A Study into the Operation of the Queensland Mental Health Review Tribunal.

The Queensland Mental Health Review Tribunal makes difficult decisions regarding involuntary treatment of people with mental illness, applying strict legislative criteria against a backdrop of fundamental human rights considerations. This article reports on focus group research with lawyers and advocates for people with mental illness who appear before the Queensland Mental Health Review Tribunal. Participants expressed concerns regarding the manner in which decisions are made. For example, participants said that their clients' views on the side effects of treatment do not receive adequate consideration when involuntary treatment is authorised. We review these concerns in the light of applicable legal obligations, including those arising from human rights law. We conclude that if these concerns are accurate, some adjustments to the Queensland Mental Health Review Tribunal's decision-making processes are required.

Psychiatric commitment under the criminal law in China: An empirical perspective.

This article examines the legislation and practice of compulsory treatment in China. Part I traces the Chinese history of criminal commitment law, explains the research methodology, and highlights some general empirical findings. Part II provides a comprehensive empirical analysis of compulsory treatment law in China, it covers both substantial issues such as criteria of compulsory treatment and procedural issues such as the commitment hearing, enforcement, and discharge of compulsory treatment. It also explores the compulsory treatment law from the human rights protection perspective. Our primary objective is to present the empirical findings to enable the legislative and other involved government agencies to make informed decisions about the future evolution of Chinese law in this area.

The Connecticut Experience with Sell Legislation.

Since 2004, Connecticut has had two different mechanisms for involuntary medication of defendants hospitalized for restoration of competence to stand trial. In this article, we first describe the development of these two mechanisms and compare their procedural elements. The first procedure required a hearing in criminal court, in a process parallel to the subsequent U.S. Supreme Court holding in Sell v. United States; the later procedure uses a civil mechanism in probate court and was enacted in response to the dicta in Sell regarding the preferential use of alternate mechanisms for involuntary medication orders. To compare the effectiveness and efficiency of the two mechanisms, we examined 1,455 admissions to the state's secure forensic hospital for competency restoration for the calendar years 2005 through 2011. Petitions for involuntary medication of defendants were filed in five cases in criminal court (0.3%) and in 177 cases (12.2%) in probate court. The probate mechanism resulted in a significantly shorter duration of the resolution of the competence matter. Both mechanisms were effective at restoring defendants' competency (i.e., two thirds were restored by the criminal court process, and nearly 74% were restored in the civil process).

Is consent causing confusion for clinicians? A survey of child and adolescent Mental health professional's confidence in using Parental Consent, Gillick Competence and the Mental Capacity Act.

All professionals engaged in clinical work should be competent to assess consent for the interventions they provide. This study assesses CAMHS clinicians confidence and knowledge in the various forms of consent and the number of minors admitted to mental health units in England under parental consent alone.An online questionnaire using vignettes of possible scenarios was sent to child and adolescent mental health practitioners in Tees Esk and Wear Valleys Trust. A freedom of information request was used to determine the number of young people admitted through parental consent.Thirteen of the 20 trusts contacted had no knowledge of the number of young people admitted under parental consent. A total of 93 participants completed the survey. Out of six vignettes, there were two where the majority of responses were discordant with current legal advice. Both of these vignettes considered the use of parental consent for admission to a mental health unit.This study provides further evidence to indicate that the current consent processes in CAMHS causes confusion for clinicians. There continues to be very few safeguards for children admitted under parental consent, with most trusts in England and Wales having no centralised knowledge of whether this is occurring and the numbers involved if it is.

[Involuntary detention and seclusion measures in psychiatry: Where are we now? A regional Centre-Val de Loire 2012-2017 study]. / Soins sans consentement et mesures d'isolement en psychiatrie adulte : où en est-on ? L'exemple de la région Centre-Val de Loire via le Programme de médicalisation des systèmes d'information 2012­2017.

