Involuntary psychiatric hospitalisation - differences and similarities between patients detained under the mental health act and according to the legal guardianship legislation.

BACKGROUND: Involuntary psychiatric hospitalisation occurs under different legal premises. According to German law, detention under the Mental Health Act (MHA) is possible in cases of imminent danger of self-harm or harm to others, while detention according to the legal guardianship legislation (LGL) serves to prevent self-harm if there is considerable but not necessarily imminent danger. This study aims to compare clinical, sociodemographic and environmental socioeconomic differences and similarities between patients hospitalised under either the MHA or LGL. METHODS: We conducted a retrospective health records analysis of all involuntarily hospitalised cases in the four psychiatric hospitals of the city of Cologne, Germany, in 2011. Of the 1,773 cases, 87.3% were detained under the MHA of the federal state of North Rhine-Westphalia and 6.4% were hospitalised according to the federal LGL. Another 6.3% of the cases were originally admitted under the MHA, but the legal basis of detention was converted to LGL during the inpatient psychiatric stay (MHA→LGL cases). We compared sociodemographic, clinical, systemic and environmental socioeconomic (ESED) variables of the three groups by means of descriptive statistics. We also trained and tested a machine learning-based algorithm to predict class membership of the involuntary modes of psychiatric inpatient care. RESULTS: Cases with an admission under the premises of LGL lived less often on their own, and they were more often retired compared to MHA cases. They more often had received previous outpatient or inpatient treatment than MHA cases, they were more often diagnosed with a psychotic disorder and they lived in neighbourhoods that were on average more socially advantaged. MHA→LGL cases were on average older and more often retired than MHA cases. More often, they had a main diagnosis of an organic mental disorder compared to both MHA and LGL cases. Also, they less often received previous psychiatric inpatient treatment compared to LGL cases. The reason for detention (self-harm or harm to others) did not differ between the three groups. The proportion of LGL and MHA cases differed between the four hospitals. Effect sizes were mostly small and the balanced accuracy of the Random Forest was low. CONCLUSION: We found some plausible differences in patient characteristics depending on the legal foundation of the involuntary psychiatric hospitalisation. The differences relate to clinical, sociodemographic and socioeconomical issues. However, the low effect sizes and the limited accuracy of the machine learning models indicate that the investigated variables do not sufficiently explain the respective choice of the legal framework. In addition, we found some indication for possibly different interpretation and handling of the premises of the law in practice. Our findings pose the need for further research in this field.

Crime, punishment, and detention in secure psychiatric hospital.

Many legal jurisdictions offer some form of hospital diversion and disposal as an alternative to incarceration in prison for mentally disordered offenders. Such diversion is commonly understood as offering a non-punitive alternative in terms of sentencing decisions. However, complete loss of responsibility with respect to acts of violence is rare and indicative of extreme degrees of mental disorder. This raises challenges for sentencers when considering disposal options. From the perspective of the patient and healthcare providers while hospital may be framed as non-punitive, it still involves marked loss of freedom and rights. In this essay, it is argued that failure to acknowledge the punitive element, inherent in hospital detention, risks its repression, and a false dichotomy being established with prison being seen as solely punitive and hospital as solely therapeutic. It is suggested that this division is unhelpful, even potentially harmful, and that a synthesis as solution to this dialectic opposition may be generative in terms of therapeutic work in hospitals, clarification of the role of hospitals in terms of criminal justice disposal, and greater transparency in relation to multi-agency working and the social circumstances of patients detained in secure hospitals. Further work to understand this process is suggested with a particular emphasis being placed on the experience of specific groups of patients, such as women, who may find themselves in a notably precarious state within secure care.

[Psychiatry without coercion-Exclude the coercion or the patients?] / Psychiatrie ohne Zwang ­ den Zwang ausschließen oder Patient:innen?

