[Characteristics of patients who received an indication of involuntary admission, with or without the involvement of a third party, in a Parisian psychiatric emergency unit]. / Caractérisation d'une population de patients hospitalisés sous contrainte en ASPDT/u et ASPPI à partir d'un service d'urgence psychiatrique parisien.

BACKGROUND: The French mental health law, first enacted on July 5, 2011, introduced the possibility of psychiatric commitment in case of extreme urgency (imminent peril - ASPPI). The decision of involuntary admission can then be made by the hospital director based on a medical certificate, without the need of a third party request. This procedure was intended to be applied on an exceptional basis, but its use is steadily increasing against the other types of involuntary care. Our study aimed at comparing the characteristics of patients who had received an indication for involuntary admission due to imminent peril (ASPPI) or at the request of a third party (ASPDT/u) in a psychiatric emergency ward, according to sociodemographic and clinical characteristics and regarding the potential implication of a third party. METHODS: An observational study was conducted among patients from the Centre Psychiatrique d'Orientation et d'Accueil (CPOA), located at Sainte-Anne hospital in Paris, from August 1st to 31st, 2016. RESULTS: One hundred and fifty patients with an indication for involuntary commitment were included, 101 of whom for ASPDT/u (67 %) and 49 for ASPPI (33 %). For more than half of the patients from the ASPPI group, a third party had been identified with (39 %) or without (17 %) contact information. Compared to ASPDT/u patients, ASPPI individuals were more socially vulnerable, showed more negligence, and had a lower mean functioning score. The indication for ASPPI status was also associated with behavioural quirks, prior psychiatric hospitalization (especially as an ASPPI patient) and with the diagnosis of chronic psychosis instead of mood disorder. CONCLUSION: Our exploratory results help to better understand how the ASPPI procedure is used in psychiatric emergency wards six years after enactment of the law. They highlight the differences between ASPPI patients and ASPDT/u and raise ethical issues regarding involuntary psychiatric care.

[Seclusion in emergency psychiatry]. / Skjerming i akuttpsykiatrien.

BACKGROUND: In Norway, seclusion (also called «shielding¼ or «open-area seclusion¼) is often used as an intervention in inpatient psychiatric wards as a continuation of milieu therapy, but the method remains controversial in health policy. A psychiatrist or occasionally a psychologist is responsible for making a decision on seclusion pursuant to Section 4-3 of the Mental Health Care Act. Because of the uncertainty regarding the content and academic legitimacy of this model, we have undertaken a review of available literature on the justification, practical application and effect of the Norwegian tradition of seclusion. MATERIAL AND METHOD: The article is based on systematic searches in national and international databases for the years 1930-2013. RESULTS: The seclusion method is closely associated with the development of psychiatric institutions, especially the establishment of emergency units and milieu therapy. The concept of seclusion covers a variety of approaches, and its knowledge base is generally poor. Clinical treatment studies are largely of older origin and most likely not descriptive of current practices. The absence of efficacy studies means that as of today, we have little knowledge on the benefits of using seclusion as treatment. INTERPRETATION: We detected a major discrepancy between the clinical ubiquity of the seclusion method and its knowledge basis. There is a clear need for more research on various types of seclusion to be able to assess the effects of seclusion in current practice.

[Decision of emergency involuntary hospitalization: categorical or dimensional approach?]. / La décision d'hospitalisation sans consentement aux urgences: approche dimensionnelle ou catégorielle?

BACKGROUND: In 2005, in its recommendations on the modalities of decision making for compulsory hospitalization, the French Health High Authority (HAS) had already stressed the need for rapid implementation of studies and epidemiological analyses on the subject to compensate the lack of adequate data in France. The new French law of July 5, 2011, on the rights and protection of persons under psychiatric care, establishes a judicial review of decisions for compulsory hospitalization. Therefore, healthcare professionals need to better define and characterize the criteria for such decisions, especially in their relation to psychopathology. The concept of capacity to consent to treatment includes the ability to understand (to receive information about the disease), the ability to appreciate (to weigh the risks and benefits of treatment), the ability to reason (determining the best choice rationally) and the ability to freely express a decision. However, assessment tools of capacity to consent to treatment seem to fail to predict the modality of hospitalization. OBJECTIVE: This study examined the impact of clinical and contextual characteristics on the decision in emergency services to admit patients to compulsory inpatient psychiatric units. METHOD: Data was collected from 442 successive patients admitted to hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent course of care, clinical diagnosis, Global Assessment of Functioning scale (GAF) and Insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the HAS for the severity of mental disorders and the necessity of emergency care. RESULTS: Multivariable logistic regression shows that diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being married as well as being referred by a doctor or family are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for compulsory admission. CONCLUSION: Our study shows a dimensional rather than categorical assessment of patients by clinicians. Assessment of insight is the main operational criterion used by clinicians in our study. This supports using insight and GAF evaluation in clinical practice to clarify assessment and decision-making in an emergency setting regarding compulsory hospitalization.

