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.

OPCAT: How an international treaty regarding torture is relevant to the Australian mental health system.

The United Nations Subcommittee on the Prevention of Torture visits signatory nations to the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Its role is to monitor and support signatory nations in implementing and complying with the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). In October 2022, the United Nations Subcommittee on the Prevention of Torture visited Australia but was barred from visiting mental health wards in Queensland and all detention facilities in New South Wales leading to the termination of its visit. This breach of Australia's obligations under the OPCAT presents a significant setback for the rights of people with mental illness and other involuntarily detained populations. This piece sets out to demonstrate the relevance of OPCAT to the mental health system in Australia. Individuals who are detained for compulsory treatment in locked facilities such as acute psychiatric inpatient wards and forensic mental health facilities are deprived of their liberty, often out of public view. Thus, it highlights the ethical and professional obligations of all mental health professionals, especially psychiatrists, to safeguard the human rights of individuals being detained in mental health facilities as enshrined in Australia's international legal obligations under the OPCAT. Adhering to these obligations diminishes the risk of future human rights violations of people with mental illness.

Professional Values and Mental Health Tribunals: How Healthcare Professionals' and Lawyers' Views Are Shaped by Values, and How This Might Impede Reform.

Most countries that provide for compulsory treatment for mental illness have a system by which this treatment is subject to independent legal oversight. Many countries use a special type of legal body for this purpose, called a mental health tribunal. Mental health tribunals have been subject to criticism from the points of view of both legal professionals and mental healthcare practitioners. Similar themes have manifested in these criticisms and have been consistent across several decades; legal professionals tend to focus on the tribunals being biased toward the medical opinion, and acting as a 'rubber stamp', whereas healthcare practitioners tend to focus on the adversarial nature of the trial, and the adverse effect that this can have on clients. However, empirical studies of the tribunals have not separated and directly compared these perspectives. This study aimed to explore this dynamic between lawyers' views and healthcare practitioners' views of mental health tribunals. We used thematic analysis to re-analyse data from two previous research studies, one which looked at lawyers' views of the tribunals, and one which looked at healthcare practitioners' views. Our results are divided into three themes: views of the problems with tribunals, professional roles in relationship to the tribunals and professional values demonstrated through these views and roles. We then consider if the 'clash of values' represented by these findings, and found in the literature, may pose an impediment to tribunal reform. Identifying and exploring this barrier is an important step to moving beyond critique to reform.

[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.

Mental Health Acts - Perspectives from Mental Health and Law in Ireland and in Portugal.

Mental health legislation is a cornerstone to ensure that individuals with severe mental illness access proper care and treatment. Each country establishes their own legislation. We aimed to compare the Portuguese and Irish Mental Health Acts (MHAs). We reviewed the respective MHA and the literature. While the definition of mental disorder is similar in general, who, where, when and how one can be detained differ. Judges decide on detentions in Portugal, while consultant psychiatrists may do so in Ireland. Community-based compulsory treatment is possible and used in Portugal while it is not possible in Ireland. Pros and cons of each approach are discussed with a reflection on the protection of human rights. Further theoretical and empirical studies comparing systems in different jurisdictions would be helpful to deepen our understanding of the legislation and guide on how to better serve individuals with severe mental illness.

Deprivation of liberty and the community nurse.

In this month's Policy column, Iwan Dowie discusses the 'deprivation of liberty' - which is used to safeguard patients who may be lacking sufficient mental capacity to manage their own safety. The author, through previous legal cases, shares how the Deprivation of Liberty Safeguards (DoLS)-an amendment to the Mental Capacity Act 2005-came into being, and the importance of community nurses in knowing the DoLS.

Tidligere kriminalitet og psykisk helsehjelp hos personer med soningserfaring som blir dømt til tvungent psykisk helsevern.

Background: In the period 2002-2020, a total of 431 people were sentenced to coercive mental health care. Many of these had served time in prison, either previously or in connection with the criminal acts that led to the current sentences. This study examines the background, criminal history and mental health status of individuals before they committed the offences that led to their imprisonment. Material and method: Data from the Norwegian Correctional Service's Register of Imprisonments, the Register of Convictions, the Norwegian Patient Registry and Statistics Norway were used to study former prisoners who were sentenced to coercive mental health care in the period 2002-2020, who had served prison terms. Results: Among 286 former prisoners who were sentenced to coercive mental health care, 246 (86.0 %) had previous convictions, and 140 (49.0 %) had previously had criminal charges dropped due to doubt as to criminal culpability. Previous psychiatric illness in the last two years was studied in 186 individuals. Of these, 151 (81.2 %) had undergone treatment in the mental health service, with psychotic disorders (106/186 (57.0 %)) and substance use disorders (109/186 (58.6 %)) being the most common diagnoses. Interpretation: Former prisoners who are sentenced to coercive mental health care tend to have an extensive criminal and mental health care history prior to committing criminal acts that lead to coercive mental health care.

