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

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

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

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

Legal and Ethical Challenges, Part 1: General Population.

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

The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders.

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Psychiatric Boarding in Washington State and the Inadequacy of Mental Health Resources.

Psychiatric boarding is a term derived from emergency medicine that describes the holding of patients deemed in need of hospitalization in emergency departments for extended periods because psychiatric beds are not available. Such boarding has occurred for many years in the shadows of mental health care as both inpatient beds and community services have decreased. This article focuses on a 2014 Washington State Supreme Court decision that examined the interpretation of certain sections of the Washington state civil commitment statute that had been used to justify the extended boarding of detained psychiatric patients in general hospital emergency departments. The impact of this decision on the state of Washington should be significant and could spark a national debate about the negative impacts of psychiatric boarding on patients and on the nation's general hospital emergency services.

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

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

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

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

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

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

The outcome of mental health care users admitted under Section 40 of the South African Mental Health Care Act (No 17 of 2002).

OBJECTIVE: To determine the outcomes of mental health care users (MHCU's) admitted in terms of Section 40 of the South African Mental Health Care Act (No 17 of 2002) (MHCA) and the factors, if any, that are associated with these outcomes. METHOD: The study was a retrospective record review of MHCU's, 18 years and older, referred by the South African Police Service (SAPS) to Chris Hani Baragwanath Hospital (CHBH). All mental health care users handed over to CHBH by SAPS with completed MHCA form 22's during the period July 2007 to December 2007 were included in the study. The outcomes, demographics and clinical characteristics of these referrals were obtained from hospital records. RESULTS: During the six-month study period, 718 MHCU's were referred by members of SAPS to the CHBH Emergency Department. Associations were found between discharged MHCU's and i) being male, ii) being less than 35 years of age, iii) being unemployed, iv) having a lower level of education, v) having a past history of substance abuse and/or vi) a past psychiatric illness. Females were twice as likely to be unemployed and admitted to hospital (either to a psychiatric or general medical ward). MHCU's diagnosed with delirium were more likely to be admitted into a medical ward as compared to a psychiatric ward. CONCLUSION: As has been the case in most countries where police services have been incorporated into mental health acts, South Africa's new Mental Health Care Act (No 17 of 2002) has resulted in a large number of referrals by the police to mental health services. However, many of these referrals may not be necessary as most MHCU's end up not being admitted. The characteristics of police referrals suggest that the receiving facility should have the capacity to identify factors that favour outpatient care (especially substance abuse problems) and divert MHCU's presenting with such factors to appropriate treatment facilities without admitting them to the hospital.

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

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

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

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

Covert medication in psychiatric emergencies: is it ever ethically permissible?

Covert administration of medications to patients, defined as the administration of medication to patients without their knowledge, is a practice surrounded by clinical, legal, ethics-related, and cultural controversy. Many psychiatrists would be likely to advocate that the practice of covert medication in emergency psychiatry is not clinically, ethically, or legally acceptable. This article explores whether there may be exceptions to this stance that would be ethical. We first review the standard of emergency psychiatric care. Although we could identify no published empirical studies of covert administration of medicine in emergency departments, we review the prevalence of this practice in other clinical settings. While the courts have not ruled with respect to covert medication, we discuss the evolving legal landscape of informed consent, competency, and the right to refuse treatment. We discuss dilemmas regarding the ethics involved in this practice, including the tensions among autonomy, beneficence, and duty to protect. We explore how differences between cultures regarding the value placed on individual versus family autonomy may affect perspectives with regard to this practice. We investigate how consumers view this practice and their treatment preferences during a psychiatric emergency. Finally, we discuss psychiatric advance directives and explore how these contracts may affect the debate over the practice.

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

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

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

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

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

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