Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England.

BACKGROUND: Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. METHODS: Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. RESULTS: Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. CONCLUSIONS: We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Gravely Disabled: The Vestigial Prong of 5150 Designations.

Effective July 1, 1972, California's Lanterman-Petris-Short Act (LPS Act) set the precedent for modern mental health commitment procedures in the U.S. named after its authors, State Assemblyman Frank Lanterman and State Senators Nicholas C. Petris and Alan Short, the LPS Act sought to "end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorder"; to "provide prompt evaluation and treatment of persons with mental health disorders or impaired by chronic alcoholism"; and to "guarantee and protect public safety." Despite citing to these articles of intent, the LPS Act violates its own legislative intent through its inclusion of "gravely disabled" in its enforcement of involuntary psychiatric hold designations (also known as "5150 designations"). First, police officers are not required to make a medical diagnosis of a mental health disorder at the time of a 5150 designation; the broad scope of "gravely disabled" increases the number of persons police officers can involuntarily transport, increasing the likelihood of inappropriate and involuntary commitment of persons with mental health disorders. Second, the broad scope of "gravely disabled" produces an onslaught of 5150-designated persons (whether improperly designated or not) being sent to LPS-designated hospitals with limited resources (e.g., lack of beds and psychiatric staff); this results in patients waiting for an inordinate amount of time for a psychiatric evaluation and/or a hospital bed. Third, it is unclear whether the LPS Act sought to provide protection for the mentally ill or to provide protection from the mentally ill in its guarantee of protecting "public safety"; the inclusion of "gravely disabled" in 5150 designations indicates that the LPS Act provided the public with a duplicitous means of removing the mentally ill, impoverished, and houseless from the streets under the guise of "public safety." This Paper suggests the following to help remedy the effects of implementing the broadly defined "gravely disabled" in 5150 designations: (1) Remove "gravely disabled" from the 5150 criteria; (2) integrate the community with mental health advocacy efforts by creating outreach and education programs; and (3) implement a client-centric approach to interacting with persons with mental health disorders through restorative policing and the establishment of a restorative court.

[Coronavirus disease 2019 (COVID-19): Involuntary admission yes, involuntary treatment no]. / Coronavirus disease 2019 (COVID-19): internamiento involuntario sí, tratamiento obligatorio no.

We had the opportunity to know a judicial decision in relation to a nonagenarian COVID-19 patient, which is clarifying regarding the complex issue of involuntary admission and involuntary treatment of the elderly. The judge authorized the involuntary admission but denied the possibility of imposing medical treatment against the will of the patient. This situation invites us to review the different types of involuntary admission that our legal system provides and how involuntary medical treatment is regulated according to its purpose and the patient's ability to decide. In the field of public health, the determining element to be able to impose any sanitary measure against the will of the patient is the risk to the health of the population. In the case presented, the judge rejects the possibility of authorizing medical treatment for not contributing anything from the point of view of public health. However, it does authorize involuntary admission as it is essential to guarantee isolation.

A qualitative study of clinicians' perspectives on independent rights advice for involuntary psychiatric patients in British Columbia, Canada.

BACKGROUND: In British Columbia (BC), Canada, clinicians are responsible for giving involuntary psychiatric patients rights information upon admission. Yet an investigation by the BC Office of the Ombudsperson found that clinicians are not always fulfilling this responsibility. The Ombudsperson recommended that the provincial government fund an independent body to give rights advice to patients. METHODS: To understand how clinicians feel about this recommendation, focus groups of clinicians who may give psychiatric patients rights information (n = 81) were conducted in Vancouver, BC, to probe their attitudes toward independent rights advisors. The focus group transcripts were thematically analyzed. RESULTS: Most clinicians believe that giving rights information is within their scope of practice, although some acknowledge that it poses a conflict of interest when the patient wishes to challenge the treatment team's decisions. Participants' chief concerns about an independent rights-advice service were that (a) patients may experience a delay in receiving their rights information, (b) integrating rights advisors into the workflow would complicate an already chaotic admission process, and (c) more patients would be counselled to challenge their hospitalization, leading to an increased administrative workload for clinical staff. However, many participants believed that independent rights advisors would be a positive addition to the admission process, both allowing clinicians to focus on treatment and serving as a source of rights-related information. CONCLUSIONS: Participants were generally amenable to an independent rights-advice service, suggesting that the introduction of rights advisors need not result in an adversarial relationship between treatment team and patient, as opponents of the proposal fear. Clearly distinguishing between basic rights information and in-depth rights advice could address several of the clinicians' concerns about the role that independent rights advisors would play in the involuntary admission process. Clinicians' and other stakeholders' concerns should be considered as the province develops its rights-advice service.

Experiences of Court Clinicians Who Perform Civil Commitment Evaluations for Substance Use Disorders.

