Perfil epidemiológico de los ingresos involuntarios en el Servicio de Psiquiatría del Hospital Universitario de Gran Canaria Doctor Negrín / Epidemiological profile of involuntary admission in the Psychiatry Service of The University Hospital of Gran Canaria Doctor Negrin

Introducción los ingresos involuntarios por razón de trastorno psíquico se producen con relativa asiduidad en las unidades de internamiento hospitalarias de nuestro país. Este trabajo someterá a estudio las características socio-demográficas y clínicas que se encuentran en relación con este tipo de pacientes, para disponer de más información, tanto clínica como legal, con la que trabajar y desempeñar una mejor función, administración de recursos y desarrollo de habilidades necesarias ante estas situaciones. Material y métodos estudio observacional descriptivo retrospectivo, en el cual se analizarán diferentes variables, seleccionadas previamente, presentes en la población de pacientes psiquiátricos ingresados involuntariamente en el Hospital Doctor Negrín en un período de tiempo de 2 años, 2019 y 2020, determinando así el grado de prevalencia de cada una de ellas. Resultados entre las variables más asociadas al ingreso involuntario se encuentran: ser varón, en la cuarta década de la vida, soltero, sin hijos ni empleo y con un diagnóstico de trastorno psicótico o afectivo mayor que muy probablemente ha abandonado el tratamiento. Discusión sería conveniente hacer un especial seguimiento a los pacientes que cumplan el perfil anteriormente descrito con el objetivo de minimizar la involuntariedad. Es necesario el desarrollo de programas educacionales, de seguimiento y adherencia al alcance de la población de pacientes psiquiátricos para así poder minimizar la necesidad de ingresos involuntarios en nuestro medio. (AU)

Introduction Involuntary admissions due to mental disorders occur with relative regularity in hospital admission units in our country. This work will study the socio-demographic and clinical characteristics found in relation to this type of patients, in order to have more information, both clinical and legal, with which to work and perform a better function, administration of resources and development of necessary skills in these situations. Material and methods Retrospective descriptive observational study, in which different variables will be analyzed, previously selected, present in the population of psychiatric patients involuntarily admitted to the Doctor Negrín Hospital in a period of 2 years, 2019 and 2020, thus determining, the degree of prevalence of each of them. Results Among the variables most associated with involuntary admission are, being a man, in the fourth decade of life, single, without children, or employment, with a diagnosis of major psychotic or affective disorder who has most likely abandoned treatment. Discussion It would be advisable to carry out a special follow-up of patients who meet the profile described above in order to minimize involuntary occurrence. It is necessary to develop educational, follow-up and adherence programs within the reach of the population of psychiatric patients in order to minimize the need for involuntary admissions in our environment. (AU)

[Involuntary detention and seclusion measures in psychiatry: Where are we now? A regional Centre-Val de Loire 2012-2017 study]. / Soins sans consentement et mesures d'isolement en psychiatrie adulte : où en est-on ? L'exemple de la région Centre-Val de Loire via le Programme de médicalisation des systèmes d'information 2012­2017.

BACKGROUND: The French legal framework in psychiatry for involuntary detention (ID) and seclusion measures was modified in 2011 and 2016, respectively. This study aimed to describe the evolution of ID and seclusion measures in the Centre-Val de Loire region (CVL France) between 2012 and 2017, using the psychiatric hospital discharge database. METHODS: A cross-sectional study was conducted, including adult patients (≥ 18 years old) from CVL hospitalized in psychiatry or included in a care program (outpatient care) between 2012 and 2017. Hospital stays for each patient were identified by an anonymized number. RESULTS: In 2017 in CVL, 13,942 patients were hospitalised for psychiatric reasons, with 2378 in ID (17%), a proportion that has remained stable since 2012. Among them, 3% were in care due to imminent danger (+ 54% since 2013, stabilisation since 2016), and 11% were hospitalized following a third party request (-13%). However, regarding location results varied from one department to the next. Seclusion measures involved 10% of full-time patients (stable), 27% of ID patients and 3% of those under voluntary care (stable). One quarter of the secluded patients were in voluntary care. Mean seclusion duration was 12 days, consecutive or not, and somewhat less for patients in voluntary care alone (10 days). CONCLUSION: The region wide ID rate and average duration of seclusion were lower than the nationwide rate (24% in full-time ID in 2015; 15 days of seclusion/patient), whereas the number of imminent danger procedures increased, as did the persistence of seclusion measures for patients in voluntary care (recommended only as a last resort and/or for ID patients). These results should lead to renewed assessment of care center practices. The French psychiatric hospital discharge database has several limitations, including lack of financial incentive and highly complex structuration. However, since 2018 new data regarding seclusion and restraint measures have been added to the existing registry, and they should facilitate more accurate analyses, particularly as concerns restraint.

Tratamiento ambulatorio involuntario: una propuesta de regulación / Involuntary outpatient treatment: a proposal of regulation

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Involuntary hospitalization among young people with early psychosis: A population-based study using health administrative data.

