Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth.

As hospital beds are scarce, and emergency admissions to a psychiatric ward are major life-events for children and adolescents, it is essential to have insight into the decision-making process that leads to them. To identify potentially modifiable factors, we, therefore, studied the contextual and clinical characteristics associated with the voluntary and compulsory emergency admission of minors. We used registry data (2008-2017) on 1194 outpatient emergencies involving children aged 6-18 who had been referred to the mobile psychiatric emergency service in two city areas in The Netherlands. Demographic and contextual factors were collected, as well as clinical characteristics including diagnoses, psychiatric history, Global Assessment of Functioning (GAF), and the Severity of Psychiatric Illness (SPI) scale. Logistic regression analyses were used to identify factors that predict voluntary or compulsory admission. Of 1194 consultations, 227 (19.0%) resulted in an admission, with 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) compulsorily. Independently of legal status, the following characteristics were associated with admission: severity of psychiatric symptoms, consultation outside the patient's home, and high levels of family disruption. Relative to voluntary admission, compulsory admission was associated with more severe psychiatric problems, higher suicide risk, and prior emergency compulsory admission. Two potentially modifiable factors were associated with psychiatric emergency admission: the place where patients were seen for consultation, and the presence of family problems. Psychiatric emergency admissions may be reduced if, whenever possible, minors are seen in their homes and if a system-oriented approach is used.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study.

BACKGROUND: There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission. METHODS: This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors. RESULTS: Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED. CONCLUSIONS: We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Reasons behind the rising rate of involuntary admissions under the Mental Health Act (1983): Service use and cost impact.

There has been a significant rise in the use of the Mental Health Act (1983) in England over the last 10 years. This includes both health-based Place of Safety detentions and involuntary admissions to NHS mental health facilities. Although these trends should clearly inform the implementation of mental health care and legislation, there is currently little understanding of what caused these increased rates. We therefore sought to explore potential underlying reasons for the increase in involuntary admissions and Place of Safety detentions and to ascertain the associated service costs. We extracted publicly available data to ascertain the observed number of involuntary admissions (Section 2 or 3) and health-based Place of Safety detentions in England between 1999/2000 and 2015/2016. A simple regression analysis then enabled us to compare observed admission rates with predicted rates, between 2008/2009 and 2015/2016. This prediction model was based on observed figures before 2008. We then generated a costing model for these rates and compared admission costs to alternative interventions. Finally, we added relevant covariates to the prediction model, to explore potential relationships with observed rates. Since 2008/2009, there has been a marked increase in the number of involuntary admissions (38%) and Place of Safety detentions (617%). The analysis revealed that for involuntary admissions, the period of greatest increase occurred after 2012, two years after austerity measures were implemented. For Place of Safety detentions, substantial rises were seen from 2008/2009 to 2015/2016, coinciding with the economic recession. The rise in Place of Safety detentions may have been worsened by a reduction in mental health bed availability. During the study period, involuntary admissions are estimated to have cost the English NHS £6.8 billion; with a further £120 million spent on Place of Safety detentions. This is approximately £597 million greater than predicted, had involuntary admissions continued to change at pre-2008 rates. We conclude that the rise in involuntary admissions, and to a lesser extent Place of Safety detentions, were associated with three specific impactful events: the economic recession, legislative changes and the impact of austerity measures on health and social care services. In addition to the extensive arguments presented elsewhere, there is also an urgent economic case for addressing this trend.

The social-psychiatric service and its role in compulsory hospitalization.

Coercive measures are a sensitive, much-discussed ethical and legal issue in the psychiatric context. Hence, the identification of their predictors and ways of prevention are of utmost importance. The present study aimed to determine the impact of the social-psychiatric services (SPS) in North Rhine Westphalia (NRW) on involuntary admissions according to the German Mental Health Act and to identify predictors for the reduction of these involuntary admissions. A dataset including details from 31 districts and 23 towns in NRW over a time period of 10 years (2005-2014) was analysed regarding the number of involuntary admissions, gender and age of admitted patients, and person/institution initiating the compulsory act. All 56 SPS in NRW were contacted for information on the number of clients/contacts, home visits, areas of responsibility and their involvement in involuntary admissions. Thirty SPS participated in the survey. We found a significant increase of involuntary admissions over time with significantly higher proportions of male patients and patients younger than 60 years in every year. Regarding the characteristics of SPS, a negative correlation between the number of clients contacting the SPS on their own initiative and low-income households was observed. Additionally, the number of clients contacting the SPS on their own initiative was significantly higher in districts/towns associated with lower involuntary admission rates. These data suggest that patient-based factors were of great importance in the context of involuntary admissions. Furthermore, the SPS and home treatment should be strengthened and intensified to achieve lower involuntary admission rates.

