Current appeal system for those detained in England and Wales under the Mental Health Act needs reform.

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their will. This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered.

[Mandatory treatment of forensic psychiatric patients in the Netherlands: costs and benefits in perspective]. / De tbs-maatregel: kosten en baten in perspectief.

BACKGROUND: So far, it is not known what costs and benefits are connected with the tbs-measure, a measure that involves a mandatory treatment programme for forensic psychiatric patients.
AIM: To explore the costs and benefits that the tbs-measure has on society, on other important stakeholders such as victims and/or next-of-kin and the forensic psychiatric patients themselves.
METHOD: We studied the relevant literature.
RESULTS: The average costs of the tbs-treatment programme are 1.5 million euros. Additional costs result from recidivism among patients after tbs-treatment. Of these, 21.2% commit another serious offence after 9 years; this recidivism rate is much lower than rates for former offenders who have not received tbs-treatment (63.8%). Other costs arise through the impact that crimes have on stake-holders. Among the benefits of the tbs-programme are a reduction in psychopathological symptoms and in risk factors and lower recommitment rates (including judicial, non-judicial, voluntary and mandatory recommitment rates). Yet another benefit is the resultant increase of protective factors.
CONCLUSION: Forensic psychiatric patients form a unique group within the mental health system in the Netherlands; these patients have multiple complex psychiatric problems and display serious criminal behavior. This group cannot easily be treated elsewhere in the existing judicial or mental health care system because these systems differ in (judicial) frameworks and have different treatment goals, and the forensic psychiatric patients have different psychiatric disorders and display more serious criminal behaviour than patients in the alternative systems. The daily costs of treatment in the tbs-system are higher that in other systems - but they are not exorbitant, given the complexity of the group. The tbs-measure therefore contributes to the safety of society.

[Between European harmonisation and the consequences of the Greek economic crisis]. / Entre l'harmonisation européenne et les conséquences de la crise grecque.

Since 1984, psychiatry in Greece has undergone a gradual and complex evolution. One of the aims of the Psychargos programme which began in 2002 is to deinstitutionalise chronic patients and to implement a system of regionalisation across the whole country. Inserting the momentum of users' and families' associations remains a major objective.

Deprivation of Liberty Safeguards in England: implementation costs.

BACKGROUND: The Deprivation of Liberty Safeguards (DoLS), introduced into the Mental Capacity Act 2005, were fully implemented on 1 April 2009 in England and Wales. The government estimated 20 000 assessments for DoLS at a cost of £600 per assessment. Aims To estimate the costs likely to be incurred with the implementation of DoLS in England. METHOD: The cost of conducting a single DoLS assessment was estimated using resource-utilisation data ascertained from 37 professionals, secretarial staff and independent mental capacity advocates involved with DoLS assessments in six diverse local DoLS offices. RESULTS: The estimated average cost of a single DoLS assessment was £1277. CONCLUSIONS: The estimated average cost of a single DoLS assessment was significantly higher than the £600 estimated by the government. However, the allocated budget, based on 20 000 estimated DoLS assessments in the first year of its implementation, is likely to be adequate because a significantly lower number of assessments (only 5200) were conducted in the first 9 months after its implementation.

[A call for immediate abolishment of the Medical Treatment and Supervision Act].

The author demonstrates that Japan's Medical Treatment and Supervision Act of 2005 is meaningless and harmful from the perspective of psychiatric treatment, and worthless in terms of enhancing public safety. He goes on to propose a step-by-step process for reforming both the practice of psychiatry in general and that branch of the justice system that deals with defendants who have psychiatric disorders. The author suggests that the cost of reforms can be offset by abolishing the law in question and reducing the number of psychiatric hospital beds, and argues that it is possible to immediately halve the number of those beds. The author emphasizes that, while it is possible to immediately abolish the law, there will be anxiety associated with the progression of reforms.

Involvement in the US criminal justice system and cost implications for persons treated for schizophrenia.

BACKGROUND: Individuals with schizophrenia may have a higher risk of encounters with the criminal justice system than the general population, but there are limited data on such encounters and their attendant costs. This study assessed the prevalence of encounters with the criminal justice system, encounter types, and the estimated cost attributable to these encounters in the one-year treatment of persons with schizophrenia. METHODS: This post-hoc analysis used data from a prospective one-year cost-effectiveness study of persons treated with antipsychotics for schizophrenia and related disorders in the United States. Criminal justice system involvement was assessed using the Schizophrenia Patients Outcome Research Team (PORT) client survey and the victimization subscale of the Lehman Quality of Life Interview (QOLI). Direct cost of criminal justice system involvement was estimated using previously reported costs per type of encounter. Patients with and without involvement were compared on baseline characteristics and direct annual health care and criminal justice system-related costs. RESULTS: Overall, 278 (46%) of 609 participants reported at least 1 criminal justice system encounter. They were more likely to be substance users and less adherent to antipsychotics compared to participants without involvement. The 2 most prevalent types of encounters were being a victim of a crime (67%) and being on parole or probation (26%). The mean annual per-patient cost of involvement was $1,429, translating to 6% of total annual direct health care costs for those with involvement (11% when excluding crime victims). CONCLUSIONS: Criminal justice system involvement appears to be prevalent and costly for persons treated for schizophrenia in the United States. Findings highlight the need to better understand the interface between the mental health and the criminal justice systems and the related costs, in personal, societal, and economic terms.

Criminal justice involvement, behavioral health service use, and costs of forensic assertive community treatment: a randomized trial.

