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.

Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth.

As hospital beds are scarce, and emergency admissions to a psychiatric ward are major life-events for children and adolescents, it is essential to have insight into the decision-making process that leads to them. To identify potentially modifiable factors, we, therefore, studied the contextual and clinical characteristics associated with the voluntary and compulsory emergency admission of minors. We used registry data (2008-2017) on 1194 outpatient emergencies involving children aged 6-18 who had been referred to the mobile psychiatric emergency service in two city areas in The Netherlands. Demographic and contextual factors were collected, as well as clinical characteristics including diagnoses, psychiatric history, Global Assessment of Functioning (GAF), and the Severity of Psychiatric Illness (SPI) scale. Logistic regression analyses were used to identify factors that predict voluntary or compulsory admission. Of 1194 consultations, 227 (19.0%) resulted in an admission, with 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) compulsorily. Independently of legal status, the following characteristics were associated with admission: severity of psychiatric symptoms, consultation outside the patient's home, and high levels of family disruption. Relative to voluntary admission, compulsory admission was associated with more severe psychiatric problems, higher suicide risk, and prior emergency compulsory admission. Two potentially modifiable factors were associated with psychiatric emergency admission: the place where patients were seen for consultation, and the presence of family problems. Psychiatric emergency admissions may be reduced if, whenever possible, minors are seen in their homes and if a system-oriented approach is used.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services.

BACKGROUND: The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES. METHODS: Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission. RESULTS: Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder. CONCLUSIONS: While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

What drives changes in institutionalised mental health care? A qualitative study of the perspectives of professional experts.

BACKGROUND: Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe. METHODS: In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis. RESULTS: Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail. CONCLUSIONS: Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

[Healthcare research in forensic commitment or poking around in the dark : Consensus paper on the necessity for more uniform and better data]. / Versorgungsforschung im Maßregelvollzug oder das Stochern im Nebel : Konsenspapier zur Notwendigkeit einheitlicher und besserer Daten.

Complex trends in occupancy determined by many influencing factors, clear state-specific differences in imprisonment practices as well as recently implemented statutory alterations to the appropriate paragraphs in criminal law, underline the necessity for qualitative high-grade concomitant research of German forensic commitment; however, neither the structural prerequisites nor an adequate data situation are currently present in order to do justification to this aim. Not even the total number of patients currently accommodated in forensic commitment can be elucidated from the publicized (partial) statistics. This consensus paper, which was formulated by three research institutes active at the state level, describes the limited possibilities for current forensic healthcare research and raises the demand for a nationwide uniform data situation on patients in forensic commitment. Furthermore, how the appropriate elicitation instrument should be organizationally and structurally achieved, is sketched from a scientific perspective. This article aims at initiating a discussion on a sustainable improvement in the prerequisites for healthcare research in German forensic commitment and targets a sensitization of decision makers in politics and administration for this topic.

Treatment During Civil Commitment for Sexual Offending Behaviors.

The first sex offender civil commitment legislation passed in Washington State in 1990. Since that time, 21 additional jurisdictions in the USA have passed similar statutes. Although considered controversial by some, the statutes have withstood legal scrutiny at the state and federal levels. These statutes have been found constitutional in large part because they offer treatment to those individuals detained under them. In the 25 years since sex offender civil commitment became a reality, significant advances in sex offender assessment and treatment have shaped the landscape of the associated treatment programs. This article reviews current practice in programs that treat individuals detained under these laws and provides a framework in which these programs are delivered.

Assessing Insanity Acquittee Recidivism in Connecticut.

For over 30 years now the movement and status of insanity acquittees in Connecticut has been supervised by the Psychiatric Security Review Board (PSRB). During this time, 365 acquittees have been committed to the jurisdiction of the PSRB, 177 individuals have achieved conditional release (CR) and 215 acquittees have been discharged from PSRB jurisdiction. This article examines revocation of CR by the PSRB, arrests of acquittees on CR, and provides the first report of arrests following discharge from the PSRB's jurisdiction. The literature on relevant aspects of recidivism is reviewed and compared with findings in Connecticut. There is little available literature about recidivism of insanity acquittees following release from supervision. In the present sample of individuals discharged from the PSRB, 16% were rearrested, a rate that compares favorably with other discharged populations of offenders. For discharged acquittees, community supervision on CR prior to discharge from the PSRB had a statistically significant effect on decreasing the risk of subsequent rearrest, as did both the length of stay in the hospital and the duration of commitment to the PSRB. This article presents descriptive information about revocations, arrests on CR, and arrests following discharge. These data are consistent with criminal justice studies demonstrating the value of community supervision in lowering recidivism. Copyright © 2016 John Wiley & Sons, Ltd.

