Risk factors for repeated emergency compulsory psychiatric admissions.

BACKGROUND: The characteristics of patients who have repeated compulsory psychiatric admissions are largely unknown. AIMS: To investigate the frequency and risk factors for repeated emergency compulsory psychiatric admission (ECPA); and to identify targets for interventions to reduce repeated ECPA. METHOD: Data were collected from a database of electronic patient files (EPFs) held by three psychiatric emergency services (PES) in the Netherlands. Analyses were based on the data for adult patients (aged 18-75 years) with a first PES contact in 2010-2015. Using descriptive statistics and regression analysis, we studied the associations between baseline patient factors and repeated ECPA and time to readmission, within a 2-year follow-up period. RESULTS: We included 6059 patients: 15.6% had two or more ECPAs. In total, 66% of second ECPAs had occurred within 6 months of the first. About 30% of all ECPAs were repeated ECPAs. Two baseline factors were associated with a higher frequency of a second ECPA: history of receiving any mental healthcare treatment, whether in-patient or out-patient or both, and a lower level of self-care. Three were associated with a lower frequency: ethnicity (other than Dutch), older age and suicidality. Lower Global Assessment of Functioning (GAF) scores and housing problems were associated with a shorter time to compulsory readmission and persistent psychiatric problems with a longer time to compulsory readmission. CONCLUSIONS: We found that 15.6% of patients had two or more ECPAs. Two-thirds of the second ECPAs had occurred within 6 months of the first. Like earlier studies, the risk factors we identified suggest that interventions to reduce the risk of repeated compulsory psychiatric admission should seek to improve self-care, general daily functioning and homelessness.

An intensive multimodal group programme for patients with psychotic disorders at risk of rehospitalization: a controlled intervention study.

BACKGROUND: On the basis of earlier experiences in Germany and England, we developed an intensive multimodal group programme (FACT Plus) for psychotic-spectrum patients. By combining it with regular Flexible Assertive Community Treatment (FACT) (care as usual), we intended to reduce psychiatric rehospitalizations and mental healthcare costs. METHODS: We included adult patients (>18 years) with a psychotic spectrum disorder who had had at least one psychiatric admission in the 2 years before inclusion. FACT Plus was delivered weekly for 9 months. The intervention group was recruited in northern Rotterdam (the Netherlands), and the control group was recruited in southern Rotterdam. The primary outcome measure was length of stay (LOS) and the secondary outcome measures were mental healthcare costs and compulsory admissions. RESULTS: We included 52 patients in the intervention group and 61 patients in the control group. During the 12-month observation period, the mean LOS per patient was 15.2 (intervention group) and 34.6 (control group). This represents a difference of 19.4 days (56.1%). This result was statistically significant (B = -.859, SE = .497, p = .042) in a regression model correcting for baseline differences between the groups. Mean total mental healthcare costs per patient were €21,098 in the intervention group) versus €25,054 in the control group, a difference of about €4000 per patient (16%). In addition, there were zero compulsory admissions in the intervention group and nine in the control group. CONCLUSIONS: After the addition of FACT Plus to regular FACT, psychiatric LOS was substantially lower in the intervention group than in the control group. This result was accompanied by a limited reduction in mental healthcare costs.

How dangerousness evolves after court-ordered compulsory psychiatric admission: explorative prospective observational cohort study.

BACKGROUND: Compulsory admission is commonly regarded as necessary and justified for patients whose psychiatric condition represents a severe danger to themselves and others. However, while studies on compulsory admissions have reported on various clinical and social outcomes, little research has focused specifically on dangerousness, which in many countries is the core reason for compulsory admission.AimsTo study changes in dangerousness over time in adult psychiatric patients admitted by compulsory court order, and to relate these changes to these patients' demographic and clinical characteristics. METHOD: In this explorative prospective observational cohort study of adult psychiatric patients admitted by compulsory court order, demographic and clinical data were collected at baseline. At baseline and at 6 and 12 month follow-up, dangerousness was assessed using the Dangerousness Inventory, an instrument based on the eight types of dangerousness towards self or others specified in Dutch legislation on compulsory admissions. We used descriptive statistics and logistic regression to analyse the data. RESULTS: We included 174 participants with a court-ordered compulsory admission. At baseline, the most common dangerousness criterion was inability to cope in society. Any type of severe or very severe dangerousness decreased from 86.2% at baseline to 36.2% at 6 months and to 28.7% at 12 months. Being homeless at baseline was the only variable which was significantly associated with persistently high levels of dangerousness. CONCLUSIONS: Dangerousness decreased in about two-thirds of the patients after court-ordered compulsory admission. It persisted, however, in a substantial minority (approximately one-third).Declaration of interestNone.