BACKGROUND: The French legal framework in psychiatry for involuntary detention (ID) and seclusion measures was modified in 2011 and 2016, respectively. This study aimed to describe the evolution of ID and seclusion measures in the Centre-Val de Loire region (CVL France) between 2012 and 2017, using the psychiatric hospital discharge database. METHODS: A cross-sectional study was conducted, including adult patients (≥ 18 years old) from CVL hospitalized in psychiatry or included in a care program (outpatient care) between 2012 and 2017. Hospital stays for each patient were identified by an anonymized number. RESULTS: In 2017 in CVL, 13,942 patients were hospitalised for psychiatric reasons, with 2378 in ID (17%), a proportion that has remained stable since 2012. Among them, 3% were in care due to imminent danger (+ 54% since 2013, stabilisation since 2016), and 11% were hospitalized following a third party request (-13%). However, regarding location results varied from one department to the next. Seclusion measures involved 10% of full-time patients (stable), 27% of ID patients and 3% of those under voluntary care (stable). One quarter of the secluded patients were in voluntary care. Mean seclusion duration was 12 days, consecutive or not, and somewhat less for patients in voluntary care alone (10 days). CONCLUSION: The region wide ID rate and average duration of seclusion were lower than the nationwide rate (24% in full-time ID in 2015; 15 days of seclusion/patient), whereas the number of imminent danger procedures increased, as did the persistence of seclusion measures for patients in voluntary care (recommended only as a last resort and/or for ID patients). These results should lead to renewed assessment of care center practices. The French psychiatric hospital discharge database has several limitations, including lack of financial incentive and highly complex structuration. However, since 2018 new data regarding seclusion and restraint measures have been added to the existing registry, and they should facilitate more accurate analyses, particularly as concerns restraint.

Italian Law no. 219/2017: consequences on the informed consent of the psychiatric patient and on the therapeutic privilege.

1Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome.

An end to coercion: rights and decision-making in mental health care.

The United Nations Convention on the Rights of Persons with Disabilities requires a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies and the social, economic and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. Although recent mental health laws in some countries have attempted to realize a rights-based approach to decision-making by reducing coercion, implementing the Convention on the Rights of Persons with Disabilities can be challenging because it requires continuous refinement and the development of alternatives to coercion. This article reviews the impact historical trends and current mental health frameworks have had on the rights affected by the practice of involuntary treatment and describes some legal and organizational initiatives that have been undertaken to promote noncoercive services and supported decision-making. The evidence and examples presented could provide the foundation for developing a context-appropriate approach to implementing supported decision-making in mental health care.

La Convention des Nations Unies relative aux droits des personnes handicapées nécessite un changement radical pour passer d'un modèle médical du handicap à un modèle social mettant l'accent sur la levée des obstacles en matière d'égalité, créés par des attitudes, des lois, des politiques gouvernementales ainsi que l'environnement social, économique et politique. L'approche adoptée par le modèle social reconnaît que les personnes présentant un handicap mental ont le même droit de prendre des décisions et de faire des choix que les autres, notamment en matière de traitement, et ont droit à une reconnaissance égale devant la loi. Par conséquent, la prise de décision directe ou accompagnée doit être la norme et il ne doit exister aucune prise de décision substitutive. Bien que certains pays aient récemment cherché, à travers des lois sur la santé mentale, à instaurer une approche fondée sur les droits en matière de prise de décision en réduisant la coercition, la mise en œuvre de la Convention relative aux droits des personnes handicapées peut poser problème, car elle exige une amélioration continue et l'élaboration de solutions autres que la coercition. Cet article examine l'impact que les tendances historiques et les cadres actuels en matière de santé mentale ont eu sur les droits lésés par la pratique du traitement involontaire et décrit plusieurs initiatives législatives et organisationnelles qui ont été prises pour promouvoir les services non coercitifs et la prise de décision accompagnée. Les données et les exemples présentés peuvent servir de fondement à l'élaboration d'une approche adaptée au contexte pour mettre en place la prise de décision accompagnée en matière de soins de santé mentale.