Civil commitment for substance use disorders is an increasingly used intervention to mitigate the risks associated with severe substance use. Although court clinicians play a vital role in helping courts determine whether respondents meet statutory requirements for commitment, little is known about their experiences conducting these evaluations. In this pilot study, we surveyed all court clinicians who perform evaluations for civil commitment for substance use disorders in Massachusetts, a state with one of the highest rates of such commitments nationally. Court clinicians reported that these evaluations are most frequently ordered for individuals who use heroin and other opioids, alcohol, and cannabis. They reported a recent suicide attempt or drug overdose, intentional physical harm to another, use of dangerous weapon, and driving while intoxicated as the behaviors most likely to satisfy the statutory requirement of imminent risk. At the same time, many court clinicians consider a much broader range of behaviors as constituting imminent risk, and many reported having endorsed commitment on one or more occasions in the absence of statutory criteria being satisfied. These findings underscore the need for additional research on the performance of civil commitment evaluations for substance use disorder and standards for such evaluations.

Under which conditions are changes in the treatment of people under involuntary commitment justified during the COVID-19 pandemic? An ethical evaluation of current developments in Germany.

The COVID-19 pandemic poses significant challenges in psychiatric hospitals, particularly in the context of the treatment of people under involuntary commitment. The question arises at various points in the procedure for and process of involuntary commitment whether procedural modifications or further restrictive measures are necessary to minimise the spread of COVID-19 and protect all people involved from infection. In the light of current developments in Germany, this article examines under which conditions changes in the treatment of people under involuntary commitment are ethically justified in view of the COVID-19 pandemic. Among others, we discuss ethical arguments for and against involuntary commitments with reference to COVID-19, the use of different coercive interventions, the introduction of video hearings, an increased use of video surveillance and interventions based on the German Infection Protection Act. We argue that strict hygiene concepts, the provision of sufficient personal protective equipment and frequent testing for COVID-19 should be the central strategies to ensure the best possible protection against infection. Any further restrictions of the liberty of people under involuntary commitment require a sound ethical justification based on the criteria of suitability, necessity and proportionality. A strict compliance with these criteria and the continued oversight by external and independent control mechanisms are important to prevent ethically unjustified restrictions and discrimination against people with the diagnosis of a mental disorder during the COVID-19 pandemic.

Gun-Related and Other Violent Crime After Involuntary Commitment and Short-Term Emergency Holds.

This article presents a survival analysis of long-term risk of firearm-related and other violent crime in a large sample of adults with serious mental illness in Florida, comparing those who received a gun-disqualifying civil commitment after a short-term hold, those who were evaluated for commitment but were released or hospitalized voluntarily, and a third group with no holds or commitments. Among 77,048 adults with a diagnosis of schizophrenia-spectrum disorder, bipolar disorder, or major depression, 42.7 percent were detained for psychiatric examination under Florida's Baker Act; of that detained group, 8.4 percent were involuntarily committed while the remainder were released within 72 hours or agreed to voluntary admission. Over a follow-up period averaging six to seven years, 7.5 percent of the sample were arrested for a violent offense not involving a gun, and 0.9 percent were arrested for a violent crime involving a gun. A short-term hold with or without commitment was associated with a significantly higher risk of future arrest for violent crime, although the study population had other violence risk factors unrelated to mental illness. Risk of gun-involved crime, specifically, was significantly higher in individuals following a short-term hold only, but not in those who were involuntarily committed and became ineligible to purchase or possess guns. Policy implications are discussed.

[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.

Case Law Considerations in the Use of ASPD in SVP/SDP Evaluations.

The use of antisocial personality disorder (ASPD) as a qualifying mental disorder for a sexually violent predator (SVP) or a sexually dangerous person (SDP) commitment continues to arouse controversy. Two common questions arise. Is ASPD considered a qualifying mental disorder in statutory or case law definitions? Can ASPD be the sole qualifying mental disorder? We review case law for guidance as to when ASPD may serve as a sole qualifying diagnosis in SVP/SDP evaluations. Other than the federal government and New York, all other jurisdictions with SVP/SDP commitments permit the use of ASPD as a stand-alone diagnosis when it can be linked to sexually violent behavior. ASPD is a viable qualifying disorder when the pattern of offending is atypical, severe, and can be linked to the risk for further sexual offending. ASPD is less viable as a qualifying diagnosis when it is manifested primarily by criminal behavior, the sex crimes are situational in context (e.g., substance abuse, negative peer affiliation), or the disorder cannot be linked to future sexual offending. Case law can provide guidelines, but the forensic clinician as the diagnostic expert bears the responsibility of providing a cogent and sound rationale as to why ASPD drives the risk for sexual reoffense.

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.

Incompetent to Stand Trial, Not Restorable, and Dangerous.

This article focuses on the preferred disposition for an individual charged with a serious crime against another person, adjudicated incompetent to stand trial and not restorable to competence, whose original criminal charges are dismissed without prejudice, and who is regarded by the state as dangerous to the general public. Three current models used today in California, Oregon, and Ohio are described. All three rely on modifications of various aspects of civil commitment law. We then propose a fourth model based on a modified version of the 1989 American Bar Association (ABA) Criminal Justice Mental Health Standards, in which individuals who are found incompetent to stand trial and not restorable to competence and are considered dangerous would be committed under the same special procedures governing the management and treatment of insanity acquittees.

