Involuntary psychiatric hospitalisation - differences and similarities between patients detained under the mental health act and according to the legal guardianship legislation.

BACKGROUND: Involuntary psychiatric hospitalisation occurs under different legal premises. According to German law, detention under the Mental Health Act (MHA) is possible in cases of imminent danger of self-harm or harm to others, while detention according to the legal guardianship legislation (LGL) serves to prevent self-harm if there is considerable but not necessarily imminent danger. This study aims to compare clinical, sociodemographic and environmental socioeconomic differences and similarities between patients hospitalised under either the MHA or LGL. METHODS: We conducted a retrospective health records analysis of all involuntarily hospitalised cases in the four psychiatric hospitals of the city of Cologne, Germany, in 2011. Of the 1,773 cases, 87.3% were detained under the MHA of the federal state of North Rhine-Westphalia and 6.4% were hospitalised according to the federal LGL. Another 6.3% of the cases were originally admitted under the MHA, but the legal basis of detention was converted to LGL during the inpatient psychiatric stay (MHA→LGL cases). We compared sociodemographic, clinical, systemic and environmental socioeconomic (ESED) variables of the three groups by means of descriptive statistics. We also trained and tested a machine learning-based algorithm to predict class membership of the involuntary modes of psychiatric inpatient care. RESULTS: Cases with an admission under the premises of LGL lived less often on their own, and they were more often retired compared to MHA cases. They more often had received previous outpatient or inpatient treatment than MHA cases, they were more often diagnosed with a psychotic disorder and they lived in neighbourhoods that were on average more socially advantaged. MHA→LGL cases were on average older and more often retired than MHA cases. More often, they had a main diagnosis of an organic mental disorder compared to both MHA and LGL cases. Also, they less often received previous psychiatric inpatient treatment compared to LGL cases. The reason for detention (self-harm or harm to others) did not differ between the three groups. The proportion of LGL and MHA cases differed between the four hospitals. Effect sizes were mostly small and the balanced accuracy of the Random Forest was low. CONCLUSION: We found some plausible differences in patient characteristics depending on the legal foundation of the involuntary psychiatric hospitalisation. The differences relate to clinical, sociodemographic and socioeconomical issues. However, the low effect sizes and the limited accuracy of the machine learning models indicate that the investigated variables do not sufficiently explain the respective choice of the legal framework. In addition, we found some indication for possibly different interpretation and handling of the premises of the law in practice. Our findings pose the need for further research in this field.

[Coercive Medication: Who, how, how Long? A Retrospective Chart Analysis in 6 Hospital Sites in Baden-Wuerttemberg]. / Ärztliche Zwangsbehandlung: Wer, wie, wie lange? Eine retrospektive Fallanalyse an sechs Klinikstandorten in Baden-Württemberg.

BACKGROUND: Evaluation of the practice of coercive treatment in Germany after the Constiutional Court's decision in 2011. METHODS: The documented emergency treatments (N=86) and judicially approved compulsory treatments (N=62) in 2015 and 2016 at 6 hospital locations in Baden-Württemberg were retrospectively analysed. RESULTS: Patients had an average of 8 previous psychiatric hospitalisations with a cumulative duration of 645 days on average and 87% had a psychotic disorder. 34% received subsequent compulsory treatment within one year. The median duration of compulsory treatment was 15 days. 92% of the patients were taking an antipsychotic at discharge, 45% received further treatment in a day hospital or a psychiatric outpatient clinic. CONCLUSION: Coercive treatment affects a relatively small, chronically severely ill group of patients and is frequently recurrent among them. For considerable part, no consecutive treatment setting can be established after discharge.

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.

The Early Impact of the COVID-19 Pandemic on Acute Care Mental Health Services.

