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.

Does legislative change affect the use and duration of compulsory treatment orders?

OBJECTIVE: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic). METHODS: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry. RESULTS: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014. CONCLUSION: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16.

BACKGROUND: Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016. METHOD: Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year. RESULTS: Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold. CONCLUSIONS: The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

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.

Rates of voluntary and compulsory psychiatric in-patient treatment in England: an ecological study investigating associations with deprivation and demographics.

BACKGROUND: Individual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment. AIMS: To describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation. METHOD: Secondary analysis of 2010/11 data from the Mental Health Minimum Dataset. RESULTS: Areas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20-39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant. CONCLUSIONS: Age structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas.

Compulsory admissions: Possibly another dark side of the Greek economic crisis.

Α number of previous articles have dealt with the negative impact of the Greek Economic crisis on public health, including significant increases in major depression prevalence and suicide and homicide rates. The mentally ill seem to represent a vulnerable social group, with particular difficulties in this context. The number of compulsory assessments and involuntary admissions was recorded by reviewing patient records in the Department of Psychiatry of the University Hospital of Patras, through years 2006-2013. Compulsory assessments increased from 176 in 2006 to 262 in 2009 and 354 in 2013, representing a 48.86% and 101.13% increase in the first and the fifth year of economic crisis, respectively. The assessments resulted in 160 involuntary admissions in 2006, which escalated to 262 admissions (63.75% rise) in 2013. Even though a rise in involuntary placements could be attributed to other factors as well, it may also partly represent a not so evident side of the Greek economic crisis.

Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary.

We examined the patient characteristics and hospital charges associated with routine medical clearance laboratory screening tests in 1,082 children younger than age eighteen who were brought to the emergency department (ED) for involuntary mental health holds--that is, each patient was brought to the ED to be evaluated for being a danger to him- or herself or to others, for being gravely disabled (unable to meet his or her basic needs due to a mental disorder), or both--from July 2009 to December 2010. Testing was performed on 871 of the children; all patients also received a clinical examination. The median charge for blood and urine testing together was $1,235, and the most frequent ordering pattern was the full comprehensive panel of tests. Of the patients with a nonconcerning clinical examination, 94.3 percent also had clinically nonsignificant test results. When we extrapolated cost savings to the national level, omitting routine screening laboratory tests in the population of pediatric patients presenting to the ED on an involuntary psychiatric hold with nonconcerning clinical exams could represent up to $90 million in savings annually, without reducing the ability to screen for emergency medical conditions. Provider-initiated diagnostic testing instead of routine screening would lead to significantly lower charges to the ED and the patient.

[Court-ordered treatment: Analysing a complex practise through a literature review]. / Les soins pénalement ordonnés : analyse d'une pratique complexe à travers une revue de la littérature.