[Denial of addiction as a mental disorder in the Dutch Compulsory Care Act]. / Miskenning van verslaving als psychische stoornis in de Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: It is difficult to qualify patients with substance-related and addictive disorders for the Dutch Compulsory Care Act (Wvggz) AIM: Investigating factors that influence rejections of substance-related and addictive disorders as mental disorders in the Wvggz RESULTS: Substance-related and addictive disorders are assessed differently as mental disorder than other psychiatric disorders under both the old Dutch Special Admissions Act (Bopz) and the Wvggz. It is often not made clear whether the assessment is made from the medical-psychiatric or legal domain. CONCLUSION: To qualify patients with substance-related and addictive disorders for the Wvggz, a medical-psychiatric classification and/or diagnosis must be converted into the required legal terms in as structured a manner as possible. It is also undesirable for a law and therefore the court to determine whether there is a mental disorder. This belongs to the medical-psychiatric domain.

[Clinical and regulatory challenges of forced hospitalization in Chile under the new Mental Health Law]. / Desafíos clínicos y normativos de la internación forzada en Chile, en virtud de la nueva Ley de Salud Mental.

Forced hospitalization is a common practice in psychiatry. It involves limiting the patient's freedom of movement in a clinical context without expressing informed consent, causing stress to the family and support network. Thus, forced hospitalization may cause violations, disturbances, or threats to the human rights of a vulnerable population. Considering this clinical reality, the present study seeks to analyze the current law on this subject in Chile compared to the international human rights guidelines. The analysis included a review of legal documents and referenced scientific articles. The new law No. 21,331 establishes a more demanding standard for the origin of forced internment, shortening the distance concerning the human rights guidelines regarding intellectual disability. The incoming development of the regulations mandated by the law could fill in the gaps in several situations that may arise and clarify fuzzy points. The key stakeholders' participation level will be critical in this matter.

Involuntary psychiatric hospitalization in Italy: critical issues in the application of the provisions of law.

Involuntary psychiatric hospitalisation in Italy raises some critical forensic issues. We analysed the sociodemographic, psychopathological, and behavioural characteristics of involuntarily hospitalised psychiatric patients, and the effectiveness of the juridical procedure of guarantee. Case files (n = 2796) related to involuntary psychiatric hospitalisation (IPH) at the Office of the Tutelary Judge of the Ordinary Court of Rome (Italy) between January 2013 and May 2016 were analysed. For each case file sociodemographic, clinical and procedural information were collected. The sample included 53.7% men, patients had a mean age of 41.8 ± 13.9. Most of the IPH proposal certificates reported more than one reason, among which the most frequent were symptoms referring to a psychotic dimension (54.8%), agitation (38.0%), and symptoms of bipolar and related disorders (26.3%) Female patients showed a higher prevalence of symptoms of the bipolar spectrum (F = 29.7%, M = 23.3%; p < 0.05), while male patients showed a higher prevalence of aggressive behaviour (F = 7.7%, M = 12.6%; p < 0.01). Over 85% of the IPH proposal certificates did not explicitly mention issues related to adherence to care, which is the second criterium requested for IH (treatment refusal) and up to 7.3% of the proposals were not properly motivated. However, only 0.8% cases were not validated by the Tutelary Judge. Possible issues in the IPH procedures emerged since a significant number of certifications showed poor concordance with law- criteria for involuntary psychiatric hospitalisation. Despite this evidence, the low rate of unvalidated procedures by the Tutelary Judge, suggests a possible limitation of this form of guarantee.

A Study into the Operation of the Queensland Mental Health Review Tribunal.

The Queensland Mental Health Review Tribunal makes difficult decisions regarding involuntary treatment of people with mental illness, applying strict legislative criteria against a backdrop of fundamental human rights considerations. This article reports on focus group research with lawyers and advocates for people with mental illness who appear before the Queensland Mental Health Review Tribunal. Participants expressed concerns regarding the manner in which decisions are made. For example, participants said that their clients' views on the side effects of treatment do not receive adequate consideration when involuntary treatment is authorised. We review these concerns in the light of applicable legal obligations, including those arising from human rights law. We conclude that if these concerns are accurate, some adjustments to the Queensland Mental Health Review Tribunal's decision-making processes are required.

Hospital treatment of persons found not guilty by reason of insanity.

After being found not guilty by reason of insanity (NGRI), individuals are typically admitted to a secure forensic hospital for evaluation and treatment. This patient population can pose a challenge to clinicians in the hospital setting due to significant violence risk, complex psychiatric presentations, and scrutiny from oversight boards and the public. This article reviews the scientific literature around several key aspects of hospital-based treatment of insanity acquittees, including the management of inpatient aggression, the provision of specific treatments to acquittees, the assessment of violence risk and readiness for release, and the process of community transition. The authors conclude that the existing literature is heavily weighted toward the study of risk assessment and recidivism, with relatively little attention paid to the study of therapeutic modalities and recovery-oriented care in this population.

[Consequences of the temporaneous lack of admissibility of involuntary medication in the state of Baden-Wuerttemberg: not less drugs, but longer deprivation of liberty]. / Auswirkungen der vorübergehend fehlenden Genehmigungsfähigkeit für Zwangsbehandlung in Baden-Württemberg: nicht weniger Medikamente, aber längere Freiheitsentziehung.