OBJECTIVE: This study aimed to explore the effects of COVID-19 and the lockdown measures adopted in England on patients with acute mental illness. METHODS: The authors analyzed referrals to the crisis resolution and home treatment (CRHT) team and inpatient admissions to acute adult wards, at Leicestershire Partnership National Health Service Trust, an integrated community and mental health trust in the United Kingdom. Number of CRHT referrals and inpatient admissions during a 4-week period starting March 16, 2020 ("COVID-19 period"), was studied and compared with the same period in 2018 and 2019 ("control periods"). Demographic and clinical characteristics of patients admitted during the COVID-19 period were compared with those admitted during the 2019 control period. RESULTS: The number of CRHT referrals and inpatient admissions were lower during the COVID-19 period, compared with the control periods, by approximately 12% and 20%, respectively. Patients admitted during the COVID-19 period were significantly more often detained under the Mental Health Act and were considered to pose a risk of aggression. The pattern of diagnoses differed significantly between 2020 and 2019. A higher percentage of patients admitted during the COVID-19 period were diagnosed as having nonaffective psychotic disorders (52% versus 35%) or bipolar disorder (25% versus 15%), and fewer received a diagnosis of depression (8% versus 16%), anxiety disorder (0% versus 3%), adjustment disorder (0% versus 8%), emotionally unstable personality disorder (6% versus 15%), or any other personality disorder (0% versus 5%) (p=0.01). CONCLUSIONS: These findings suggest that the pandemic has profoundly affected care by acute mental health services.

Older adults on involuntary hold status in the emergency department.

BACKGROUND: As the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED. METHODS: This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality. RESULTS: Of 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P ≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P = .04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS. CONCLUSIONS: Involuntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care.

OBJECTIVE: Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients. METHODS: Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables. RESULTS: Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001). DISCUSSION: These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

Analysis of involuntary admissions in Korea through the admission management information system.

The Mental Health Promotion and Welfare Act, revised in 2016, tightened the involuntary admission regulations and processes, such as reporting involuntary admission within 3 days of admission, secondary diagnosis within 2 weeks, and admission suitability evaluation within 1 month, to improve the human rights of the mentally handicapped. The Admission Management Information System (AMIS) was also developed in 2017 to support these procedures and manage patients who were involuntarily admitted to the hospital. We analyzed 34,685 cases of involuntary admission registered in the AMIS between July 2017 and June 2018. The general characteristics, diagnosis, admission hospital, admission type, age, and admission duration were examined, and diagnoses and the length of stay per hospital were analyzed. Among the research subjects, 62.8% were male and 37.2% were female. A total of 70.8% had medical insurance and 28.5% had medical aid. A total of 67.8% of patients received secondary diagnosis by a psychiatrist who worked for a public or designated institution, 24.6% received secondary diagnosis by a psychiatrist who worked for the same institution as the primary psychiatrist, and 8.4% received primary diagnosis by a psychiatrist who admitted the patient. For diagnosis, F2 code was the most common at 38.1%, followed by F1 code at 29.1% and F3 code at 17.9%. For cases with only a primary diagnosis, F1 code diagnosis was the most common at 37.6%. For types of hospitalization, and admission by legal guardians was the most common at 93.2%, while administrative admission was at 6.7% and admission by legal guardians to a long-term care facility was at 0.1%. The average length of hospitalization duration was 74.4 days. A stay between 31 and 90 days was the most common (39.3%), and hospital stay of <14 days was at 16.6%. The number of involuntary admissions for every 100,000 people was 67 cases on average, and this number was the highest in the South Gyeongsang Province, at 105.8 cases. Length of stay by diagnosis was the longest for F7 code (118 days), followed by F1code (91 days). Patients older than 60 years constituted 31.7% of the total sample, and those younger than 20 years showed the highest proportion in patients with diagnoses from F4 to F9 code. Analyzing the involuntary admissions registered on the AMIS for 1 year revealed various information, such as the type of admission, sex, age, diagnosis, region, and admitted hospital. These results could be used to improve involuntary admission policies and mental health systems.

Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis.

AIMS: Voluntary admission rates of schizophrenia vary widely across studies. In order to make the topic be informed by evidence, it is important to have accurate estimates. This meta-analysis examined the worldwide prevalence of voluntary admissions for patients with schizophrenia. METHOD: PubMed, EMBASE, PsycINFO, the Cochrane Library, Web of Science and Medline databases were systematically searched, from their commencement date until 19th November 2018. Meta-analysis of included studies was performed using the random-effects model. RESULTS: Thirty-five studies with 134,100 schizophrenia patients were included. The overall voluntary admission rate of schizophrenia was 61.9 % (95 %CI: 52.3 %-70.7 %), while the involuntary rate was 43.0 % (95 %CI: 34.8 %-51.7 %). Subgroup analyses revealed that patients in Europe had significantly higher voluntary admission rates, while their North American counterparts were more likely admitted involuntarily. Papers published prior to 2008 reported higher involuntary admission rates. Meta-regression analyses showed that higher male percentage and higher study quality were significantly associated with higher voluntary admission rate. CONCLUSION: Although the worldwide prevalence of voluntary admissions was higher than that of involuntary admissions, the latter was common for schizophrenia. With the continuing liberalization of mental health laws broadening community-based psychiatric services, the rate of voluntary psychiatric admissions is expected to further increase over time.