The Consequences of Official Labels: An Examination of the Rights Lost by the Mentally Ill and Mentally Incompetent Since 1989.

This study presents a survey of state statutes which restrict the civil rights of persons with a mental illness or who have been declared mentally incompetent. Five civil rights (voting, holding public office, jury service, parenting, and marriage) are examined. The results of this study are compared with the results of studies conducted in 1989 and 1999 to determine what changes have occurred over time in the restriction of civil rights of those suffering from mental health problems. This comparison reveals that states continue to restrict the rights of the mentally ill and incompetent, and that there is a trend towards increased restriction of political rights, including the right to vote and hold public office.

Preventing Persons Affected by Serious Mental Illnesses from Obtaining Firearms: The Evolution of Law, Policy, and Practice in Massachusetts.

A history of commitment to a mental health facility disqualifies applicants for gun licenses. Identifying such a history has become increasingly complex as the locus of confinement has become more diversified and privatized. In Massachusetts, prior to 2014, the databases used to identify individuals who would be disqualified on such grounds had not contemporaneously matched the evolution of the state's mental health systems. A survey of Massachusetts police chiefs, who, as in many jurisdictions, are charged with certifying qualification, indicates that some have broadened the scope of their background checks to include the experience of their officers with respect to certain applicants. The survey identifying these patterns, conducted in 2014, preceded by one month significant legislative reforms that mandate the modification of the reporting into a centralized database commitments to all types of mental health and substance use facilities, thus allowing identification of all commitments occurring in the state. The anticipated utilization of a different database mechanism, which has parallels in several other states, potentially streamlines the background check process, but raises numerous concerns that need to be addressed in developing and using such databases.

[The number of compulsory admissions continues to rise: implications for the new Dutch law on obligatory mental health care]. / Stijgende trend in dwangtoepassing onder de Wet Bopz zet door; implicaties voor de nieuwe Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: Since the introduction of the new Dutch law on compulsory mental health care, the Bopz, there has been a marked increase in the number of compulsory admissions in mental health care in the Netherlands. When the new law underwent its third evaluation in 2002, it was decided that the law no longer reflected current views on the admission policy in mental health care. The draft on a new law on compulsory admissions to mental health care has already been published. One of the goals of the new law is to reduce the number of compulsory hospital admissions and to ensure that patients with mental health problems receive compulsory community care and outpatient care. AIM: To describe and analyse the use of compulsory admissions and community treatment orders (CTOs), and to make recommendations. METHOD: We analyse the number of CTOs and court-ordered admissions in the Netherlands between 2003 and 2013 on the basis of figures supplied by the Council for the Judiciary. RESULTS: In the period 2003-2013 the number of compulsory emergency admissions increased from 43 to 47 per 100,000 inhabitants. During the same period the number of court-ordered admissions rose from 44 per 100,000 inhabitants in 2003 to 89 per 100,000 in 2013. (These figures include CTOs.) We were unable to perform more detailed studies because of the lack of records giving, for instance, the characteristics of patients who have undergone compulsory admission. CONCLUSION: Emergency compulsory admissions, CTOs and court-ordered admissions to mental health care continued to rise in the period 2003-2013. There is an urgent need for more detailed registration of the type an duration of compulsory admissions to psychiatric care and for more research into the type of treatment that can prevent the use of coercion to mental health care.

[Compulsory admission to hospital in Tunisia: a necessary evolution]. / Hospitalisation sans consentement en Tunisie : une évolution nécessaire.

The evolution of the legislation governing compulsory admission to hospital in Tunisia is interesting for two reasons. The country's 2011 revolution notably brought about major changes to the legislative framework, from constitutional through to ordinary laws. At the same time, the current trend for globalisation is also affecting legislation: international laws, treaties and UN charters are imposed on the laws of individual countries. This article looks at how Tunisian law governing compulsory admission to hospital has had to evolve.

New Zealand's Mental Health District Inspector in historical context: "the impartial scrutiny of a citizen of standing".

The Mental Health (Compulsory Assessment and Treatment) Act 1992 (NZ) legislates for District Inspectors who ensure that mental health consumers held under the Act are aware of their legal rights. The New Zealand District Inspector role first appeared in 19th century legislation. Its historical longevity does not, however, denote that this role has been consistent since its inception. This article looks at the historical development of the District Inspector and its companion role, the Official Visitor, focusing in particular on the period 1969-1992, when the purpose and scope of the roles was part of a Mental Health Act 1969 review. This was a time of fundamental social and professional change, shifting ideas of psychiatric practice, new locations of treatment, and growing emphasis on patient/consumer rights. The sometimes heated debates surrounding the roles reflect these changing ideas. An historical analysis of the District Inspector and Official Visitor roles aids understanding of how the social and political contexts affect mental health issues; this has relevance for current mental health law.