INTRODUCTION: In France, there are two main types of court-ordered treatment (COT) as far as mental health is concerned: obligations of treatment and injunctions of treatment. Obligations of treatment date back from 1958 whereas the law implementing injunctions of treatment is fairly recent as it was passed in 1998. Obligations and injunctions of treatment are two different types of COT that differ in terms of proceedings (obligations of treatment require no preliminary forensic psychiatric assessment; as for injunctions of treatment, they require the appointment of a coordinating medical doctor) and that are applied for different offences. However, both are psychiatric commitment procedures connecting the judicial, medical and social fields and their overall numbers have been on the rise. These common psychiatric practices have seldom been assessed and no review of the literature on the subject has ever been published. Better knowledge of such forensic practices is essential to their improvement and even to adjust the legal framework of these measures that are enjoying a boom. The purpose of this literature review is to define the prevalence of COT as well as the sociodemographic, criminal and psychiatric characteristics of those concerned by such measures. MATERIAL AND METHODS: A review of the French medical literature on COT was carried out using Science Direct up to December 2013. The results of seven studies were included and analysed. This was completed with a review of the articles listed in social sciences and law databases (Cairn and Dalloz). RESULTS: It has become increasingly frequent to rely on psychiatric teams to implement COT while at the same time public mental health services have to face a surge in activity with restricted financial means. Obligations of treatment are far more common (about 20,000 court orders a year) than injunctions of treatment (about 4000 measures are currently being enforced). However the latter have showed an increase of 506% over the 2000 decade. Both measures mainly concern men (83-99%) who are rather low on the social scale. In about half of these men, no mental disorder was found, however the prevalence of personality disorders ranged from 22 to 65% while that of psychotic disorders was low. Injunctions of treatment concerned sex offenders (90% of cases) whereas obligations of treatment concern non-sexual abusers (40-70%) rather than sex offenders (20-30%). DISCUSSION: Psychiatric research on COT is still thin on the ground and its methodology does not allow rigorous evaluation though the use of such measures is growing. When confronted with people who have not sought any care or treatment, healthcare professionals are at a loss. In France, training in forensic psychiatry is inadequate and specialised healthcare (particularly for sex offenders) need improving to reach the level of those found in many other European countries. The purpose of psychiatric treatment differs from that of lawmakers whose aim is to prevent recidivism. However, better treatment consistency requires setting up partnerships between justice, health and social services. To improve connections, there are various avenues of work such as, for instance, the creation of coordinating medical doctors for injunctions of treatment in France or European experiments using a multidisciplinary approach to prevent recidivism in sex offenders. The framework of such a partnership remains to be created as it is part and parcel of COT but has not been provided for in the law. Healthcare jurisdictions as defined in the 2009 French National Health Law might provide an appropriate framework for mental health and law professionals to collaborate.

Guns, Impulsive Angry Behavior, and Mental Disorders: Results from the National Comorbidity Survey Replication (NCS-R).

Analyses from the National Comorbidity Study Replication provide the first nationally representative estimates of the co-occurrence of impulsive angry behavior and possessing or carrying a gun among adults with and without certain mental disorders and demographic characteristics. The study found that a large number of individuals in the United States self-report patterns of impulsive angry behavior and also possess firearms at home (8.9%) or carry guns outside the home (1.5%). These data document associations of numerous common mental disorders and combinations of angry behavior with gun access. Because only a small proportion of persons with this risky combination have ever been involuntarily hospitalized for a mental health problem, most will not be subject to existing mental health-related legal restrictions on firearms resulting from a history of involuntary commitment. Excluding a large proportion of the general population from gun possession is also not likely to be feasible. Behavioral risk-based approaches to firearms restriction, such as expanding the definition of gun-prohibited persons to include those with violent misdemeanor convictions and multiple DUI convictions, could be a more effective public health policy to prevent gun violence in the population.

Prevalence of the hospitalisation of mentally ill offenders in the Forensic Unit of the Clinic of Psychiatry in Pristina over a three-year period and long-term strategy implications for the management of the Forensic Mental Health System Service.

BACKGROUND: As a new field in our country, forensic psychiatry needs strategies for management and rehabilitation programmes. AIM: The aim of this study was to evaluate the sociodemographic characteristics of psychiatrically diagnosed inpatients who were hospitalised in the three years from January 2009 to December 2011 and the prevalence of such diagnoses. The specific objectives of this study were to use our results to identify rehabilitation programmes for the treatment of patients and to identify the specific training needs of mental-health professionals. METHODS: In this retrospective study, we collected data about the sociodemographics and violent behaviour of all forensic inpatients who underwent court-ordered psychiatric forensic evaluation and assessment. We reviewed and studied the documented diagnoses based on the following criteria and sources: the ICD-10 criteria for mental disorders, the Structured Clinical Interview (SCID), recidivism rates, criminal data, court records and other hetero-anamnesis data. The data were analysed using a descriptive approach. RESULTS: The subjects were referred for forensic psychiatric evaluation, diagnosis and treatment either directly from prison (23.2%) or from the court (76.8%). The majority of the offenders (85.7%) were currently on trial, and charges of physically threatening others were more common than charges of domestic violence or murder. The prevalence of psychiatric diagnosis was 94.6%, and the most common diagnosis was psychosis (69.1%). Drug abuse and personality disorders, including high-risk behaviours, were also common. The overall relapse rate for aggressive behaviour was 48.9%. CONCLUSION: Rehabilitation programmes for treatment and management are needed that specifically focus on psychotic disorders, severe personality disorders and drug abuse.