Evolving Public Views On The Likelihood Of Violence From People With Mental Illness: Stigma And Its Consequences.

Highly publicized acts of violence routinely spark reactions that place blame on the perpetrator's presumed mental illness. Despite solid evidence that people with mental illness are unlikely to be dangerous, such prejudice can lead to support for inappropriately using legal means to force people into treatment. We examined trends in public perceptions of violence and support for coerced treatment across a twenty-two-year period using data from three National Stigma Studies. The studies gave respondents one of three vignettes describing people who met clinical criteria for mental disorders or one describing a person with nonclinical "daily troubles." Perceptions regarding potential violence and support for coercion generally rose over time-significantly so for schizophrenia. By 2018 over 60 percent of respondents saw people who met criteria for schizophrenia as dangerous to others, and 44-59 percent supported coercive treatment. Sixty-eight percent saw people with alcohol dependence as dangerous to others, and 26-38 percent supported coercion. Lower but substantial percentages were reported for people with depression and, remarkably, for those with nonclinical "daily troubles," who were viewed as dangerous. These findings reflect political discourse, not scientific data, and could lead to policies that would be ineffective and misdirect the search for the underlying roots of violence while unnecessarily increasing stigma toward people with mental illness.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services.

BACKGROUND: The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES. METHODS: Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission. RESULTS: Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder. CONCLUSIONS: While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Trends in the number of restricted patients in England and Wales 2003-2016: Implications for forensic psychiatry services.

This paper uses data produced by the Ministry of Justice to look for trends in the numbers of various categories of patients detained under the Mental Health Act in England and Wales between 2003 and 2016. Specifically, we have focussed on patients detained with Ministry of Justice restrictions in place. The number of 'restricted' patients, who are largely detained in secure psychiatric hospitals, has risen substantially during this period. If this trend continues, there will be the need for further expansion of secure psychiatric beds in the years ahead. Factors driving the increased number of restricted patients are discussed in this paper.

What drives changes in institutionalised mental health care? A qualitative study of the perspectives of professional experts.

BACKGROUND: Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe. METHODS: In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis. RESULTS: Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail. CONCLUSIONS: Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

Detention under section 136: Why is it increasing?

There has been a significant increase in the use of section 136 of the Mental Health Act 1983 in England and Wales, particularly over the past 10 years, but the reasons for this increase remain unclear. This paper presents a history of English mental-health legislation and the current evidence relating to the use of section 136. It suggests that changing police attitudes, socio-economic factors and diminished resources amongst both the police and mental-health services may have contributed towards its increase. The strain placed on health services may have also resulted in a greater reliance on the police force as an access point to NHS care and could result in the inappropriate use of section 136. With the principle of the 'least restrictive option' at the heart of the Mental Health Act, this advocates the need for reform.

A comparison of hospital and community stay in patients who underwent compulsory admission before and after the 2007 Amendment to the Mental Health Act in Taiwan.

OBJECTIVE: The main purpose of this study was to assess the empirical findings of compulsory admission for psychiatric disorders before and after the 2007 amendment to the Mental Health Act in Taiwan. METHODS: A matched case-control study design was applied. Participants were selected using the National Health Insurance Research Database (NHIRD) in Taiwan. The control and case data were collected in 2006 and 2011, and the number of compulsory admission cases was recorded with a case-control ratio of 1:4, along with information on age (±3 years) and gender. In 2006, the number of patients recruited was 9265, including 1853 compulsorily admitted patients and 7412 voluntarily admitted patients. In 2011, the number of patients recruited was 4505, including 901 compulsorily admitted patients and 3604 voluntarily admitted patients. RESULTS: The data collected for the patients who underwent compulsory admission before and after the amended Mental Health Act included gender, diagnosis, Charlson Comorbidity Index Score (CCIS), length of stay in an acute hospital ward (days), hospital accreditation level, ownership, teaching hospital status, psychiatrist gender and age, and hospital location. Although the number of compulsory admission cases (1853 vs. 901) markedly decreased and the length of stay in an acute hospital ward (30.7 ±â€¯25.0 days vs. 39.0 ±â€¯22.6 days) increased from 2006 to 2011, the readmission rate was reduced from 52.6% in 2006 to 42.5% in 2011. CONCLUSIONS: The average lengths of hospital stay and community survival time were greater for compulsorily admitted patients than those for voluntarily admitted patients. This result might be attributed to a number of changes implemented since the 2007 amendment of the Mental Health Act, including a strict review process for compulsory admissions and a new discharge planning process, which require further research for approval.