A rising tide: the increasing age and psychiatric length of stay for individuals with mild intellectual disabilities.

BACKGROUND: It is unclear whether the substantial decline in number and duration of admissions for patients with intellectual disability (ID) have occurred uniformly over time with respect to age, gender, severity of disability, legal status and location of treatment. METHOD: A retrospective analysis of NHS (National Health Service) admissions for ID and use of NHS ID beds in England between 1998/9 and 2007/8. RESULTS: NHS admissions for ID halved from 37,736 to 18,091, and admissions with a primary diagnosis of ID to beds reduced by 71% from 21,866 to 6420. This reduction was most marked among children with the result that the average age of those admitted increased from 26 years to 36 years. Mean length of stay shortened except for mild ID where it increased from 131 days to 244 days (the median increased from 6 days to 32 days). There was an 18% reduction in the number of patients with ID who were legally detained to NHS facilities but a 170% increase in those to private facilities (from 202 to 545). CONCLUSIONS: The number of patients with ID admitted to NHS facilities, especially children, has fallen dramatically. There has been a marked shift towards legal detentions to private facilities. The most notable finding was the increased duration of admissions for those with mild ID, possibly indicating that substituting mainstream for specialist services for this group has had negative consequences.

Impact of psychiatrists' qualifications on the rate of compulsory admissions.

Despite efforts to reduce coercion in psychiatry, involuntary hospitalizations remain frequent, representing more than half of all admissions in some European regions. Since October 2006, only certified psychiatrists are authorized to require a compulsory admission to our facility, while before all physicians were, including residents. The aim of the present study is to assess the impact of this change of procedure on the proportion compulsory admissions. All medical records of patients admitted respectively 4 months before and 4 month after the implementation of the procedure were retrospectively analyzed. This search retrieved a total of 2,227 hospitalizations for 1,584 patients. The overall proportions of compulsory and voluntary admissions were 63.9 % and 36.1 % respectively. The average length of stay was 32 days (SD ± 64.4). During the study period, 25 % of patients experienced two hospitalizations or more. The most frequent patients' diagnoses were affective disorders (30 %), psychotic disorders (18.4 %) and substance abuse disorders (15.7 %). Compared with the period before October 2006, patients hospitalized from October 2006 up were less likely to be hospitalized on a compulsory basis (OR = 0.745, 95 % CI: 0.596-0.930). Factors associated with involuntary admission were young age (20 years or less), female gender, a diagnosis of psychotic disorder and being hospitalized for the first time. Our results strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions.

[A descriptive study of the procedures of psychiatric admissions at Razi hospital]. / Etude descriptive des modalités d'hospitalisation en psychiatrie á l'hôpital Razi.

BACKGROUND: The law 92-83, has established the rights of the mentally ill to respect for individual freedom and to appropriate care. However some gaps in its implementation led to the revision by Act 2004-40. AIM: To study the evolution of the number of admissions with and without consent (hospitalizations at the request of a third party and compulsory hospitalizations), between 2000 and 2009. METHODS: Retrospective study of the archives of the mental health unit of Razi hospital. The study population included inpatients under the mode of voluntary and involuntary admission either compulsory hospitalizations or at the request of a third party. RESULTS: An increase in the number of hospitalizations without the consent from 2000 to 2009 was noted. The number of compulsory hospitalizations and the one of hospitalizations at the request of a third party rose respectively from 1,048 to 1,443 and from 22 to 1,323. So the number of free hospitalizations has decreased while the number of involuntary hospitalizations has increased, leading to a constant number of total hospitalizations. The sex ratio for compulsory hospitalizations has increased from 2.04 to 5.83 while it markedly decreased for hospitalizations at the request of a third party (from 10 to 1.7).Men, unlike women, were more likely to be hospitalized compulsorily than at the request of a third party. CONCLUSION: There is a larger use of hospital admissions under constraints than free ones; is it due to a concern for the respect of law or an abuse in the deprivation of freedom for some patients?

[An increase of compulsory admissions in Belgium and the Netherlands: an epidemiological exploration ]. / Stijging van het aantal gedwongen opnames in België en Nederland: een epidemiologische analyse.