OBJECTIVE: Early psychosis is an important window for establishing long-term trajectories. Involuntary hospitalization during this period may impact subsequent service engagement in people with newly diagnosed psychotic disorder. However, population-based studies of involuntary hospitalization in early psychosis are lacking. We sought to estimate the proportion of people aged 16 to 35 years with early psychosis in Ontario who are hospitalized involuntarily at first admission, and to identify the associated risk factors and outcomes. METHODS: Using linked population-based health administrative data, we identified incident cases of non-affective psychosis over a five-year period (2009-2013) and followed cases for two years to ascertain the first psychiatric hospitalization. We used modified Poisson regression to model sociodemographic, clinical, and service-related risk factors, and compared service-related outcomes for cases admitted on an involuntary versus voluntary basis. RESULTS: Among 17,725 incident cases of non-affective psychosis, 38% were hospitalized within two years, and 81% of these admissions occurred on an involuntary basis (26% of cohort). Sociodemographic factors associated with an increased risk of involuntary admission included younger age (16-20), and first-generation migrant status. The strongest risk factors were poor illness insight, recent police involvement, and admission to a general (versus psychiatric) hospital. Outcomes associated with involuntary admission included increased likelihood of control intervention use and a shorter length of stay. CONCLUSIONS: One in four young people with first-episode psychosis will have an involuntary admission early in the course of their illness. Our findings highlight areas for intervention to improve pathways to care for people with psychotic disorder.

Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis.

BACKGROUND: Community treatment orders (CTOs) are a controversial form of involuntary treatment for individuals affected by mental health disorders and yet little is known about the use of CTOs in first presentations. Therefore, this study aimed to determine the rates, determinants and outcomes associated with the use of CTOs in young people with a first episode of psychosis (FEP). METHODS: This epidemiological cohort study included all individuals aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne between 01.01.2011 and 31.12.13. RESULTS: A total of 544 young people presented with a FEP during the study period and of these, 93 (17.3%) were subject to a CTO during their episode of care. A total of 69.7% of CTOs were commenced after the first three months of treatment and the median duration of CTOs was 168.5 days. Males, a diagnosis of a schizophrenia spectrum disorder and a concurrent substance abuse disorder were associated with the use of CTOs. Additionally, young people with more severe positive psychotic symptoms were more likely to be subject to a CTO. At the time of discharge, only 38.7% of those subject to a CTO were in education or employment compared to 65.4% of those who had not been subject to a CTO. CONCLUSIONS: The majority of CTOs are commenced after at least three months of treatment, however the optimal timing of CTO implementation needs to be determined. The poor functioning of young people on a CTO should be the focus of future interventional studies.

Compulsory community treatment and ethnicity: Findings from a culturally and linguistically diverse area of Queensland.

OBJECTIVE: To compare the use of community treatment orders (CTOs) and forensic orders (FOs) in a culturally and linguistically diverse (CALD) population to that in a non-CALD population. METHODS: We analysed the relationship between coming from a CALD background and the use of CTOs and FOs on discharge from hospital using merged data from the Metro South Addiction and Mental Health Service's Transitions of Care (ToC) and Consumer Integrated Mental Health Application (CIMHA) databases. RESULTS: Nine hundred and seventy-six individual records were included in the data set, of whom eighty-six were from a CALD background (8.8%). Three hundred and eleven patients were on compulsory community treatment. Use of compulsory community treatment (CTOs and FOs) was similar for those born in Australasia, British Isles, North America and Europe but significantly higher for those born elsewhere even after adjusting for socio-demographic and clinical variables (Adj OR 2.19, 95% CI 1.36-3.52). The use of an interpreter significantly increased the likelihood of compulsory community treatment (Adj OR 2.76, 95% CI 1.20-6.35). Restricting the analyses to CTOs only did not alter these results. CONCLUSIONS: Metro South residents from a CALD background outside of Europe were over-represented on compulsory community treatment orders. This could reflect the difficulties in accessing voluntary services, communication barriers, stigma associated with mental illness, discrimination, or issues related to accurately diagnosing mental illness cross-culturally. Clinicians need to be aware of the complexity of working with people from diverse cultures and apply these orders judiciously.

A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm.

BACKGROUND: The use of involuntary psychiatric holds (IPH) to detain patients who lack the capacity to make health care decisions due to nonpsychiatric conditions is common. While this practice prevents patient harm, it also deprives civil liberties, risks liability for false imprisonment, and may hinder disposition. Medical incapacity hold (MIH) policies, which establish institutional criteria and processes for detaining patients who lack capacity but do not meet criteria for an IPH, provide a potential solution. METHODS: A retrospective chart review was conducted on adult medical/surgical inpatients placed on an IPH or MIH over the 1-year periods before and after implementation of a MIH policy at an academic medical center. The primary outcome was frequency of IPH utilization in patients who did not qualify for an IPH as determined by 2 independent physician reviewers. A Cohen's kappa was calculated to determine inter-rater reliability. Differences in patient demographics and outcomes were compared using a Student's t-test, Wilcoxon rank-sum test, and Pearson chi-square test (α = 0.05). RESULTS: The Cohen's kappa was 0.72 indicating substantial agreement. Seventy MIHs were placed after implementation (mean duration 4.3 days). Before MIH implementation, 17.6% of IPHs were placed on non-qualifying patients, which decreased to 3.9% following MIH implementation (p < 0.01). The average length of stay for patients on an IPH or MIH did not change following MIH implementation. No instances of patient elopement, grievances, or litigation were found. CONCLUSION: MIH policies benefit both patients lacking capacity and the health care systems seeking to protect them while avoiding inappropriate use of IPHs.