Decarceration of U.S. jails and prisons: where will persons with serious mental illness go?

Decarceration (decreasing the number of persons incarcerated in U.S. jails and prisons) has begun. It is estimated that more than 350,000 persons with serious mental illness (SMI) are among those incarcerated in the United States and that many thousands of them will probably be among those released. Currently, the prison population in general is being reduced as a consequence of concerns about overcrowding and of policies and programs such as reclassification of drug possession, which would affect many persons with mental illness. Court-ordered diversion and changes in sentencing guidelines are also serving to reduce prison populations. In recent years, the mental health system did not have to manage as large a number of persons with SMI, especially those who were among the most difficult and expensive to treat, because many of them were incarcerated in jails and prisons. Now, with decarceration and the release of many such persons, the mental health system may be expected to assume more responsibility for them and should be prepared and funded to meet their needs. This population of persons with SMI needs structure and treatment that, depending upon their individual needs, may include 24-hour supportive housing, ACT and FACT teams, assisted outpatient treatment, psychiatric medication, and psychiatric hospitalization.

[Compulsory hospitalizations, which cantonal law does apply? The situation in west Switzerland]. / Placement à des fins d'assistance, quelles dispositions appliquer? La situation en Suisse romande.

The Swiss cantons authorize doctors to order compulsory hospitalization for a maximal duration of four to six week. The examination of cantonal proceedings highlights new exceptions to medical confidentiality in respect of the protection authority. The Civil Code (Art. 442) specifies which cantonal laws do apply when the patient lives in another canton. In urgent cases, doctors may order a hospitalization according to their cantonal law or according to the cantonal law of the patient's residence. However, only Berne and Fribourg allow all doctors in Switzerland to hospitalize their residents. If possible the decision should be made according to the law of the canton, where the patient will be hospitalized.

Is the effect of compulsory community treatment on preventable deaths from physical disorders mediated by better access to specialized medical procedures?

OBJECTIVES: Compulsory community treatment has been shown to reduce preventable deaths from physical disorders-these causes being up to 10 times more common than suicide in psychiatric patients. We investigated whether this was mediated by better access to specialized medical procedures. METHOD: All patients on compulsory community treatment for over 11 years were compared with matched control subjects using linked administrative health data from Western Australia (state population of about 2.24 million). Outcomes were access to revascularization and other specialized procedures at 1-, 2-, and 3-year follow-up. Logistic regression was used to adjust for demographics, prior health service use, diagnosis, and length of psychiatric history. RESULTS: There were 2757 patients and 2687 control subjects (total n = 5444). Sixty-five per cent were males (n = 3522), and the average age was 36 years (SD 13.2). Most had schizophrenia or other nonaffective psychoses (74%), followed by affective disorders (26%). At 2-year follow-up, 2% (n = 53) of patients and 2.6% (n = 69) of control subjects had undergone a specialized intervention. Compulsory community treatment did not result in greater access to specialized procedures at all 3 time points even after adjusting for potential confounders. CONCLUSIONS: Greater access to specialized procedures does not explain the reduced mortality from preventable physical illness that had been reported in patients on community treatment orders. There must be other explanations for this finding, such as mental health staff facilitating access to chronic disease management in primary care. This warrants further research.