La Convención de las Naciones Unidas sobre los Derechos de las Personas con Discapacidad requiere un cambio de paradigma, de un modelo médico de discapacidad a un modelo social que haga hincapié en la superación de las barreras a la igualdad creadas por las actitudes, las leyes, las políticas gubernamentales y el entorno social, económico y político. El enfoque adoptado por el modelo social reconoce que las personas con discapacidad psicosocial tienen el mismo derecho a tomar decisiones y a elegir como cualquier otra persona, especialmente en lo que se refiere al tratamiento, y tienen derecho a un reconocimiento igualitario ante la ley. Por lo tanto, la toma de decisiones directa o apoyada debería ser la norma y no debería haber un responsable sustituto de la toma de decisiones. Aunque las recientes leyes sobre salud mental de algunos países han tratado de aplicar un enfoque basado en los derechos para la adopción de decisiones mediante la reducción de la coerción, la implementación de la Convención sobre los Derechos de las Personas con Discapacidad puede ser un reto, ya que requiere un continuo perfeccionamiento y el desarrollo de alternativas a la coerción. Este artículo evalúa el impacto que las tendencias históricas y los marcos actuales de salud mental han tenido sobre los derechos afectados por la práctica del tratamiento involuntario y describe algunas iniciativas legales y organizativas que se han emprendido para promover servicios no coercitivos y apoyar la toma de decisiones. La evidencia y los ejemplos presentados podrían servir de base para desarrollar un enfoque apropiado al contexto para la implementación de la toma de decisiones apoyada en la atención de la salud mental.

The Abolition or Reform of Mental Health Law: How Should the Law Recognise and Respond to the Vulnerability of Persons with Mental Impairment?

Vulnerability theory challenges the assumption that human beings are abstract and invulnerable liberal subjects and insists that any decent and just society must create law that takes into account and tries to ameliorate human vulnerability. In this article, I explore how vulnerability might apply in the context of the debate about the future of mental health law that has arisen since the entry into force of the Convention on the Rights of Persons with Disabilities (CRPD) in 2008; namely, whether mental health law should be abolished or reformed. In doing so, this article addresses three key issues: (i) how to conceptualise vulnerability; (ii) whether persons with mental impairments really are vulnerable and in what ways; and (iii) how the law should respond to the vulnerability of persons with mental impairments post-CRPD. It describes and compares three different approaches with respect to how well they address vulnerability: the Abolition with Support, Mental Capacity with Support, and the Support Except Where There is Harm Models. It argues that the law should try to accurately capture and ameliorate the vulnerability of those who are subject to it as much as possible. It also argues that from a vulnerability perspective, the reform of mental health law may be better than its abolition and that decreasing the vulnerability of persons with mental impairment requires systemic reform, resources, and cultural change.

Opinión de los psiquiatras sobre el tratamiento ambulatorio involuntario / Psychiatrists' opinion about involuntary outpatient treatment