Voluntary and Involuntary Admissions for Severe Mental Illness in China: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to examine the prevalence of voluntary and involuntary psychiatric admissions for severe mental illness in China and explore their associated factors. METHODS: The PubMed, Cochrane Library, PsycINFO, EMBASE, CNKI, CQVIP, and WanFang databases were systematically searched for the span since their inception to October 2018. Meta-analyses were conducted with the random-effects model. RESULTS: Fourteen studies with 94,305 patients were included in the analyses. The voluntary and involuntary admission rates were 30.3% (95% confidence interval [CI]=18.06% to 46.23%) and 32.3% (95% CI=10.39% to 66.21%), respectively, for severe mental illness and 19.6% (95% CI=14.09% to 26.54%) and 44.3% (95% CI=5.98% to 90.88%), respectively, for schizophrenia. Meta-regression analyses found an increase in the voluntary admission rate between 1998 and 2018. CONCLUSIONS: The voluntary admission rate for severe mental illness has increased in China, whereas the involuntary admission rate has remained high, particularly for schizophrenia. Concerted efforts should be made to further decrease the rate of involuntary admissions.

Psychiatric inpatients subjected to physical restraint have a higher risk of deep vein thrombosis and aspiration pneumonia.

Physical restraint in clinical settings can lead to potentially lethal complications. Although this is a life-and-death issue, no comprehensive large-scale study relating medical complications to physical restraint has yet been performed. The 1308 psychiatric inpatients in our retrospective cohort study were categorized into two groups: a physical restraint group (those who had been subjected to physical restraint while hospitalized; n = 110) and a non-physical restraint group (those never subjected to physical restraint; n = 1198). We assessed differences between the two groups with respect to the occurrence of medical complications subsequent to restraint. To control for potentially confounding factors, linear discriminant regression analysis was used to identify whether physical restraint itself affected the occurrence of medical complications. The physical restraint group had a higher risk for deep vein thrombosis (P < .01, OR = 6.0, 95%CI: 2.4-13.9) and aspiration pneumonia (P < .01, OR = 4.1, 95%CI: 2.1-7.6) when compared with the non-physical restraint group. Even after controlling for potentially confounding factors, physical restraint substantially raised the risk of deep vein thrombosis and aspiration pneumonia (P < .01, P = .01, respectively). Although this study population was derived from a single psychiatric unit, physical restraint may lead to serious medical conditions. To avoid this unwanted consequence, the use of physical restraint should be minimized and physical therapy is highly recommended.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study.

BACKGROUND: Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France. METHODS: A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis. SETTING: Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews. PARTICIPANTS: 400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French. INTERVENTIONS: The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care. MAIN OUTCOMES AND MEASURES: The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs. DISCUSSION: Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Repeated Police Mental Health Act Detentions in England and Wales: Trauma and Recurrent Suicidality.

Most police Mental Health Act (Section 136) detentions in England and Wales relate to suicide prevention. Despite attempts to reduce detention rates, numbers have risen almost continually. Although Section 136 has been subject to much academic and public policy scrutiny, the topic of individuals being detained on multiple occasions remains under-researched and thus poorly understood. A mixed methods study combined six in-depth interviews with people who had experienced numerous suicidal crises and police intervention, with detailed police and mental health records. A national police survey provided wider context. Consultants with lived experience of complex mental health problems jointly analysed interviews. Repeated detention is a nationally recognised issue. In South East England, it almost exclusively relates to suicide or self-harm and accounts for a third of all detentions. Females are detained with the highest frequencies. The qualitative accounts revealed complex histories of unresolved trauma that had catastrophically damaged interviewee's relational foundations, rendering them disenfranchised from services and consigned to relying on police intervention in repeated suicidal crises. A model is proposed that offers a way to conceptualise the phenomenon of repeated detention, highlighting that long-term solutions to sustain change are imperative, as reactive-only responses can perpetuate crisis cycles.