Objectifs : Le traitement obligatoire en milieu communautaire s'est révélé réduire les décès évitables de maladies physiques, lesquels étant jusqu'à 10 fois plus fréquents que le suicide chez les patients psychiatriques. Nous avons recherché si cela était favorisé par un meilleur accès aux procédures médicales spécialisées. Méthode : Tous les patients soumis à un traitement obligatoire en milieu communautaire pendant plus de 11 ans ont été comparés avec des sujets témoins appariés à l'aide des données conjointes de santé et administratives d'Australie-Occidentale (population de quelque 2,24 millions). Les résultats étaient l'accès à la revascularisation et à d'autres procédures spécialisées aux suivis de 1, 2 et 3 ans. La régression logistique a servi à ajuster les données démographiques, l'utilisation précédente des services de santé, le diagnostic, et la durée des antécédents psychiatriques. Résultats : Il y avait 2 757 patients et 2 687sujets témoins (total n = 5 444). Soixante-cinq pour cent étaient des hommes (n = 3 522) et l'âge moyen était de 36 ans (ET 13,2). La plupart souffraient de schizophrénie ou d'autres psychoses non affectives (74 %), suivies de troubles affectifs (26 %). Au suivi de 2 ans, 2 % (n = 53) des patients et 2,6 % (n = 69) des sujets témoins avaient subi une intervention spécialisée. Le traitement obligatoire en milieu communautaire n'a pas donné un meilleur accès aux procédures spécialisées à tous les 3 points chronologiques, même après ajustement pour des facteurs de confusion éventuels. Conclusions : L'accès accru aux procédures spécialisées n'explique pas la mortalité réduite des maladies physiques évitables qui avait été rapportée chez des patients soumis à un traitement obligatoire en milieu communautaire. Il doit y avoir une autre explication pour ce résultat, comme le personnel de la santé mentale qui facilite l'accès au traitement des maladies chroniques dans les soins de première ligne. Cela justifie plus de recherche.

Decisions to initiate involuntary commitment: the role of intensive community services and other factors.

OBJECTIVE: This study examined the predictors of actions to initiate involuntary commitment of individuals experiencing a mental health crisis. METHODS: Emergency services clinicians throughout Virginia completed a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis. Over a one-month period in 2007, a total of 2,624 adults were evaluated. Logistic hierarchical multiple regression was used to analyze the relationship between demographic, clinical, and service-related variables and outcomes of the emergency evaluations. RESULTS: Several factors predicted 84% of the actions taken to initiate involuntary commitment. These included unavailability of alternatives to hospitalization, such as temporary housing or residential crisis stabilization; evaluation of the client in a hospital emergency room or police station or while in police custody; current enrollment in treatment; and clinical factors related to the commitment criteria, including risk of self-harm or harm to others, acuity and severity of the crisis, and current drug abuse or dependence. CONCLUSIONS: A lack of intensive community-based treatment and support in lieu of hospitalization accounted for a significant portion of variance in actions to initiate involuntary commitment. Comprehensive community services and supports for individuals experiencing mental health crises may reduce the rate of involuntary hospitalization. There is a need to enrich intensive community mental health services and supports and to evaluate the impact of these enhancements on the frequency of involuntary mental health interventions.

[Persons held in preventive detention (§ 66 Criminal Code): characteristics of offenders and the impact on prospects for successful completion of therapy]. / Sicherungsverwahrte (§ 66 StGB): Merkmale der Täter und ihre Bedeutung für die Erfolgsaussichten eines therapeutischen Vollzugs.

With its verdict in May 2011 the German Federal Constitutional Court declared the current law for preventive detention unconstitutional and obliged the legislative bodies to undertake a freedom- and treatment-oriented reform. Psychiatrists and psychotherapists are bound to provide therapeutic concepts. Currently there is a lack of information on the intended clientele. In our study we examined 26 persons serving preventive detention, 32 regular prisoners and 29 non-delinquent probands. The groups were matched according to age and intelligence. We gathered sociodemographic data, criminal records and conducted the tests SCID I, SCID II und PCL-R, K-FAF and BIS-11 to obtain diagnoses and characteristics. Based on this information, the HCR-20 and GAF were performed. In comparison to regular prisoners and non-delinquents, the group of those serving preventive detention is characterised by medium to advanced age, antisociality, psychopathy, substance abuse or addiction, aggressivity, a strong criminal record, years of imprisonment, insufficient educational and vocational training and a high risk of recidivism. In our examination of persons serving preventive detention, we demonstrate that this clientele is a group of recidivists difficult to treat. The current laws and a lack of early intervention programs have prevented and delayed their timely and possibly successful treatment. From a psychiatric point of view, there is a strong need for new therapeutic concepts to meet this challenge.