[The imminent peril in the law of July the fifth 2011, two years later: the impact on health?]. / Le péril imminent dans la loi du 5 juillet 2011: quelles implications sur les soins?

In 1938, the French government decided to enact a first legislation to enforce admission of the mentally ill to hospitals. Later in 1990, the law took into consideration the evolution of practices with an increase of free admissions and the right to maintain the mentally ill in cities. Three types of psychiatric hospitalization were defined: free, on third party request and for involuntary confinement. A review had theoretically to be conducted every 5 years. In practice this was not the case, probably due to the balance between individual freedom, patient care and public safety always hard to find. However, considering the imperative European harmonization and the fact the Constitutional Council declared a double unconstitutionality of the law, the Act of July 5th was enacted in a hurry during the summer 2011. The Act defines the "rights and the protection of people subject to psychiatric care and methods of coverage". In this document, we will briefly review the context of this law. We will also explore the clinical implications of the very innovative measure: the "péril imminent". We will use the admissions at the Sainte-Anne hospital in Paris in 2010 to 2012. Three major key points were introduced in the law: a judge controls an agreeable release after 15 days and 6 months of continuous hospitalization. The law let the new possibility to provide ambulatory cares under constraints, and these to make an involuntary confinement without a third party request, using the "imminent peril". This law implies the involvement of the judge and the lawyer. This one has to defend a client who needs care, he controls the formal validity of decisions concerning the patient. To provide treatment without consent in "imminent peril" to someone, conditions are requested: these mental disorders make his consent impossible and his mental state requires immediate care with immediate care of constant medical monitoring justifying a full hospitalization or regular medical monitoring for support under another form of full hospitalization (Article L.3212. 1 of the Code of Public Health). Moreover, a demand for care by a third party has also to be impossible to obtain and an imminent peril to the person's health has to exist, supported by a medical certificate from a doctor who does not belong to the patient's psychiatric hospital. The imminent peril would be an immediate danger to the health or life of the patient. What has been the impact of this law adopted in emergency at Sainte-Anne hospital? This psychiatric hospital is in charge of the population in southern Paris, where reside about 655,000 people. This work observes the evolution of the type of hospitalization and care before and after the adoption of the law. We can observe an overall increase in entries under constraints. There is a decrease in admissions for involuntary confinement for the benefit of imminent peril. This imminent peril corresponds to only a small proportion of hospitalizations without consent but are rising between 2011 and 2012, perhaps in part due to a better understanding of the law. But this progression is to monitor to ensure compliance with the restrictive conditions laid down by this law. Also note that the imminent peril may be used at the refusal of the family or entourage to make the demand for care. The number of hospitalizations at the request of a third party with two certificates is down, which is probably due to a change in status of the CPOA, emergency structure within Sainte-Anne, which is no longer seen as extraterritorial. The imminent peril has advantages: it allows access to the care of people isolated and desocialized, of people whose identity is unknown, of pathological travellers. It avoids hospitalization at the request of the representative of the State for social reasons and not for risks to the safety of persons, even when this type of hospitalization is more stigmatizing and often more difficult to remove. It protects the entourage sometimes, when the family is ambivalent or hostile to care, or has been designated as a persecutor. The imminent peril also has disadvantages. One of them is the risk of its misuse to allow rapid hospitalization without taking the time to seek a third party. The imminent danger made when there is an entourage but which refuses to request care can undermine the development work on information about the disease, the need for care and treatment and the importance of the involvement of the entourage in the care plan. The alliance with the patient may be compromised. In some cases, a decision of care by the request of the representative of the State is more appropriate than the "imminent peril". The "imminent peril" may be preferred because of the administrative burden of prefectural measures when patient presents clinical improvement and we would go up to the ambulatory care in a care program. Yet, the use of a symbolic third, carrying authority, can avoid the too direct confrontation with the patient. Do not use it can complicate the management of the patient. Finally, with desocialized patients, imminent peril can facilitate access to care, but not continuity of care. Indeed, for the care program it is necessary to have an address for the patient. Once the crisis is not to develop a plan of care. Finally in some situations of desocialized patients, the imminent peril can promote access to care but not the continuity of care as to the care program it is necessary to have an address for the patient. Once the crisis is past, it is impossible to implement a program of care. The Law of 5 July 2011 marks a change in the practice of psychiatrists. Take into account the fundamental rights of the patient and to harmonize legislation at EU level was necessary. Some measures are designed to promote access to care as the "imminent peril", we now need to be vigilant to ensure that it is not diverted to promote an increase in care under constraints and that psychiatrists remain in an obligation of means and not of result.