BACKGROUND: With reference to the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD), a fundamental change in psychiatric care in Germany was proposed in 2019 by Zinkler and von Peter, supported by a legal perspective from Kammeier, which has since led to controversial debates. Essentially, the aim is not only to reduce coercion in psychiatry to a minimum, but also to fundamentally exclude it in a psychiatry that only provides care. The function as an agent of social control is to be returned from psychiatry to state institutions. Psychiatric hospitals will only admit patients with their consent; patients who refuse therapy will not be admitted regardless of their capacity for self-determination and will remain untreated or, if they have committed a criminal offence or threaten to commit a criminal offence, they will be taken into custody or imprisoned in accordance with the legal regulations applicable to all people. There they will receive psychiatric care if they so wish. AIM OF THE PAPER: The paper outlines the background of this concept, including international sources, traces the discussion in German specialist literature and takes a critical look at it. RESULTS: The criticism is primarily directed against the fact that responsibility for a relevant proportion of psychiatric patients would be handed over to the police and judiciary and that, as a result, two realities of care would be established that would considerably differ in terms of quality. CONCLUSION: Arguments are put forward in favor of retaining the function of social control and considerations are suggested as to how caring coercion can be largely minimized.

The Basaglia Law. Returning dignity to psychiatric patients: the historical, political and social factors that led to the closure of psychiatric hospitals in Italy in 1978.

Law no. 180 of 1978, which led to the closure of psychiatric hospitals in Italy, has often been erroneously associated with one man, Franco Basaglia, but the reality is much more complex. Not only were countless people involved in the movement that led to the approval of this law, but we should also take into account the historical, social, and political factors that came into play. The 1970s in Italy were a time of change and political ferment which made this psychiatric revolution possible there and nowhere else in the world.

Admission of a minor to a psychiatric hospital under Polish law. Part I. / Przyjecie maloletniego do szpitala psychiatrycznego w mysl polskiego prawa. Czesc I.

Within the scope of mental health protection, numerous practical problems arise concerning the issue of providing health services to a minor. Admission of a minor to a psychiatric hospital is associated in practice with numerous doubts. This part of the article describes the conditions of admission to hospital with the consent of the patient. It distinguishes and accurately describes situations where a minor is under or over 16 years of age. In addition, it explains situations where there is a contradiction of declarations of will by legal guardians in relation to admission, their inability to perform legal acts, or a contradiction of the statements of the minor and guardian. It also addresses the aspect of receiving written consent during the COVID-19 epidemic.

Achieving Access Parity for Inpatient Psychiatric Care Requires Repealing the Medicaid Institutions for Mental Disease Exclusion Rule.

Approximately 3.4% of Americans have a mental health condition and suicide is the 10th leading cause of death. While the rate of mental health conditions has slightly increased for adult populations, America's youth has experienced a significant rise in depression. From 2008 to 2017, occurrence of depression in the adolescent population increased from 8.3% to 13.3%. As adolescents mature into adults; it is likely the rate of mental health conditions for the adult population will rise as well as it is the common thread that binds the diseases of despair: drug abuse, alcoholism, and suicide. Arising out of the deinstitutionalization movement of the 1960s, the Medicaid Institutions for Mental Disease (IMD) Exclusion Rule (§1905(a)(B) of the Social Security Act) prohibits reimbursement for Medicaid recipients ages 21 to 64 years receiving inpatient care at a psychiatric hospital with 16 or more beds. Consequently, the rule limits payment for psychiatric treatment to general hospitals and smaller, nonspecialized centers, which blocks patients from receiving inpatient care and transfers the financial burden of care onto psychiatric hospitals. The IMD Rule is approaching its 55th anniversary. It requires reevaluation. Although a state waiver process is available, use of this option has the potential to increase the incidence of racial and ethnic disparities across states. Full repeal of the IMD Exclusion Rule could help provide immediate access to inpatient care that is consistent nationwide and be a vital step toward creating financial, treatment and ethical parity for mental health services.

Isolation of patients in psychiatric hospitals in the context of the COVID-19 pandemic: An ethical, legal, and practical challenge.

