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.

[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.

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.

[Coercive Medication: Who, how, how Long? A Retrospective Chart Analysis in 6 Hospital Sites in Baden-Wuerttemberg]. / Ärztliche Zwangsbehandlung: Wer, wie, wie lange? Eine retrospektive Fallanalyse an sechs Klinikstandorten in Baden-Württemberg.

BACKGROUND: Evaluation of the practice of coercive treatment in Germany after the Constiutional Court's decision in 2011. METHODS: The documented emergency treatments (N=86) and judicially approved compulsory treatments (N=62) in 2015 and 2016 at 6 hospital locations in Baden-Württemberg were retrospectively analysed. RESULTS: Patients had an average of 8 previous psychiatric hospitalisations with a cumulative duration of 645 days on average and 87% had a psychotic disorder. 34% received subsequent compulsory treatment within one year. The median duration of compulsory treatment was 15 days. 92% of the patients were taking an antipsychotic at discharge, 45% received further treatment in a day hospital or a psychiatric outpatient clinic. CONCLUSION: Coercive treatment affects a relatively small, chronically severely ill group of patients and is frequently recurrent among them. For considerable part, no consecutive treatment setting can be established after discharge.

[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.

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.

High-Risk Medicolegal Conditions in Pediatric Emergency Medicine.

The top 5 reasons for pediatric malpractice are cardiac or cardiorespiratory arrest, appendicitis, disorder of male genital organs, encephalopathy, and meningitis. Malpractice is most likely to result from an "error in diagnosis." Claims involving a "major permanent injury" were more likely to pay out money, but of all claims, only 30% result in a monetary pay out. Consideration of "high-risk misses" may help to direct a history, examination, testing, and discharge instructions.

Gravely Disabled: The Vestigial Prong of 5150 Designations.

Effective July 1, 1972, California's Lanterman-Petris-Short Act (LPS Act) set the precedent for modern mental health commitment procedures in the U.S. named after its authors, State Assemblyman Frank Lanterman and State Senators Nicholas C. Petris and Alan Short, the LPS Act sought to "end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorder"; to "provide prompt evaluation and treatment of persons with mental health disorders or impaired by chronic alcoholism"; and to "guarantee and protect public safety." Despite citing to these articles of intent, the LPS Act violates its own legislative intent through its inclusion of "gravely disabled" in its enforcement of involuntary psychiatric hold designations (also known as "5150 designations"). First, police officers are not required to make a medical diagnosis of a mental health disorder at the time of a 5150 designation; the broad scope of "gravely disabled" increases the number of persons police officers can involuntarily transport, increasing the likelihood of inappropriate and involuntary commitment of persons with mental health disorders. Second, the broad scope of "gravely disabled" produces an onslaught of 5150-designated persons (whether improperly designated or not) being sent to LPS-designated hospitals with limited resources (e.g., lack of beds and psychiatric staff); this results in patients waiting for an inordinate amount of time for a psychiatric evaluation and/or a hospital bed. Third, it is unclear whether the LPS Act sought to provide protection for the mentally ill or to provide protection from the mentally ill in its guarantee of protecting "public safety"; the inclusion of "gravely disabled" in 5150 designations indicates that the LPS Act provided the public with a duplicitous means of removing the mentally ill, impoverished, and houseless from the streets under the guise of "public safety." This Paper suggests the following to help remedy the effects of implementing the broadly defined "gravely disabled" in 5150 designations: (1) Remove "gravely disabled" from the 5150 criteria; (2) integrate the community with mental health advocacy efforts by creating outreach and education programs; and (3) implement a client-centric approach to interacting with persons with mental health disorders through restorative policing and the establishment of a restorative court.

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.

Experiences of Court Clinicians Who Perform Civil Commitment Evaluations for Substance Use Disorders.

Civil commitment for substance use disorders is an increasingly used intervention to mitigate the risks associated with severe substance use. Although court clinicians play a vital role in helping courts determine whether respondents meet statutory requirements for commitment, little is known about their experiences conducting these evaluations. In this pilot study, we surveyed all court clinicians who perform evaluations for civil commitment for substance use disorders in Massachusetts, a state with one of the highest rates of such commitments nationally. Court clinicians reported that these evaluations are most frequently ordered for individuals who use heroin and other opioids, alcohol, and cannabis. They reported a recent suicide attempt or drug overdose, intentional physical harm to another, use of dangerous weapon, and driving while intoxicated as the behaviors most likely to satisfy the statutory requirement of imminent risk. At the same time, many court clinicians consider a much broader range of behaviors as constituting imminent risk, and many reported having endorsed commitment on one or more occasions in the absence of statutory criteria being satisfied. These findings underscore the need for additional research on the performance of civil commitment evaluations for substance use disorder and standards for such evaluations.

The Early Impact of the COVID-19 Pandemic on Acute Care Mental Health Services.

OBJECTIVE: This study aimed to explore the effects of COVID-19 and the lockdown measures adopted in England on patients with acute mental illness. METHODS: The authors analyzed referrals to the crisis resolution and home treatment (CRHT) team and inpatient admissions to acute adult wards, at Leicestershire Partnership National Health Service Trust, an integrated community and mental health trust in the United Kingdom. Number of CRHT referrals and inpatient admissions during a 4-week period starting March 16, 2020 ("COVID-19 period"), was studied and compared with the same period in 2018 and 2019 ("control periods"). Demographic and clinical characteristics of patients admitted during the COVID-19 period were compared with those admitted during the 2019 control period. RESULTS: The number of CRHT referrals and inpatient admissions were lower during the COVID-19 period, compared with the control periods, by approximately 12% and 20%, respectively. Patients admitted during the COVID-19 period were significantly more often detained under the Mental Health Act and were considered to pose a risk of aggression. The pattern of diagnoses differed significantly between 2020 and 2019. A higher percentage of patients admitted during the COVID-19 period were diagnosed as having nonaffective psychotic disorders (52% versus 35%) or bipolar disorder (25% versus 15%), and fewer received a diagnosis of depression (8% versus 16%), anxiety disorder (0% versus 3%), adjustment disorder (0% versus 8%), emotionally unstable personality disorder (6% versus 15%), or any other personality disorder (0% versus 5%) (p=0.01). CONCLUSIONS: These findings suggest that the pandemic has profoundly affected care by acute mental health services.