[Reform of mental health legislation: a practical tool]. / Réforme des soins psychiatriques : loi du 5 juillet 2011. Outils pratiques.

INTRODUCTION: It was widely agreed that the June 27, 1990 law needed to be changed. The new mental health legislation provides new procedures, which challenge our work habits and balance the rights of individual patient with the need to ensure public safety. In view of the very short time between the publication of the law in the Bulletin Officiel (July 6, 2011) and its application (August 1, 2011), the changes in legislation have led to concrete modifications of our practices. AIM AND METHOD: The scope of this article is to provide a practical tool, which will help to better understand the new measures in the law and to provide an accessible guide of use in relation to mental health care decisions. For the purpose of involuntary admissions, we provide two flow-charts outlining the changes in the legislation in its various aspects. We propose to summarize the points, which are not modified by this legislation, and we further develop the several new aspects of the law. Notably, procedures involving compulsory detention including the care and observation period of 72 hours, medical certificates, care in an emergency situation, the panel of caregivers, systematic review of each decision to detain by the Juge de la Détention et des Libertés (JLD), the particular case of patients under a criminal procedure or subjects who were hospitalized in units for dangerous patients, planned discharges, and disagreements between psychiatrists and the civil servant responsible. DISCUSSION: The aim of this article is not to criticize the law. It simply sets out the new measures for the compulsory admission of patients in hospital and defines the new procedures for continued detention or discharge. Due to its recent implementation, we don't have any feedback concerning long-term implications of this reform of mental health legislation, and it is premature to fully appreciate its advantages or disadvantages.

[The objectives of the reform of hospitalisation under restraint in psychiatry]. / Les objectifs de la réforme de l'hospitalisation sous contrainte en psychiatrie.

The law of July 5th, 2011 reforms legislation dating from June 27th, 1990. It adds elements identified as missing from the original text over the course of the years following its application. The systematic intervention of a liberties and detention judge could counterbalance the measures simplifying hospitalisation under restraint. Stricter monitoring of "unwieldy" patients is also included in measures which enable treatment under restraint to be given through outpatient care.

[Is it really possible to be treated without consent? ]. / Peut-on réellement se soigner sans consentement?

The law of July 5th, 2011 focuses on two distinct areas: the security aspect and that of the protection of people through the intervention of the liberties and detention judge. The care programme thus resembles house arrest, despoiling the sincerity of the trust-based relationship sought by caregivers. The systematic appearance of patients hospitalised under restraint before the liberty and detention judge risks creating confusion between care and delinquency. This article gives the viewpoint of the "39 contre la nuit securitaire" collective.

[Admission and treatment without consent in Spain]. / L'internement et le traitement sans consentement en Espagne.

The notions of voluntary and involuntary admission are specific to the hospitalisation methods in Spain. In this context, the court is present at every stage of hospitalisation. Likewise, involuntary outpatient treatment, which has existed for several years, is a source of controversy and debate between the imposition of treatment and the therapeutic alliance.

[A reaffirmed French psychiatric public sector]. / Un secteur public psychiatrique français réaffirmé.

Psychiatry in France is considered here with regard to patient care systems, long-term treatments, treatment without consent and the place of the users in the system. The implementation of the new law in 2011 relating to admission to hospital without consent will have to be revised as a result of the problems identified during its application.

Who initiates emergency commitments?

Florida's Mental Health Act was amended in 2005 and 2006 to include licensed mental health counselors and licensed marriage and family therapists, respectively, to the list of professionals authorized to initiate emergency commitments. The present study evaluates the volume of involuntary emergency commitments by type of initiator for a 5 year period. The results indicate that allowing licensed mental health counselors and licensed marriage and family therapist to initiate emergency commitments has not been related to increased numbers of emergency commitments or a higher proportion of emergency commitments being initiated by mental health professionals. Potential policy and fiscal implications, as well as future directions for research, are discussed.

"Personality disorder" and capacity to make treatment decisions.

Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of "personality disorder" is examined. Patients presenting to a psychiatric emergency clinic with threats of self-harm are considered, two having been assessed and reviewed in detail. It was found that capacity can be meaningfully assessed in such patients, although the process is more complex than in patients with diagnoses of a more conventional kind. The process of assessing capacity in such patients is very time-consuming and may become, in itself, a therapeutic intervention.

