Should Dignity Preservation Be a Precondition for Safety and a Design Priority for Healing in Inpatient Psychiatry Spaces?

Therapeutic security in inpatient psychiatric settings requires careful planning and implementation if it is to support patients' safety and dignity. This commentary on a case considers patients' dignity experiences when restrictions on their freedom are used to keep them safe.

What is the role of gender in perceived coercion during psychiatric admission?

OBJECTIVES: This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission. METHODS: We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020. RESULTS: Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation. CONCLUSIONS: Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.

Seclusion, Restraint, Therapeutic Alliance, and Legal Admission Status: What Really Matters?

OBJECTIVE: To determine the relationships, if any, between use of seclusion and restraint and factors such as demographic parameters, diagnosis, legal admission status (voluntary or involuntary), symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, and insight, among psychiatry inpatients in Ireland. METHODS: We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry units at 2 general hospitals in Dublin, Ireland over a 30-month period, between September 2017 and February 2020. RESULTS: The most common diagnoses in our sample were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioral disorders (11.2%). Over a quarter (n=29, 27.1%) of the participating patients had involuntary legal status. Of the 107 patients, 11 patients (10.3%) experienced sedation and/or physical restraint, with 9 patients (8.4%) experiencing at least 1 episode of seclusion and 10 patients (9.3%) experiencing at least 1 episode of physical restraint. On the basis of multivariable analyses, seclusion was associated with younger age and involuntary status, while physical restraint was associated with involuntary status. Each multivariable model explained just over one third of the variance in the distribution of these seclusion and restraint practices. CONCLUSIONS: Use of seclusion and restraint was most strongly associated with involuntary admission status and, in the case of seclusion, younger age, rather than sex, diagnosis, symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, or insight. The network of interactions between involuntary status and use of seclusion and restraint merits much closer attention, especially as use of seclusion and physical restraint appears to be associated with involuntary legal status independent of level of symptoms, therapeutic alliance, or insight.

The association between objective necessity for involuntary treatment as measured during admission, legal admission status and clinical factors in an inpatient psychiatry setting.

Involuntary psychiatric admission is a common feature of mental health services around the world, but there is limited research about tools to support clinical assessment of objective necessity for compulsory care. Our study aimed to determine the relationships between objective necessity for involuntary treatment as measured by the Compulsory Treatment Checklist (CTC), legal admission status (voluntary or involuntary) and various clinical parameters (e.g. symptoms, insight) in an Irish inpatient psychiatry setting. The CTC is relatively new tool, developed and described by Brissos et al. (2017) in Portugal and designed to evaluate the necessity for compulsory treatment; its total score ranges from 0 to 50 (with higher scores indicating greater need for involuntary care). In our study, we used validated tools, including the CTC, to perform detailed assessments of 107 adult patients admitted to the acute psychiatry inpatient units of two general hospitals in Dublin, Ireland over a 30-month period. The most common diagnoses were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioural disorders (11.2%). Over a quarter (27.1%) of patients had involuntary legal status. Higher CTC scores were significantly and independently associated with involuntary status (p < 0.001), more positive symptoms of schizophrenia (p < 0.001), and younger age (p = 0.031). The original Portuguese study of the CTC identified an optimal cut-off score of 23.5, which detected compulsory treatment with a sensitivity of 75% and specificity of 93.6% in that sample. In our sample, the optimal cut-off score was 16.5, which detected compulsory treatment with a sensitivity of 82.8% and specificity of 69.2%. We conclude that the CTC is a useful tool not only in Portugal but in other countries too, and that its performance will likely vary across jurisdictions, resulting in different optimal cut-off scores in different countries.

The association between perceived coercion on admission and formal coercive practices in an inpatient psychiatric setting.

Involuntary care is a feature of mental health services around the world. In addition to involuntary admission and treatment, specific coercive practices include seclusion and physical restraint. Our study aimed to determine the relationships, if any, between these practices and perceived coercion on admission among psychiatry inpatients in Ireland, as well as any relationships between perceived coercion on admission and variables such as age, gender and diagnosis. We included 107 psychiatry inpatients aged 18 years or over who were admitted to the acute psychiatry admission units in Tallaght University Hospital and Connolly Hospital, Dublin, Ireland over a 30-month period between September 2017 and February 2020. Over a quarter (27.1%) of participating patients had involuntary status; nine (8.4%) had experienced at least one episode of seclusion, and ten (9.3%) had experienced at least one episode of restraint. Perceived coercion on admission was significantly associated with involuntary status and female gender; perceived negative pressures on admission were significantly associated with involuntary status and positive symptoms of schizophrenia; perceived procedural injustice on admission was significantly associated with fewer negative symptoms, involuntary status, cognitive impairment and female gender; and negative affective reactions to hospitalisation on admission were significantly associated with birth in Ireland and being employed. Total score across these four subscales was significantly associated with involuntary status and positive symptoms, and had borderline significant associations with birth in Ireland, being employed and female gender. Overall, perceived coercion on admission, assessed in retrospect by the patient, is more closely associated with involuntary status and symptoms than it is with subsequent formal coercive practices, such as seclusion and restraint. The role of gender merits particular attention in future research, especially in relation to procedural injustice on admission and perceived coercion on admission.