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.

Under which conditions are changes in the treatment of people under involuntary commitment justified during the COVID-19 pandemic? An ethical evaluation of current developments in Germany.

The COVID-19 pandemic poses significant challenges in psychiatric hospitals, particularly in the context of the treatment of people under involuntary commitment. The question arises at various points in the procedure for and process of involuntary commitment whether procedural modifications or further restrictive measures are necessary to minimise the spread of COVID-19 and protect all people involved from infection. In the light of current developments in Germany, this article examines under which conditions changes in the treatment of people under involuntary commitment are ethically justified in view of the COVID-19 pandemic. Among others, we discuss ethical arguments for and against involuntary commitments with reference to COVID-19, the use of different coercive interventions, the introduction of video hearings, an increased use of video surveillance and interventions based on the German Infection Protection Act. We argue that strict hygiene concepts, the provision of sufficient personal protective equipment and frequent testing for COVID-19 should be the central strategies to ensure the best possible protection against infection. Any further restrictions of the liberty of people under involuntary commitment require a sound ethical justification based on the criteria of suitability, necessity and proportionality. A strict compliance with these criteria and the continued oversight by external and independent control mechanisms are important to prevent ethically unjustified restrictions and discrimination against people with the diagnosis of a mental disorder during the COVID-19 pandemic.

The COVID-19 pandemic and the human rights of persons with mental and cognitive impairments subject to coercive powers in Australia.

The purpose of this paper is to explore the effect of the COVID-19 pandemic on the human rights of persons with mental and cognitive impairments subject to coercive powers in Australia. It sets out the relevant human rights in the Convention on the Rights of Persons with Disabilities which have been engaged by the COVID-19 pandemic and the government's response to it. It examines the effect of emergency legislation on the relaxation of human rights safeguards in mental health laws, with a focus on mental health tribunals (although it is limited by a lack of published decisions and gaps in publicly available information). However, some of the issues created for persons with disabilities during the COVID-19 pandemic are evident in some decisions published by the New South Wales Guardianship Tribunal. The paper critically analyses two guardianship decisions UZX [2020] NSWCATGD 3 (3 April, 2020) and GZK [2020] NSWCATGD 5 (23 April, 2020) and some emergency South Australian legislation COVID-19 Emergency Response Act, 2020 (SA) Schedule 1 to demonstrate the ways in which the human rights of persons with mental and cognitive impairments can be more at risk than those of the general population, even when the general population is itself in "lockdown."

Psychiatric commitment under the criminal law in China: An empirical perspective.

This article examines the legislation and practice of compulsory treatment in China. Part I traces the Chinese history of criminal commitment law, explains the research methodology, and highlights some general empirical findings. Part II provides a comprehensive empirical analysis of compulsory treatment law in China, it covers both substantial issues such as criteria of compulsory treatment and procedural issues such as the commitment hearing, enforcement, and discharge of compulsory treatment. It also explores the compulsory treatment law from the human rights protection perspective. Our primary objective is to present the empirical findings to enable the legislative and other involved government agencies to make informed decisions about the future evolution of Chinese law in this area.

Mental health, mental capacity, ethics, and the law in the context of COVID-19 (coronavirus).

The emergence of the COVID-19 (coronavirus) pandemic in late 2019 and early 2020 presented new and urgent challenges to mental health services and legislators around the world. This special issue of the International Journal of Law and Psychiatry explores mental health law, mental capacity law, and medical and legal ethics in the context of COVID-19. Papers are drawn from India, Australia, the United Kingdom, Ireland, Germany, Portugal, and the United States. Together, these articles demonstrate the complexity of psychiatric and legal issues prompted by COVID-19 in terms of providing mental health care, protecting rights, exercising decision-making capacity, and a range of other topics. While further work is needed in many of these areas, these papers provide a strong framework for addressing key issues and meeting the challenges that COVID-19 and, possibly, other outbreaks are likely to present in the future.

Implementation of the European Psychiatric Association (EPA) guidance on forensic psychiatry in Poland. Current state and required measures. / Implementacja wytycznych Europejskiego Towarzystwa Psychiatrycznego (EPA) w zakresie psychiatrii sadowej w Polsce. Stan obecny i konieczne dzialania.

The article discusses the key aspects of the guidance of the European Psychiatric Association (EPA) on forensic psychiatry and the required actions to implement guidance into clinical practice. The authors pay attention to the discrepancies between the recommendations resulting from the guidance and clinical practice and current systemic solutions. The basic difficulties were discussed in relation to the implementation of the guidelines in the clinical practice in Poland as regards providing services as an expert by psychiatrists and psychologists, risk assessment and management, psychiatric therapy in detention centers, implementation of protection measures in inpatient and outpatient treatment conditions, efficiency of pharmacological and non-pharmacological interventions. We hope that discussing the content of the guidance will help to deepen the knowledge of clinicians in the field of work as court expert witnesses and persons responsible for the implementation of the preventive measure. Based on the clinical experience measures were proposed that enable implementation of the guidance, and thus improvement of the quality of care exercised over the mentally ill criminal offenders.