Age, psychiatry admission status and linear mental capacity for treatment decisions.

The relationship between age and mental capacity among psychiatry inpatients is not fully understood. We aimed to assess mental capacity for treatment decisions in voluntary and involuntary psychiatry inpatients in Ireland and, in this analysis of our data-set, to elucidate the linear relationship, if any, between linear (as opposed to categorical) mental capacity and age. We used the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to assess mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland. Mean age was 46.2 years and majorities were male (58.1%), never married (74.0%), unemployed (64.2%) and of Irish ethnicity (87.0%). The most common primary diagnoses were schizophrenia and related disorders (42.8%) followed by affective disorders (36.7%). On multi-variable linear regression analysis, linear mental capacity was significantly associated with voluntary admission status, being employed, having a primary diagnosis other than schizophrenia or a related disorder, and younger age. Together, these factors accounted for 44.4% of the variance in mental capacity between participants. Overall, while increased age is associated with diminished mental capacity, other factors appear more significant, including involuntary admission status which is likely an indicator of symptom severity. There is a need for further research to (a) elucidate the relationships between the significant factors identified in this study and the cognitive status of patients (which impacts on assessments of mental capacity); (b) identify and elucidate other factors of likely relevance to mental capacity (e.g. medical illness, medication use); and (c) translate these findings into targeted interventions to support decision-making in clinical practice among psychiatry inpatients, especially those with involuntary status.

Gender, diagnosis and involuntary psychiatry admission in Ireland: A report from the Dublin Involuntary Admission Study (DIAS).

Involuntary admission and treatment are common, long-standing features of psychiatry but the relationships between gender, diagnosis and other features of involuntary treatment are not clear. We studied all voluntary and involuntary psychiatry admissions at Tallaght University Hospital, Dublin over 2 years (n = 1230). Admission rates in Tallaght were lower than national rates for all admissions (224.9 admissions per 100,000 population per year in Tallaght versus 376.8 nationally), voluntary admissions (194.0 versus 328.4) and involuntary admissions (30.9 versus 48.4). Compared to men, proportionately fewer admissions of admissions of women were involuntary (11% versus 16%) and women were more commonly diagnosed with affective (mood) disorders (29.5% of women versus 22.6% of men), neuroses (anxiety disorders) (14.0% versus 8.8%) and personality and behavioural disorders (18.0% versus 9.2%), and less commonly diagnosed with schizophrenia group disorders (21.8% versus 32.0%), alcohol disorders (2.9% versus 4.3%) and drug disorders (3.6% versus 8.1%). Schizophrenia group disorders accounted for a greater proportion of male (63.2%) than female (55.6%) involuntary admissions, and affective disorders accounted for a greater proportion of female (17.5%) than male (12.3%) involuntary admissions. Duration of admission was independently associated with, in order of strength of association, involuntary status, schizophrenia group disorders and increasing age, but duration of involuntary care was not associated with any of these factors. The chief gender-related features of involuntary psychiatry admission are that (a) proportionately fewer admissions of admissions of women are involuntary compared to men, and (b) diagnoses of affective disorders are more common in women, and schizophrenia group diagnoses more common in men. Future research could usefully explore gender differences in grounds for involuntary detention and police involvement in the involuntary admission process. Future research is also warranted into whether gender associations differ in older compared to younger involuntary patients.

Comparison of offenders in forensic-psychiatric treatment or prison in Germany.