Dignity: The elephant in the room in psychiatric inpatient care? A systematic review and thematic synthesis.

Involuntary psychiatric inpatient care presents a unique ethical challenge not least because the dignity of a person whose liberty and autonomy are restricted is inherently at risk. Understanding patients' experience of voluntary and involuntary care is an important part of ensuring that dignity is upheld as a key value. This study aimed to provide the first thematic synthesis of the existing literature on patient experience of dignity in voluntary and involuntary inpatient psychiatric care. PubMed (United States National Library of Medicine), PsycInfo (American Psychological Association), the Cochrane Library and bibliographies of relevant articles were searched for peer-reviewed, English-language studies from the start date of the databases through May 2020. Systematic searches identified 202 original papers. Consensus criteria were used to determine study inclusion through abstract and manuscript review. Eighteen articles were initially identified as suitable and nine met criteria for the final analysis. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Given the high proportion of qualitative literature, a thematic synthesis approach was adopted. Critical Appraisal Skills Program (CASP) checklists were used to assess quality of papers. Familiarization and line-by-line coding were carried out on qualitative studies and a thematic framework developed using an iterative approach. Six key themes emerged: coercion; powerlessness; care environment; relationship to staff; impact of involuntary treatment, and paradoxes. These encompassed 15 subthemes, comprising 111 individual statements. Despite dignity being at the core of this review, only five of the identified papers explicitly referenced the term. Nevertheless, core similarities in patient experiences and perspectives existed across a wide variety of primary studies from multiple sites. These themes can be taken to represent the components of dignified care and used as a framework for further research and service reform.

Categorical mental capacity for treatment decisions among psychiatry inpatients in Ireland.

This study aimed to assess mental capacity for treatment decisions among psychiatry inpatients in Ireland and explore the relationship, if any, between mental capacity and various demographics and clinical variables. We assessed mental capacity for treatment decisions in 215 psychiatry inpatients in four psychiatry admission units. Almost half of the participants were female and the most common diagnoses were schizophrenia or a related disorder and affective disorders. Overall, 1.9% of participants lacked mental capacity for treatment decisions; 50.7% had partial mental capacity; and 47.4% had full mental capacity. These proportions did not differ between female and male patients. On multi-variable regression analysis, greater mental capacity was significantly associated with, in order of strength of association, voluntary admission status, Irish ethnicity, being employed and younger age. However, while these relationships were statistically significant (i.e. were unlikely to have occurred by chance), together they accounted for just 27.6% of the variance in mental capacity between participants (i.e. they were not very strong). The relatively high rate of "partial mental capacity" identified in our work suggests that decision-making supports are likely to be of substantial importance in assisting psychiatry inpatients making decisions about treatment, especially involuntary inpatients whose mental capacity is especially likely to be impaired. Future research could usefully clarify and quantify the role of cognitive and other factors in relation to the unexplained variance (72.4%) in mental capacity identified in this study; and explore which models of supported decision-making are most likely to assist the substantial proportion (50.7%) of psychiatry inpatients who have partial mental capacity for treatment decisions, as well as the minority lacking such mental capacity (1.9%).

Concordance of mental capacity assessments based on legal and clinical criteria: A cross-sectional study of psychiatry inpatients.

This study aimed to compare assessments of mental capacity based on legal criteria with assessments based on clinical criteria among psychiatry inpatients to establish the concordance, if any, between these two approaches to assessing mental capacity. We assessed mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland using both legal criteria (Ireland's Assisted Decision-Making (Capacity) Act 2015) and clinical criteria (the MacArthur Competence Assessment Tool for Treatment; MacCAT-T). Over one third of participants (34.9%) lacked mental capacity for treatment decisions according to the legal criteria. Mental incapacity was associated with involuntary admission status, being unemployed, a primary diagnosis of schizophrenia or a related disorder, and older age. Patients who lacked mental capacity according to the legislation scored significantly lower on all subscales of the MacCAT-T than patients who had mental capacity. We conclude that mental capacity assessments based on legal criteria correlate closely with those based on clinical criteria. These findings support current legal definitions of mental incapacity in Ireland and other jurisdictions with similar legislation (e.g. England and Wales).