Psychiatric inpatients are particularly vulnerable to the transmission and effects of COVID-19. As such, healthcare providers should implement measures to prevent its spread within mental health units, including adequate testing, cohorting, and in some cases, the isolation of patients. Respiratory isolation imposes a significant limitation on an individual's right to liberty, and should be accompanied by appropriate legal safeguards. This paper explores the implications of respiratory isolation in English law, considering the applicability of the common law doctrine of necessity, the Mental Capacity Act 2005, the Mental Health Act 1983, and public health legislation. We then interrogate the practicality of currently available approaches by applying them to a series of hypothetical cases. There are currently no 'neat' or practicable solutions to the problem of lawfully isolating patients on mental health units, and we discuss the myriad issues with both mental health and public health law approaches to the problem. We conclude by making some suggestions to policymakers.

[The implementation of the law 4509/2017 in the Forensic Department of the Psychiatric Hospital of Thessaloniki].

According to the Explanatory Memorandum of the law 4509/2017, a significant change is being made to the current institutional framework of Articles 69 and 70 of the ECHR concerning the penal treatment of mentally ill offenders, in order to ensure a high level of treatment for perpetrators with mental or intellectual disorder. In application of the law, it was examined in court the abolishment, maintenance or replacement of the treatment measure of 47 patients from the Department of Forensic Psychiatry in Thessaloniki. The results were compared with the previous status quo. In 22 cases, abolishment was ordered for the patients to be discharged and return to their parent's home or to Psychosocial Rehabilitation Units. In 11 of them, their stay was in direct violation of the law due to exceeding the cap as defined by the severity of the offense. However, 7 patients remain voluntarily in the Department, as no beds are available in reintegration structures. 13 patients who have committed homicide remain with the psychiatrist's agreement beyond the overrunning the ten years of treatment due to the severity of the disease or the risk for violent behavior. The Public Prosecutor has provided solutions in many cases and has appointed lawyers for all patients as prescribed by law. However, the judiciary remains cautious and the trend towards exhaustion of the limits is clear, despite the fact that their fears are not confirmed by international bibliographic data. The application of N 4509/2017 attempts to change the landscape for this particular group of patients and allows visions for de-institutionalization, elimination of the stigma and personalized treatment, despite any ambiguities or potential problems that may arise. However, as the predominant social viewpoint, shown by the media, treats the mentally ill as dangerous, any positive changes are doomed to fail. In addition, it is necessary to develop psychiatric services for the treatment of patients which will not only treat psychotic symptoms but also antisocial and aggressive behavior in general.

Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent-all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily.

Humane treatment versus means of control: coercive measures in Norwegian high-security psychiatry, 1895-1978.

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway - Kriminalasylet (Criminal Asylum) and Reitgjerdet - during the period 1895-1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

[Smoke-free psychiatric hospitals and the role of aggression: a systematic review]. / Is er een risico op toename van agressie bij een rookvrije ggz? Een literatuurstudie.

AIM: To provide an overview of the literature on transitions towards smoke-free psychiatric hospitals and the risk of aggression.
METHOD: A systematic search was made in medline, Embase and Psycinfo. Studies were included if they reported data on: a smoke-free intervention in a psychiatric hospital or ward, the number of aggressive incidents, and seclusions or prn drugs.
RESULTS: A total of 17 studies matched the inclusion/exclusion criteria; 5 reported a decrease in the number of aggressive incidents after implementation of a smoke-free ward, 7 showed an increase in the number of incidents, and 5 studies reported no differences. Heterogeneity between the studies was high with respect to the definition and implementation of the intervention, the definition and measurement of aggression, study design, length of follow-up, and the sample size.
CONCLUSION: These findings suggest that, after changing the policy towards a smoke-free psychiatric hospital, the risk of aggression is limited. However, several precautions related to the preparation and implementation of this transition seem to be essential. The results support further investment in the implementation of smoke-free psychiatric hospitals in the Netherlands, while maintaining safety.

[Six years of open-door policy at the University Psychiatric Hospital Basel]. / Sechs Jahre "offene Türen" an den Universitären Psychiatrischen Kliniken Basel.