BACKGROUND: Although compulsory admission (CA) is highly relevant to society, epidemiological data for European countries are scarce and of limited reliability and comparability. In several European countries the incidence of CA seems to be increasing. AIM: To estimate the incidence and evolution of CA in Belgium and the Netherlands by pooling and analysing available epidemiological data. METHOD: We reviewed the literature systematically, paying particular attention to relevant epidemiological data (in published articles and in grey literature). All data were (re)calculated into yearly incidence rates of CA per 100,000 inhabitants. RESULTS: The incidence of CA increased by 42% in Belgium (1999-2008) and by 25% in the Netherlands (2002-2009), culminating in incidence rates of 47/100,000/y (Belgium, 2008) and 80/100.000/y (Netherlands, 2009). Between-country differences can be attributed partly to differences in the legal systems. More detailed results, regional differences, and problems with the comparison of epidemiological data on CA are discussed. CONCLUSIONS: Our data point to a significant increase of the incidence of CA in both Belgium and the Netherlands. To improve the comparability and quality of the data on CA, European countries will need to strive for greater uniformity and standardisation in the way these data are registered.

Compulsory commitment to care of substance misusers: international trends during 25 Years.

PURPOSE: The study explores international trends in law on compulsory commitment to care of substance misusers (CCC), and two subtypes - civil CCC and CCC within criminal justice legislation - as well as maximum length and amount of applications of such care. METHOD: The time period covers more than 25 years, and a total of 104 countries and territories. The study is based on available data in three times of observation (1986, 1999 and 2009). Applications of CCC in number of cases are studied on European level for the years 2002-2006. Trends are analyzed using nonparametric tests and general linear models for repeated measures. Findings are discussed from contextual analysis. RESULT: There is a trend towards decrease in the number of countries worldwide having civil CCC legislation after the millennium, while CCC under criminal law has increased since the mid-1980s, resulting in some total net decrease. The shift results in longer mean duration of CCC and an increase in the number of cases sentenced. CONCLUSION: There is a risk that the shift from civil CCC to penal CCC implies more focus on young out-acting males in compulsory treatment and that the societal responsibility for more vulnerable persons might be neglected.

[German practice of involuntary commitment at both federal and state level after introduction of the Guardianship law (1992-2009)]. / Deutsche unterbringungsrechtliche Praxis auf Bundes- und Länderebene nach Einführung des Betreuungsgesetzes (1992-2009).

BACKGROUND: Given the steady rise of psychiatric coercive measures in Germany, the question arises whether this development is significantly influenced by the corresponding legal basis or through epidemiological, socio-economic or socio-structural factors. METHODS: Based on full surveys of the Federal Ministry of Justice we examined the development and associations of 10 indicators of coercive psychiatric measures over a period of 18 years. Time trends of all indicators have been descriptively analysed. Statistical associations between time trends and between involuntary and admissions economic indicators were analysed by regression models. RESULTS: All annual involuntary commitment rates have increased, judicial ordered physical restraint measures particularly strongly (848%). The rate of judicial rejections of applied involuntary measures showed the lowest increase. On the other hand, quotas of involuntary admissions remained stable. In former East Germany, the involuntary admission rates are only a third of those in the former West Germany. Results of regression analyses indicate an excess increase of physical coercive measures in psychiatric hospitals in relation to the increase of psychiatric admissions. In former East Germany the rate of involuntary admissions at the federal state level is negatively correlated with the average gross income. DISCUSSION: The continuous increase of coercive psychiatric measures in consequence to the change in the Guardianship law suggests that this change has influenced the practice. The differences at federal and state levels, and the sharper rise in the former East Germany by lower rates in comparison to the former West Germany need an explanation, as well as the fact that the rate of involuntary admissions is associated at least in the former East Germany with economic conditions.

[Regional differences in the care and treatment of compulsory admissions in the Netherlands]. / Regionale verschillen in nazorg bij inbewaringstelling.

BACKGROUND: In the Netherlands compulsory admissions are on the increase. However, there are regional differences even when demographic factors are taken into account. AIM: To find out whether there are regional differences in the type and duration of care given to detainees. METHOD: On the basis of case-register data for Groningen, South Limburg, Utrecht and Rotterdam, we monitored the psychiatric history and aftercare that followed emergency compulsory admissions and we analysed the differences between patient groups ('old acquaintances', 'newcomers' and 'passers-by'). RESULTS: Almost 60% of patients were well known to the mental health care service and had previously received psychiatric care. 85% of the patients were still receiving care three months after admission. Even when patient and admission characteristics were taken into account, there were still regional variations in the type and length of mental health care episodes before and after compulsory admission. CONCLUSION: The continuity of health care for emergency admissions in the context of the Dutch Mental Health Act varies from region to region. It remains to be seen whether the situation will change when the new Mental Health Act comes into force.