Crucial factors preceding compulsory psychiatric admission: a qualitative patient-record study.

BACKGROUND: Compulsory admissions have a strong effect on psychiatric patients and represent a deprivation of personal liberty. Although the rate of such admissions is tending to rise in several Western countries, there is little qualitative research on the mental health-care process preceding compulsory admission. The objective of the study was to identify crucial factors in the mental health-care process preceding compulsory admission of adult psychiatric patients. METHODS: This retrospective, qualitative multiple-case study was based on the patient records of patients with severe mental illness, mainly schizophrenia and other psychotic disorders. Twenty two patient records were analyzed. Patients' demographic and clinical characteristics were heterogeneous. All were treated by Flexible Assertive Community Treatment teams (FACT teams) at two mental health institutions in the greater Rotterdam area in the Netherlands and had a compulsory admission in a predefined inclusion period. The data were analyzed according to the Prevention and Recovery System for Monitoring and Analysis (PRISMA) method, assessing acts, events, conditions, and circumstances, failing protective barriers and protective recovery factors. RESULTS: The most important patient factors in the process preceding compulsory admission were psychosis, aggression, lack of insight, care avoidance, and unauthorized reduction or cessation of medication. Neither were health-care professionals as assertive as they could be in managing early signs of relapse and care avoidance of these particular patients. CONCLUSION: The health-care process preceding compulsory admission is complex, being influenced by acts, events, conditions and circumstances, failing barriers, and protective factors. The most crucial factors are patients' lack of insight and cessation of medication, and health-care professionals' lack of assertiveness.

Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-analysis.

IMPORTANCE: Compulsory admissions, defined as admissions against the will of the patient (according to local judicial procedures), have a strong effect on psychiatric patients. In several Western countries, the rate of such admissions is tending to rise. Its reduction is urgently needed. OBJECTIVE: To establish which interventions effectively reduce compulsory admissions in adult psychiatric patients in outpatient settings. DATA SOURCES: A systematic computerized literature search was performed using EMBASE, MEDLINE, Web of Science, PsycINFO, CINAHL, PubMed (not yet indexed for MEDLINE), Cochrane Central, and Google Scholar. Every database was searched from its inception until April 30, 2015. STUDY SELECTION: Randomized clinical trials (RCTs) that studied any kind of intervention designed to reduce compulsory admission rates in adult psychiatric patients (age range, 18-65 years) in outpatient settings were eligible. Eligibility was independently assessed by 2 of us. DATA EXTRACTION AND SYNTHESIS: Two of us independently extracted relevant data. The Cochrane Collaboration's tool was used for assessing risk of bias. Overall risk reduction (random-effects estimate) was calculated in the following 4 subgroups of interventions: advance statements, community treatment orders, compliance enhancement, and integrated treatment. MAIN OUTCOMES AND MEASURES: Relative risk (RR) was calculated on the basis of the number of patients who had been compulsorily admitted. RESULTS: Our meta-analyses included 13 RCTs comprising 2970 psychiatric patients. The meta-analysis of the RCTs on advance statements showed a significant 23% (RR, 0.77; 95% CI, 0.60-0.98; I2 = 2.2%) (n = 1102) risk reduction in compulsory admissions. In contrast, the RCTs on community treatment orders (RR, 0.95; 95% CI, 0.81-1.10; I2 = 0.0%) (n = 742), compliance enhancement (RR, 0.52; 95% CI, 0.11-2.37; I2 = 55.7%) (n = 250), and integrated treatment (RR, 0.71; 95% CI, 0.49-1.02; I2 = 49.0%) (n = 876) showed no significant risk reduction in compulsory admissions. CONCLUSIONS AND RELEVANCE: The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.

['Steroid psychosis' during treatment for premature labour]. / 'Steroïdpsychose' bij behandeling van dreigende vroeggeboorte.

A 30-year-old woman, 33 weeks pregnant, without a significant psychiatric history, was admitted for treatment of premature labour. She was treated with betamethasone intramuscularly, with a total dose of 24 mg divided over 2 days, and nifedipine orally with beneficial effect on the contractions. However, within 24 h after completion of tocolytic treatment, she developed a psychosis with delusions and hallucinations necessitating readmission, first to an obstetric ward, later to a psychiatric ward. At least part of this episode may be characterized as delirium. Eventually, she was treated with haloperidol. It is argued that her psychosis was caused by the corticosteroid, since psychiatric disturbance is a well-known complication of corticosteroid therapy. To our knowledge, psychosis during pregnancy as a result of treatment with corticosteroids has not been reported previously.