PURPOSE: Arrangements for the management of mentally disordered offenders vary widely across countries, as do rates of imprisonment and detention in forensic-psychiatric settings of such individuals. This study aims to quantify the characteristics of offenders detained in forensic-psychiatric settings in Germany over a 15 year period from 1995 and compare these with those sentenced to imprisonment over the same period. METHODS: Using official national statistical data, the index offences, demographic characteristics and criminal histories for all individuals convicted to forensic-psychiatric detention during the study period are described together with changes over time. This group was then compared with offenders convicted to a prison sentence of at least two years in the same time period for equivalent offences. RESULTS: Relevant differences and similarities between the two treatment groups were identified. Compared to offenders in prison, those in forensic care were older, with a higher proportion of women and a lower proportion of those with foreign backgrounds. Significant previous offending and levels of diminished responsibility were present in both groups. CONCLUSIONS: These findings provide data for future comparative research and indicate potential opportunities for earlier intervention to prevent trajectories into more serious offending, particularly in young people and those with mental disorder.

Changing patterns and influencing factors of involuntary admissions following the implementation of China's mental health law: A 4-year longitudinal investigation.

Involuntary admission (IA) is limited to particular situations in mental health laws to protect patients from unnecessary coercion. China's first national mental health law has been in effect since 2013; however, the status of IA has not been sufficiently explored. To explore the changing patterns of IA since the clinical application of the IA criteria specified in the new law, an investigation of IA status was undertaken in 14 periods (each period lasting for one month from 05/2013 to 05/2017) in the tertiary specialized psychiatric hospital in Shanghai. The socio-demographic and clinical characteristics of 3733 patients were collected. The differences among IA rates in different periods were compared, and the characteristics of patients who were and were not involuntarily admitted were analysed. Multiple logistic regression analysis was used to clarify the independent variables of IA. The IA rate dramatically decreased after the implementation of the new law, while the overall trend gradually increased. The implementation of the IA risk criteria is effective, but IA is still common in China. The medical factors influencing IA following the implementation of the new law are similar to those in previous studies at home and abroad. Non-medical factors might be the main causes of the high IA rates in Chinese psychiatric institutions.

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.

The prevalence and impact of psychiatric comorbidity in inpatients admitted to a district general hospital in England: a 1-week cross-sectional study.

BACKGROUND: Mental health problems are amongst the most frequent health problems throughout life and they interfere deeply with physical wellbeing. This study investigated the prevalence and impact of psychiatric comorbidities in a general hospital in the National Health Service. METHODS: A single-centre cross-sectional study of all inpatients during a 1-week period. RESULTS: The prevalence of psychiatric comorbidity was 11.8% in 2,444 inpatients. These patients had higher inpatient mortality (8.7 vs 3.3%; p < 0.001), 30-day readmission rates (24.7 vs 9.7%; p < 0.001), length of stay (mean 16.7 vs 5 days; p < 0.001), admission numbers (mean 1.3 vs 0.6; p < 0.001) and emergency department presentations in the year prior to their index admission (mean 2.3 vs 1.1; p < 0.001). A total of 86.2% were admitted via emergency medicine, with peaks on Saturdays and Tuesdays, in the afternoon and around midnight. CONCLUSION: This detailed account of psychiatric comorbidity in a general hospital shows a significant prevalence of mental health problems and its effect in a large general hospital serving a mixed urban and rural population in the UK.

External factors influencing length of stay in forensic services - a European evaluation. / Czynniki zewnetrzne wplywajace na dlugosc pobytu w osrodkach psychiatrii sadowej ­ badanie europejskie.

OBJECTIVES: A growing number of patients whose length-of-stay in forensic services is aboveaverage length are identifiable in several European countries. Forensic services are situated within a particular sociocultural setting. Accordingly, this trend to increased admission length cannot be solely attributed to patient characteristics. This is the first known study exploring the influence of external factors on length-of-stay in forensic services. METHODS: Representatives from 16 European countries, members of the international COST project, focused on forensic psychiatric service, analyzed their respective forensic services using a structured tool. Responses were combined and analyzed using thematic analysis. RESULTS: Four themes described the factors influencing length-of-stay: care and treatment pathways; resources; legal and systemic impact; and sharing expertise. CONCLUSIONS: Findings suggest multidisciplinary consideration of the whole care pathway is required to address increased length-of-stay. Further research is required to support development of evidence-based standards applicable across Europe, and improve outcomes for patients at risk of increased length-of-stay in forensic services.

Patients Threatening Harm to Others Evaluated in the Emergency Department under the Florida Involuntary Hold Act (Baker Act).

OBJECTIVES: This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems. METHODS: This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected. RESULTS: We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED. CONCLUSIONS: We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.