INTRODUCCIÓN: El tratamiento ambulatorio involuntario (TAI) es una forma de tratamiento obligatorio de carácter extrahospitalario aplicado en la comunidad, que pretende mejorar la adhesión al tratamiento de las personas con una enfermedad mental grave, sin conciencia de enfermedad, en los que el abandono terapéutico supone un riesgo alto de recaída, con aparición de conductas disruptivas y/o autoagresivas o heteroagresivas, hospitalizaciones repetidas y urgencias frecuentes. La aplicación del TAI no está exenta de polémica y, por tanto, la necesidad o no de su regulación legislativa en España es un tema controvertido desde hace varios años, que encuentra tanto defensores como detractores. OBJETIVO: Recoger la opinión de los psiquiatras clínicos y médicos internos residentes en psiquiatría acerca del tratamiento ambulatorio involuntario y su regulación legislativa. MATERIAL Y MÉTODO: Se trata de un estudio de carácter descriptivo. La población de estudio está compuesta por 42 profesionales clínicos de la salud mental (32 psiquiatras y 10 médicos internos residentes en psiquiatría), los cuales estaban ejerciendo en alguno de los dispositivos de los que se compone el Servicio de Psiquiatría del Complejo Hospitalario Universitario de Huelva al inicio del estudio (en marzo de 2018). Se realizó una encuesta personal en formato papel constituida por diez cuestiones sobre el TAI a cada uno de los miembros de la muestra. RESULTADOS: El 85,7% de los clínicos conoce la iniciativa actual de intentar llevar a cabo la regulación legislativa del TAI, estando de acuerdo con dicha regulación el 92,8% de ellos. En este sentido, un 83,3% está en contra de que estén reguladas medidas más coercitivas para el paciente psiquiátrico, como el internamiento involuntario o la incapacitación civil, y no lo esté el TAI. Por otra parte, un 78,6% de los profesionales de la salud mental cree que el TAI es beneficioso para los pacientes, mientras que un 95,2% piensa que también es beneficioso para sus familias. Por otro lado, el 78,6% de los clínicos no considera estigmatizante la aplicación del TAI a los enfermos mentales graves. CONCLUSIÓN: La gran mayoría de los clínicos ve necesaria la regulación legislativa del tratamiento ambulatorio involuntario en España, al considerarlo beneficioso para el enfermo mental grave y su familia

INTRODUCTION: Involuntary outpatient treatment (IOT) is a kind of compulsory outpatient treatment, whose aim is to improve the adherence to the treatment in people with severe mental illness and with no awareness of disease. In these cases, therapeutic abandonment involves a high risk of relapse, with appearance of disruptive and/or self-aggressive or hetero-aggressive behavior, repeated hospitalizations and frequent emergencies. The application of IOT is not an issue without contention. Therefore, the need of legislative regulation in Spain has been a controversial subject for several years, and there are both advocates and opponents. OBJECTIVE: The objective of this study is to bring together the opinion of clinical psychiatrists and resident doctors in psychiatry on the involuntary outpatient treatment and its legislative regulation. MATERIAL AND METHOD: This study is descriptive in nature. The study population consists of 42 clinical professionals in mental health (32 psychiatrists and 10 resident doctors in psychiatry). At the beginning of this study (March 2018), some of these professionals were working in the Psychiatry Department's facilities of the University Hospital Complex of Huelva. A personal survey in paper form consisting of ten questions about IOT was carried out to each member of this study. RESULTS: 85.7% of clinicians know the current initiative that tries to carry out the legislative regulation of IOT, and 92.8% of them agree to such regulation. In this sense, 83.3% of them are against the fact that more coercive measures for the psychiatric patients such as the involuntary commitment or the civil incapacitation are regulated and IOT is not. On the one hand, 78.6% of the professionals in mental health believe that IOT is beneficial for the patients. Moreover, 95.2% of them think that is beneficial for their relatives, too. On the other hand, 78.6% of clinicians do not consider that the application of IOT to mentally-ill patients is stigmatizing. CONCLUSIONS: The vast majority of clinicians think that the legislative regulation of involuntary outpatient treatment is necessary in Spain, and they think this treatment is beneficial not only for the patient but also for their family

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data.

BACKGROUND: Evidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations. METHODS: For this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137. FINDINGS: Our search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03-3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62-3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07-1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22-4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21-1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages. INTERPRETATION: BAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention. FUNDING: University College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

The legal oversight of community treatment orders: A qualitative analysis of tribunal decision-making.