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.

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.

Risk for suicide among medicaid beneficiaries.

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.

Cost of care of patients with personality disorders in forensic psychiatric hospitals in the Netherlands.

BACKGROUND: Ter beschikking stelling (TBS) clinics form the mainstay of forensic psychiatric services in the Netherlands. Their costs are rising, but little is known about how these costs are distributed. AIM: To determine the distribution of service costs for patients with personality disorders in TBS medium security units in the Netherlands. METHOD: Data on service use were extracted retrospectively from the case files of 55 people with personality disorder who are residents in six medium security units within two TBS centres during 2006 (De Rooyse Wissel and Pompestichting). Standard unit costs were obtained for each service, and multiplied by frequency of service use to obtain the total cost of service per patient. A modified version of the Secure Facilities Service Use Schedule was completed. RESULTS: The average daily cost of a bed in a TBS hospital in 2006 was 388 Euros (402 (SD 37) Euros in De Rooyse Wissel; 375 (SD 48) Euros in the Pompestichting). Over half of this was spent on non-treatment fixed costs (overheads). There was considerable difference between patients and between unit variations in the other costs, but about one-third went on costs of staying in department (sociotherapists), and less than 10% each on specific therapeutic interventions or daily activities. About 3% of the budget overall was spent on other costs, but, as these included escorted leaves, at times these costs accounted for a much higher proportion of the per patient expenditure. CONCLUSION: Our results may provide a baseline measurement, with which future costs of TBS treatment can be compared as the services expand and develop. More attention to costs in this way may help to contain budget increases. New studies could examine more specific aspects of treatment or other specific patient groups.

The SM judgment and the Mental Health Act 2008.

The Mental Health Act 2008 was subject to little debate. This Act ensured that the detentions of involuntary psychiatric patients under the Mental Health Act 2001 remained lawful. The direct costs of administering the Act are estimated at Euro 993,377, which could have provided 37 years of supported accommodation to the patient involved.

The cost of borderline personality disorder: societal cost of illness in BPD-patients.

BACKGROUND: Borderline personality disorder (BPD) is a highly prevalent, chronic condition. Because of its very problematic nature BPD is expected to be associated with substantial societal costs, although this has never been comprehensively assessed. OBJECTIVE: Estimate the societal cost of BPD in the Netherlands. STUDY DESIGN: We used a prevalence-based bottom-up approach with a sample of 88 BPD patients who enrolled in a multicenter clinical trial comparing two kinds of outpatient psychotherapy. Costs were assessed by means of a structured interview, covering all healthcare costs, medication, informal care, productivity losses, and out-of-pocket expenses. Only BPD-related costs were included. All costs were expressed in Euros for the year 2000. A bootstrap procedure was performed to determine statistical uncertainty. PATIENTS: All patients had been diagnosed with BPD using DSM-IV criteria. Mean age was 30.5 years and 92% was female. RESULTS: Based on a prevalence of 1.1% and an adult population of 11,990,942, we derived that there were 131,900 BPD patients in the Netherlands. Total bootstrapped yearly cost of illness was 2,222,763,789 euros (1,372,412,403-3,260,248,300 euros), only 22% was healthcare-related. Costs per patient were 16,852 euros. CONCLUSIONS: Although healthcare costs of non-institutionalized Borderline patients might not be disproportionate, total societal costs are substantial.

Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care.

Importance: A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences. Objective: To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use. Design, Setting, and Participants: This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017. Exposures: On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment. Main Outcomes and Measures: The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending. Results: This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million). Conclusions and Relevance: Higher cost sharing for seriously ill and low-income patients could discourage treatment of vulnerable populations and create substantial downstream costs.

Mental health services costs within the Alberta criminal justice system.

BACKGROUND: Mental illness has been widely cited as a driver of costs in the criminal justice system. OBJECTIVE: The objective of this paper is to estimate the additional mental health service costs incurred within the criminal justice system that are incurred because of people with mental illnesses who go through the system. Our focus is on costs in Alberta. METHODS: We set up a model of the flow of all persons through the criminal justice system, including police, court, and corrections components, and for mental health diversion, review, and forensic services. We estimate the transitional probabilities and costs that accrue as persons who have been charged move through the system. Costs are estimated for the Alberta criminal justice system as a whole, and for the mental illness component. RESULTS: Public expenditures for each person diverted or charged in Alberta in the criminal justice system, including mental health costs, were $16,138. The 95% range of this estimate was from $14,530 to $19,580. Of these costs, 87% were for criminal justice services and 13% were for mental illness-related services. Hospitalization for people with mental illness who were reviewed represented the greatest additional cost associated with mental illnesses. CONCLUSION: Treatment costs stemming from mental illnesses directly add about 13% onto those in the criminal justice system.

The shift of psychiatric inpatient care from hospitals to jails and prisons.

Far-reaching structural changes have been made in the mental health system. Many severely mentally ill persons who come to the attention of law enforcement now receive their inpatient treatment in jails and prisons, at least in part, because of a dramatic reduction of psychiatric inpatient beds. While more high-quality community treatment, such as intensive case management and assertive community treatment, is needed, the authors believe that for many, 24-hour structured care is needed in the mental health system for various lengths of time to decrease criminalization. Another central theme of this article is that when a mentally ill individual is arrested, that person now has a computerized criminal record, which is easily accessed by the police and the courts in subsequent encounters. This may influence their decisions and reinforce the tendency to choose the criminal justice system over the mental health system.