BACKGROUND: Coercive measures in psychiatry have well-known negative consequences for the patients and their treatment. They are considered ethically problematic and must only be used as a last resort. Locked wards may promote a threatening atmosphere leading to more aggression and a subsequent higher use of coercive measures. The aim of this was to investigate the frequency of seclusion and forced medication during clinic-wide implementation of an open-door policy. MATERIAL AND METHODS: In this 6­year longitudinal observational study (2010-2015) the frequencies of seclusion and forced medication were investigated on the basis of 17,359 cases treated in the University Psychiatric Hospital Basel. During the observational period, six formerly permanently locked wards were opened. RESULTS: The examined data showed a clinically relevant decrease in the frequency of seclusion (from 8.2% to 3.5%) and forced medication (from 2.4% to 1.2%) during the observational period. CONCLUSION: These results underline the potential of a less restrictive policy in psychiatry to reduce the frequency of coercive measures.

Clinical and socio-demographic characteristics associated with involuntary admissions in Switzerland between 2008 and 2016: An observational cohort study before and after implementation of the new legislation.

BACKGROUND: Involuntary admission (IA) for psychiatric treatment has a history of controversial discussions. We aimed to describe characteristics of a cohort of involuntarily compared to voluntarily admitted patients regarding clinical and socio-demographic characteristics before and after implementation of the new legislation. METHODS: In this observational cohort study, routine data of 15'125 patients who were admitted to the University Hospital of Psychiatry Zurich between 2008 and 2016 were analyzed using a series of generalized estimating equations. RESULTS: At least one IA occurred in 4'560 patients (30.1%). Of the 31'508 admissions 8'843 (28.1%) were involuntary. In the final multivariable model, being a tourist (OR = 3.5) or an asylum seeker (OR = 2.3), having a schizophrenic disorder (OR = 2.1), or a bipolar disorder (OR = 1.8) contributed most to our model. Male gender, higher age, prescription of neuroleptics (all OR < 2.0) as well as having a depressive disorder, prescription of psychotherapy, prescription of antidepressants and admission after implementation of the new legislation (all OR > 0.6) were also weakly associated with IA. CONCLUSIONS: Besides schizophrenic or bipolar disorders, a small group of patients had an increased risk for IA due to non-clinical parameters (i.e. tourists and asylum seekers). Knowledge about risk factors should be used for the development of multi-level strategies to prevent frequent (involuntary) hospitalizations in patients at risk. On the organizational level, we could show that the new legislation decreased the risk for IA, and therefore may have succeeded in strengthening patient autonomy.

The Baldovan Institution Abuse Inquiry: a forgotten scandal.

In this paper, I resurrect a long-forgotten inquiry into abuse and maladministration at an institution for people with learning disabilities, the Baldovan Institution near Dundee, that has lain buried in the archives for the past 60 years. I contrast the response to it with the very different response to the similar revelations of the Ely Hospital Inquiry more than a decade later. Whereas Ely opened up the institutional sector to greater public scrutiny and brought with it a formal commitment from the government to shift the balance of care away from the long-term hospital, Baldovan produced recommendations that were limited to the institution and had no impact on public policy or institutional practice. I consider the reasons for this and its implications.

The recognition and expectations of ex-inpatients of mental health services: A web-based questionnaire survey in Japan.

Concern about mental health issues and the treatment of mentally disordered offenders attracts considerable public attention. This study aimed to gather the experiences and opinions of people who have experienced admission to a psychiatric ward in order to grasp their reaction to, and understanding of, the legislation behind the involuntary admission of psychiatric patients. A web-based questionnaire survey was conducted with a total of 379 participants, using a cross-sectional, exploratory design. The data were analyzed using a chi-squared test, Fisher's exact test, and a logistic regression analysis. According to the results, many patients were satisfied with their treatment during psychiatric admission; however, only few participants said that they had been given an adequate explanation for their involuntary treatment. Most participants expected qualified assistance after discharge, although the prospect of a regular visit from an official was not entirely supported by the participants. Patient satisfaction was relevant to the discussion of their needs after discharge and in developing a crisis plan during admission. These findings suggest that psychiatric patients accept inpatient treatment as long as they receive an adequate explanation. More qualified care such as relapse prevention would be expected to lead to better satisfaction. For them to welcome regular visits from an official, patients may need more information and discussion.