Closed venereology wards in postwar Hamburg.

BACKGROUND: A number of research results on closed venereology facilities in the Soviet Occupation Zone (SOZ) and the German Democratic Republic (GDR) have been presented in recent years. However, little is known about similar facilities in the Western Occupation Zones (WOZ) and in the early Federal Republic of Germany (FRG). METHOD: We have researched the records of the State Archive in Hamburg. Subsequently, the analysed sources were evaluated using the historically critical method. RESULTS: Three closed venereology wards existed in Hamburg. Compulsory commitments were conducted according to a three-stage procedure. In the immediate postwar period, the wards had barred windows and the doors were locked. Everyday life in the wards was initially determined by the postwar situation - poor facilities, poor hygiene, overcrowding. In the early 1950s, the number of beds was drastically reduced. The function of the wards consisted of isolation and medical care for the compulsorily committed persons. Medical care was in accordance with professional medical standards. DISCUSSION: Closed venereology wards in Hamburg followed the tradition established during the period of the Weimar Republic. This becomes apparent both in terms of the legal framework and in terms of the structure and functions of the wards. Thus, they clearly differ from the closed venereology facilities in the SOZ and in the GDR. These facilities were established in the tradition of Soviet prophylactics institutions. The wards in Hamburg served as isolation and treatment centres, the facilities in the SOZ and in the GDR also had a disciplinary function.

Deprivation of Liberty in Care. An ECHR and CRPD Approach and its Consequences for Belgium.

This contribution examines deprivation of liberty in Belgian healthcare within the frameworks of the ECHR and CRPD. We develop and apply an ECHR-based framework to demonstrate that it is not the admissions to care facilities based on Belgium's involuntary commitment law that give rise to the unjustified deprivation of liberty, but those based on representation regimes. This can be remedied by broadening Belgium's involuntary commitment law. However, doing so would go against a CRPD-based framework, which is incompatible with the ECHR; the former opposes disability-based laws. Building on the right to legal capacity and to liberty, the scope of the CRPD's approach is uncovered. It is suggested that to reconcile the two frameworks, Belgium's involuntary commitment law should be abolished, and representation regimes should be changed to avoid (rather than to justify) deprivation of liberty. Although its desirability is open for discussion, this could solve a problem that occurs worldwide.

Your Liberty or Your Gun? A Survey of Psychiatrist Understanding of Mental Health Prohibitors.

This first-of-its-kind national survey of 485 psychiatrists in nine states and the District of Columbia (DC) finds substantial evidence of clinicians being uninformed, misinformed, and misinforming patients of their gun rights regarding involuntary commitments and voluntary inpatient admissions. A significant percentage of psychiatrists (36.9%) did not understand that an involuntary civil commitment triggered the loss of gun rights, and the majority of psychiatrists in states with prohibitors on voluntary admissions (57%) and emergency holds (56%) were unaware that patients would lose gun rights upon voluntary admission or temporary commitment. Moreover, the survey found evidence that psychiatrists may use gun rights to negotiate "voluntary" commitments with patients: 15.9% of respondents reported telling patients they could preserve their gun rights by permitting themselves to be voluntarily admitted for treatment, in lieu of being involuntarily committed. The results raise questions of whether psychiatrists obtained full informed consent for voluntary patient admissions, and suggest that some medical providers in states with voluntary admission prohibitor laws may unwittingly deprive their patients of a constitutional right. The study calls into question the fairness of state prohibitor laws as policy, and - at minimum - indicates an urgent need for psychiatrist training on their state gun laws.

An Ethicolegal Analysis of Involuntary Treatment for Opioid Use Disorders.

Supply-side interventions such as prescription drug monitoring programs, "pill mill" laws, and dispensing limits have done little to quell the burgeoning opioid crisis. An increasingly popular demand-side alternative to these measures - now adopted by 38 jurisdictions in the USA and 7 provinces in Canada - is court-mandated involuntary commitment and treatment. In Massachusetts, for example, Part I, Chapter 123, Section 35 of the state's General Laws allows physicians, spouses, relatives, and police officers to petition a court to involuntarily commit and treat a person whose alcohol or drug abuse poses a likelihood of serious harm. This paper explores the ethical underpinnings of this law as a case study for others. First, we highlight the procedural and substantive standards of Section 35 and evaluate the application of the law in practice, including the frequency with which it has been invoked and outcomes. We then use this background to inform an ethical critique of the law. Specifically, we argue that the infringement of autonomy and privacy associated with involuntary intervention under Section 35 is not currently justified on the grounds of a lack of evidenced benefits and a risk of significant of harm. Further ethical concerns also arise from a lack of standard of care provided under the Section 35 pathway. Based on this analysis, we advance four recommendations for change to mitigate these ethical shortcomings.

Perceived Benefits and Harms of Involuntary Civil Commitment for Opioid Use Disorder.

Involuntary civil commitment (ICC) to treatment for opioid use disorder (OUD) prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and "on-demand" treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way.