BACKGROUND: After the decisions of the German Federal Constitutional Court in 2011 and the Federal Supreme Court in 2012, involuntary treatment was not approvable for a period of seven months in the State of Baden-Wuerttemberg. Previous analyses of routine data had demonstrated that at that time in a rather small group of patients, aggressive incidents and coercive interventions had significantly increased and then decreased to the previous level after the new legislation came into force. The changes concerned a relatively small group of involuntary patients. Based on an analysis of medical charts in 6 hospitals, this study aimed to investigate 1) whether refusal of prescribed medication became more frequent in that period and 2) how frequently antipsychotic medication was administered without coercion. METHOD: We conducted a longitudinal intra-individual comparison and included all of the patients with schizophrenic and manic disorders who had been admitted in the period without the option of involuntary treatment and in a defined control period one year before as well (N = 174). Thus, study group and control group were identical. RESULTS: In the period without the option of involuntary treatment, patients remained involuntarily committed significantly more frequently (+ 26 %) but only insignificantly longer. Length of stay and number of mechanical restraints remained unchanged, number of seclusions doubled, and some patients could not leave the ward for long periods of time and had frequent readmissions. Persistent refusal of prescribed medication was significantly more frequent (+ 130 %, p < .001). However, the percentage of patients who received an antipsychotic drug during their hospital stay did not differ (96.0 vs. 96.6 %). The dosage at discharge as calculated in chlorpromazine units tended to be even higher during the period without option of involuntary treatment (+ 7.9 %, p = .06). All differences concerned both voluntary and involuntary patients. CONCLUSIONS: Without the option of involuntary treatment, persistent refusal of medication and different forms of deprivation of liberty increased. Nevertheless, oral antipsychotic treatment was realized in nearly all cases until discharge.

Deprivation of Liberty in Care. An ECHR and CRPD Approach and its Consequences for Belgium.

This contribution examines deprivation of liberty in Belgian healthcare within the frameworks of the ECHR and CRPD. We develop and apply an ECHR-based framework to demonstrate that it is not the admissions to care facilities based on Belgium's involuntary commitment law that give rise to the unjustified deprivation of liberty, but those based on representation regimes. This can be remedied by broadening Belgium's involuntary commitment law. However, doing so would go against a CRPD-based framework, which is incompatible with the ECHR; the former opposes disability-based laws. Building on the right to legal capacity and to liberty, the scope of the CRPD's approach is uncovered. It is suggested that to reconcile the two frameworks, Belgium's involuntary commitment law should be abolished, and representation regimes should be changed to avoid (rather than to justify) deprivation of liberty. Although its desirability is open for discussion, this could solve a problem that occurs worldwide.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study.

BACKGROUND: Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France. METHODS: A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis. SETTING: Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews. PARTICIPANTS: 400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French. INTERVENTIONS: The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care. MAIN OUTCOMES AND MEASURES: The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs. DISCUSSION: Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

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.

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

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

Public Perceptions of Moral Insanity in the 19th Century.

The diagnosis of moral insanity was primarily used through the best part of the 19th century to define and justify the psychiatric treatment of a particular type of conduct in which the patient seemed otherwise rational but displayed certain inexplicable and undesirable behaviors deemed socially perverse or "unfit." This article traces the history of this highly contested concept, which mirrors a historical arc in which psychiatry emerges as a discipline and stakes territorial claims on defining and regulating moral behavior. As illustration, I focus on the Hinchman Conspiracy Trial of 1849 as a less known case of wrongful confinement that hinged on proving the diagnosis of moral insanity in court. Moral insanity is a case study of the efforts to medicalize human ethical conduct, an effort starkly resisted by both the courts and the public. Some of the legacies of the term are the contemporary use of insanity as a legal defense, and the ability of patients to dispute psychiatric ward confinement orders in court.

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.

[After the reform is before the reform : Results of the amendment processes of mental health law in German federal states]. / Nach der Reform ist vor der Reform : Ergebnisse der Novellierungsprozesse der Psychisch-Kranken-Hilfe-Gesetze der Bundesländer.

BACKGROUND: On the basis of mental health law, which differs between the federal states in Germany, courts can order the involuntary commitment of people with severe mental disorders in psychiatric hospitals, if they present a danger to themselves or to others. Due to decisions of the highest courts, these laws have been subject to revision since 2011. The aim of this paper is to analyze and compare the results of the revision processes in order to define the need for action for federal and state legislature. MATERIAL AND METHODS: Research of the current status of the revision processes in the federal states and a comparative analysis. The state laws were compared on the basis of selected particularly relevant areas with respect to human rights and treatment. RESULTS: In spite of the revisions the state laws are extremely heterogeneous and in many states do not fully comply with the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) or the highest courts' decisions. CONCLUSION: The state laws should be harmonized, particularly where they restrict basic and human rights, e. g. regarding prerequisites and objectives of involuntary commitment and coercive measures.