Monitoring the correspondence of the mentally ill in Spanish psychiatric institutions: from care to censorship, 1852-1987. / El control de la correspondencia de los enfermos mentales en las instituciones psiquiátricas españolas: entre el cuidado y la censura, 1852-1987.

This article examines the legislation allowing confiscation of the correspondence of the mentally ill in psychiatric hospitals. Arguing a duty of care, patients' letters were read by physicians and administrators. A study was performed of the regulations governing this practice in different Spanish institutions from the nineteenth century on; the measure was implemented by staff members under orders from their superiors. This arbitrary decision meant that a great deal of correspondence remains in the archives of psychiatric establishments in different locations; nowadays, these letters can be used as valuable clinical documents that help us to understand daily life in those institutions and, obviously, mental health patients' subjective experience of their confinement.

Este trabajo pretende aproximarse a la legislación que ha permitido retener la correspondencia de los enfermos mentales en los hospitales psiquiátricos. Amparándose en el cuidado, las cartas eran leídas por médicos y administradores. Se ha realizado una búsqueda de los reglamentos que avalaban esta práctica en diferentes instituciones españolas desde el siglo XIX, medida ejercida por el personal subalterno por orden de sus superiores. Esta arbitraria decisión ha provocado que numerosa correspondencia permanezca en archivos de establecimientos psiquiátricos de diferentes latitudes, de modo que, actualmente, se pueden utilizar como valiosos documentos clínicos para conocer la vida cotidiana de dichas instituciones y, sin duda, la experiencia subjetiva de los enfermos mentales ante el internamiento.

El control de la correspondencia de los enfermos mentales en las instituciones psiquiátricas españolas: entre el cuidado y la censura, 1852-1987 / Monitoring the correspondence of the mentally ill in Spanish psychiatric institutions: from care to censorship, 1852-1987

Resumen Este trabajo pretende aproximarse a la legislación que ha permitido retener la correspondencia de los enfermos mentales en los hospitales psiquiátricos. Amparándose en el cuidado, las cartas eran leídas por médicos y administradores. Se ha realizado una búsqueda de los reglamentos que avalaban esta práctica en diferentes instituciones españolas desde el siglo XIX, medida ejercida por el personal subalterno por orden de sus superiores. Esta arbitraria decisión ha provocado que numerosa correspondencia permanezca en archivos de establecimientos psiquiátricos de diferentes latitudes, de modo que, actualmente, se pueden utilizar como valiosos documentos clínicos para conocer la vida cotidiana de dichas instituciones y, sin duda, la experiencia subjetiva de los enfermos mentales ante el internamiento.

Abstract This article examines the legislation allowing confiscation of the correspondence of the mentally ill in psychiatric hospitals. Arguing a duty of care, patients' letters were read by physicians and administrators. A study was performed of the regulations governing this practice in different Spanish institutions from the nineteenth century on; the measure was implemented by staff members under orders from their superiors. This arbitrary decision meant that a great deal of correspondence remains in the archives of psychiatric establishments in different locations; nowadays, these letters can be used as valuable clinical documents that help us to understand daily life in those institutions and, obviously, mental health patients' subjective experience of their confinement.

Medicare Program; FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 2019). Final rule.

This final rule updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs), which include psychiatric hospitals and excluded psychiatric units of an acute care hospital or critical access hospital. These changes are effective for IPF discharges occurring during the fiscal year (FY) beginning October 1, 2018 through September 30, 2019 (FY 2019). This final rule also updates the IPF labor-related share, the IPF wage index for FY 2019, and the International Classification of Diseases 10th Revision, Clinical Modification (ICD- 10-CM) codes for FY 2019. It also makes technical corrections to the IPF regulations, and updates quality measures and reporting requirements under the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program. In addition, it updates providers on the status of IPF PPS refinements.

Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance.

BACKGROUND: Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government's tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation. METHODS: This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis. RESULTS: Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified. CONCLUSIONS: Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required.