Community treatment orders (CTOs) have been in place in various jurisdictions for over three decades, and yet are still a controversial aspect of mental health provision. One of the ethical concerns CTOs may engender is how difficult it can be to secure discharge from them, which in some jurisdictions can result in service users being subject to compulsion in the community indefinitely. Given the questions that can therefore be raised about the discharge process, it is important to understand the role of the mental health tribunal as a key safeguard in the management of CTOs. However, whilst a substantial body of literature exists on CTOs and on various aspects of tribunal practice in inpatient settings respectively, relatively little has been written about the role of the tribunal in the oversight of CTO discharge decisions. This article presents the results of an eight month ethnographic investigation into CTO use in England, focusing on the factors which contribute to tribunal decisions. A total of 62 participants were involved in the study, including 18 service users on CTOs, 36 mental health practitioners and 8 tribunal chairs. A combination of interviews, observations and documentary analysis are drawn upon to illustrate tribunal decision-making practice on CTOs. The key themes reported on are: the mediating influence of participant presentation and interaction in tribunals; tribunal framing and interpretation of insight and risk; and the importance of timing to tribunals, both in terms of the perceived stability of a service user's social circumstances, and the length of the CTO. The findings highlight the cumulative and interrelated effect of such factors on tribunal decision-making, and point to how tribunal judgements are heavily weighted towards upholding CTOs, with the implications that holds for individual rights.

Involuntary mental health treatment in the era of the United Nations Convention on the Rights of Persons with Disabilities.

Based on interviews with a variety of participants, Vikram Patel and colleagues advocate for philosophical and practical progress toward recognizing decision-making capacity in people with psychosocial disabilities.

Mary Todd Lincoln, Elizabeth Keckley, and America's Psychiatric Republic.

This article reveals how Elizabeth Keckley framed American citizenship as a psychiatric rather than political category. In Behind the Scenes (1868), Keckley emblematizes Mary Todd Lincoln's "scandalous" behavior to describe and critique what I call the psychiatric republic: a politico-economic paradigm that paradoxically condemns women as mad, often for expressing the very traits required of men elected to public office, while simultaneously positing feminine virtues as foundational for republican citizenship. Focusing on how notions of civic femininity were originally linked to psychiatric nosology, I show how nineteenth-century women were circumscribed temporally in a seemingly inescapable loop of diagnosis, treatment, and moral refinement. The spectacular case of Mary Todd Lincoln is an extreme example of how women were considered mentally unstable enough to merit exclusion from civic life but were also forced to perform in cure cultures that would ostensibly ready them for civic duties predicated on rational democratic subjecthood.

Demographic and clinical characteristics of patients involuntarily hospitalized in an Italian psychiatric ward: a 1-year retrospective analysis.

BACKGROUND: In Italy, psychiatric compulsory treatments are regulated by Law 180 of 13-5-1978 that establishes three criteria: 1) acute psychiatric conditions requiring urgent treatment, 2) patient's refusal of treatment, 3) inpatient treatment is necessary and cannot be postponed. AIM: To highlight demographic and clinical risk factors for involuntary treatments. METHODS: We retrospectively collected all hospitalizations in the Service of Psychiatric Diagnosis and Treatment of a northern Italian town from 1-1-2015 to 31-12-2015. We statistically compared demographic and clinical variables related to voluntarily and involuntarily admitted patients and their hospitalizations. RESULTS: We divided our sample into patients voluntarily hospitalized (PVH=236) and involuntarily (PIH=160) according to their voluntary (VH= 304) and involuntary (IH=197) hospitalizations. PIH were older than PVH and, more frequently, lived alone and were unemployed (p<0.001). "Acute worsening of psychopathology" for IH and "Suicidality" for VH were the prevalent reasons (p<0.001). IH was longer than VH (p<0.001). Among PIH, the most frequent diagnoses were "Schizophrenia and Other Psychosis" (ICD-9-CM) and "Ineffective Impulse Control + Disturbed Personal Identity" (NANDA-I) (p<0.001). During hospitalizations, PIH more often than PVH presented aggressive behavior (p<0.001). At discharge, PIH were more frequently sent to another psychiatric ward or protected facility with long-acting injectable antipsychotics (p<0.001). CONCLUSIONS: Our involuntarily admitted patients were affected by severe psychiatric disorders with social maladjustment and required complex therapeutic and rehabilitative programs to counteract aggressive behaviour, poor therapeutic compliance and prolonged hospitalizations. The assessment of patients' characteristics can help clinicians recognize who are at risk for compulsory treatment and prevent it.