[Healthcare research in forensic commitment or poking around in the dark : Consensus paper on the necessity for more uniform and better data]. / Versorgungsforschung im Maßregelvollzug oder das Stochern im Nebel : Konsenspapier zur Notwendigkeit einheitlicher und besserer Daten.

Complex trends in occupancy determined by many influencing factors, clear state-specific differences in imprisonment practices as well as recently implemented statutory alterations to the appropriate paragraphs in criminal law, underline the necessity for qualitative high-grade concomitant research of German forensic commitment; however, neither the structural prerequisites nor an adequate data situation are currently present in order to do justification to this aim. Not even the total number of patients currently accommodated in forensic commitment can be elucidated from the publicized (partial) statistics. This consensus paper, which was formulated by three research institutes active at the state level, describes the limited possibilities for current forensic healthcare research and raises the demand for a nationwide uniform data situation on patients in forensic commitment. Furthermore, how the appropriate elicitation instrument should be organizationally and structurally achieved, is sketched from a scientific perspective. This article aims at initiating a discussion on a sustainable improvement in the prerequisites for healthcare research in German forensic commitment and targets a sensitization of decision makers in politics and administration for this topic.

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.

Treatment During Civil Commitment for Sexual Offending Behaviors.

The first sex offender civil commitment legislation passed in Washington State in 1990. Since that time, 21 additional jurisdictions in the USA have passed similar statutes. Although considered controversial by some, the statutes have withstood legal scrutiny at the state and federal levels. These statutes have been found constitutional in large part because they offer treatment to those individuals detained under them. In the 25 years since sex offender civil commitment became a reality, significant advances in sex offender assessment and treatment have shaped the landscape of the associated treatment programs. This article reviews current practice in programs that treat individuals detained under these laws and provides a framework in which these programs are delivered.

The changing purpose of mental health law: From medicalism to legalism to new legalism.

The role of law in regulating mental health detention has come to engender great contention in the legal and sociological disciplines alike. This conflict is multifaceted but is centred upon the extent to which law should control the psychiatric power of detention. In this manner the evolution of law regulating mental health detention has been seen in terms of a pendulous movement between two extremes of medicalism and legalism. Drawing on socio-legal literature, legislation, international treaties and case law this article examines the changing purpose of mental health law from an English and Council of Europe perspective by utilizing the concepts of medicalism, legalism and new legalism as descriptive devices before arguing that the UN Convention on the Rights of Persons with Disabilities goes further than all of these concepts and has the potential to influence mental health laws internationally.

Assessing Insanity Acquittee Recidivism in Connecticut.

For over 30 years now the movement and status of insanity acquittees in Connecticut has been supervised by the Psychiatric Security Review Board (PSRB). During this time, 365 acquittees have been committed to the jurisdiction of the PSRB, 177 individuals have achieved conditional release (CR) and 215 acquittees have been discharged from PSRB jurisdiction. This article examines revocation of CR by the PSRB, arrests of acquittees on CR, and provides the first report of arrests following discharge from the PSRB's jurisdiction. The literature on relevant aspects of recidivism is reviewed and compared with findings in Connecticut. There is little available literature about recidivism of insanity acquittees following release from supervision. In the present sample of individuals discharged from the PSRB, 16% were rearrested, a rate that compares favorably with other discharged populations of offenders. For discharged acquittees, community supervision on CR prior to discharge from the PSRB had a statistically significant effect on decreasing the risk of subsequent rearrest, as did both the length of stay in the hospital and the duration of commitment to the PSRB. This article presents descriptive information about revocations, arrests on CR, and arrests following discharge. These data are consistent with criminal justice studies demonstrating the value of community supervision in lowering recidivism. Copyright © 2016 John Wiley & Sons, Ltd.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries.

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.