Involuntary admission of psychiatric patients: Referring physicians' perceptions of competence.

BACKGROUND: Involuntary admissions can be detrimental for patients. Due to legal, ethical and clinical considerations, they are also challenging for referring physicians. Nevertheless, not much is known about the subjective perceptions of those who have to decide whether to conduct an involuntary admission or not. AIMS: This study aimed at answering the question whether psychiatrists' perceptions of confidence during psychiatric emergency situations and consecutive involuntary admissions differ from those of physicians without a psychiatric training. METHOD: We assessed the professional background and subjective perceptions during psychiatric emergency situations in physicians who executed involuntary admissions to the University Hospital of Psychiatry Zurich. We used one-way analysis of variance (ANOVA) with Bonferroni-adjusted post hoc tests and chi-square tests to compare the responses of 43 psychiatrists with those of 64 other physicians. RESULTS: Psychiatrists felt less time constraints compared with non-psychiatric residents. The latter also had more doubts on the necessity of the involuntary admission issued. Psychiatrists considered themselves significantly more experienced in handling psychiatric emergency situations and in handling the criteria for involuntary admissions than other physicians. Psychiatrists and other physicians did not differ in their satisfaction concerning course and results of psychiatric emergency situations which was overall high. About half of all participants felt pressure from third parties. CONCLUSION: Psychiatric emergency situations are challenging situations not only for patients but also for the involved physicians. Physicians with a specialized training might be more confident in the handling of psychiatric emergency situations and exertion of involuntary admissions. Non-psychiatric physicians might benefit from specialized training programs.

Medical response time to section 5(4) (nurses' holding power) of the Mental Health Act 1983 over a 24-year period.

This study examines the trends associated with medical response time (MRT) for all section 5(4)s of the Mental Health Act 1983 applied in one mental health trust over a 24-year period. Eight hundred and three section 5(4)s were applied during the study period of which 786 had a recorded medical response time. The mean MRT was 140 minutes and 647 (82.3%) patients were seen by a doctor within the four-hour period specified in the Mental Health Act Code of Practice (DoH, 1999). Analysis of MRT showed no significant difference with the day of the week or when the weekday mean MRT was compared to that for the weekend. A significant difference was observed for the mean MRT prior to, and following, the introduction of the four-hour period noted in the MHA Code of Practice. Significant differences were also observed for the MRT over the 24-hour period . The mean MRT for the 'working hours' period was significantly higher than that for the combined period Monday-Friday, 5pm-9am, and Saturday and Sunday. The findings suggest the need for mental health trusts to review their practices to ensure that patients receive a medical assessment in the shortest period of time following the application of section 5(4).

Effects on outpatient and emergency mental health care of strict Medicaid early periodic screening, diagnosis, and treatment enforcement.

We investigated enforcement of mental health benefits provided by California Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Enforcement, compelled by a consumer-driven lawsuit, resulted in an almost 4-fold funding increase over a 5-year period. We evaluated the impact of enforcement on outpatient treatment intensity (number of visits per child) and rates of emergency care treatment. Using fixed-effects regression, we examined the number of outpatient mental health visits per client and the percentage of all clients using crisis care across 53 autonomous California county mental health plans over 32 three-month periods (quarters; emergency crisis care rates) and 36 quarters (out-patient mental health visits). Enforcement of EPSDT benefits in accordance with federal law produced favorable changes in patterns of mental health service use, consistent with policy aims.

Dilemmas related to compulsory admission: a case report.

The paper presents legal and practical dilemmas concerning compulsory admission by means of a case report.

Legal and Ethical Challenges, Part 1: General Population.

Several federal and state laws and regulations, as well as ethical medical principles, govern the emergency clinician's practice of care. Although some common legal-medical and ethical principles are shared with other medical specialties, emergency medicine and emergency psychiatry have unique legal and ethical challenges. This article presents and discusses these challenges, including the physician-patient relationship, malpractice, confidentiality and privilege, duty to report, decision-making capacity and vicarious decision-making, the Emergency Medical Treatment and Labor Act, right to treatment, hospital admissions, involuntary commitment, forced medication administration, and child and elder abuse.

Is there a duty for private employers to provide emergency mental health care services?

This article presents a discussion of whether employers in private companies have a duty to provide an emergency action plan with a mental health component for its employees. It discusses basic negligence concepts and focuses mainly on the "duty of care" component of negligence. It then applies the negligence concepts to private employers and discusses how private companies arguably might have a duty under the laws of negligence to provide employees with an emergency action plan, specifically a plan including mental health provisions.