiatric disorders.

Uma coorte retrospectiva foi conduzida para avaliar a frequência de internações psiquiátricas involuntárias entre 2001 e 2008, e para determinar características clínicas e sociodemográficas associadas. Informações de internações de adultos foram coletadas de um hospital universitário no Brasil. As hospitalizações foram classificadas como voluntárias (HV) ou involuntárias (HI). Os grupos foram comparados pelo uso do teste qui-quadrado para variáveis categóricas e Mann-Whitney para variáveis contínuas não paramétricas. O risco relativo de certos eventos foi estimado por odds ratio. De 2.289 internações, 13,3% eram HI. A proporção de HI aumentou de 2,5% para 21,2% no período de oito anos. HI foram mais frequentemente associadas ao sexo feminino, estado civil solteiro, desemprego, e mais de 9 anos de escolaridade. Sintomas psicóticos foram mais comuns entre HI. Não houve diferenças na idade, tempo de internação e comparecimento na primeira consulta após a alta hospitalar. É necessário compreender características associadas com HI para melhorar o tratamento de transtornos psiquiátricos.

Un estudio de cohorte retrospectivo se realizó para evaluar la frecuencia de los ingresos psiquiátricos involuntarios entre 2001 y 2008, y para determinar las características sociodemográficas y clínicas asociadas. Las hospitalizaciones psiquiátricas de un hospital universitario en Brasil fueron clasificadas como voluntarias (HV) o involuntarias (HI). Los grupos se compararon mediante la prueba de chi-cuadrado para las variables categóricas y la prueba de Mann-Whitney para las variables continuas no paramétricas. El riesgo relativo de ciertos eventos se estimó por la odds ratio. De 2.289 hospitalizaciones, el 13,3% eran HI. La proporción de HI aumentó del 2,5% al 21,2% en ocho años. HI fueron más asociadas con el sexo femenino, estado civil soltero, desempleo, y más de 9 años de escolaridad. Los síntomas psicóticos fueron más comunes entre HI. No hubo diferencias en la edad, la duración de la estancia y la asistencia a la cita después del alta hospitalaria. Es necesario comprender las características asociadas con HI para mejorar el tratamiento de los trastornos psiquiátricos.