Involuntary psychiatric admission based on risk rather than need for treatment: report from the Dublin Involuntary Admission Study (DIAS).

Aims Involuntary psychiatric admission in Ireland is based on the presence of mental disorder plus serious risk to self/others and/or need for treatment. This study aimed to examine differences between use of risk and treatment criteria, about which very little is known. Methods We studied 2,940 admissions, of which 423 (14.4%) were involuntary, at three adult psychiatry units covering a population of 552,019 people in Dublin, Ireland. Results Involuntary patients were more likely than voluntary patients to be male, unmarried and have schizophrenia or a related disorder. Involuntary admission based on the 'risk criterion' (rather than the 'treatment criterion' or both) was associated with a shorter period as an involuntary patient for patients with diagnoses other than schizophrenia. Conclusion If inpatient units are intended as treatment centres rather than risk management units, the balance between considerations of risk and treatment requires careful re-examination in the setting of involuntary psychiatric care.

A comparison of the reported use of involuntary treatment orders within Australian jurisdictions.

OBJECTIVE: This paper identifies publicly available data about the use of involuntary treatment orders within Australia and considers whether this reporting is sufficient given the gravity of the intervention. METHOD: A search of mental health tribunal, health department and justice department annual reports was conducted to determine the use of involuntary treatment orders in Australia. RESULTS: Reporting of involuntary treatment orders varied significantly across jurisdictions; for example, South Australia reported 11,570 distinct orders made during a 12-month period while the Australian Capital Territory reported 627 for the same period. CONCLUSION: The publicly available data for involuntary treatment orders in Australia is inadequate for jurisdictional comparisons. This concern should be addressed to enable transparent public reporting and facilitate benchmarking.

Demographic and clinical characteristics of patients involuntarily hospitalized in an Italian psychiatric ward: a 1-year retrospective analysis.

BACKGROUND: In Italy, psychiatric compulsory treatments are regulated by Law 180 of 13-5-1978 that establishes three criteria: 1) acute psychiatric conditions requiring urgent treatment, 2) patient's refusal of treatment, 3) inpatient treatment is necessary and cannot be postponed. AIM: To highlight demographic and clinical risk factors for involuntary treatments. METHODS: We retrospectively collected all hospitalizations in the Service of Psychiatric Diagnosis and Treatment of a northern Italian town from 1-1-2015 to 31-12-2015. We statistically compared demographic and clinical variables related to voluntarily and involuntarily admitted patients and their hospitalizations. RESULTS: We divided our sample into patients voluntarily hospitalized (PVH=236) and involuntarily (PIH=160) according to their voluntary (VH= 304) and involuntary (IH=197) hospitalizations. PIH were older than PVH and, more frequently, lived alone and were unemployed (p<0.001). "Acute worsening of psychopathology" for IH and "Suicidality" for VH were the prevalent reasons (p<0.001). IH was longer than VH (p<0.001). Among PIH, the most frequent diagnoses were "Schizophrenia and Other Psychosis" (ICD-9-CM) and "Ineffective Impulse Control + Disturbed Personal Identity" (NANDA-I) (p<0.001). During hospitalizations, PIH more often than PVH presented aggressive behavior (p<0.001). At discharge, PIH were more frequently sent to another psychiatric ward or protected facility with long-acting injectable antipsychotics (p<0.001). CONCLUSIONS: Our involuntarily admitted patients were affected by severe psychiatric disorders with social maladjustment and required complex therapeutic and rehabilitative programs to counteract aggressive behaviour, poor therapeutic compliance and prolonged hospitalizations. The assessment of patients' characteristics can help clinicians recognize who are at risk for compulsory treatment and prevent it.

Community treatment orders: towards a new research agenda.

OBJECTIVES: The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research. METHODS: The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects. RESULTS: Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified. CONCLUSIONS: The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.

Length of Involuntary Hospitalization Related to the Referring Physician's Psychiatric Emergency Experience.

Although involuntary commitment (IC) is a serious intervention in psychiatry and must always be regarded as an emergency measure, the knowledge about influencing factors is limited. Aims were to test the hypothesis that duration of involuntary hospitalization and associated parameters differ for IC's mandated by physicians with or with less routine experience in psychiatric emergency situations. Duration of involuntary hospitalization and duration until day-passes of 508 patients with IC at the University Hospital of Psychiatry Zurich were analyzed using a generalized linear model. Durations of involuntary hospitalization and time until day-passes were significantly shorter in patients referred by physicians with less routine experience in psychiatric emergency situations than compared to experienced physicians. Shorter hospitalizations following IC by less-experienced physicians suggest that some IC's might be unnecessary. A specific training or restriction to physicians being capable of conducting IC could decrease the rate of IC.

Cultural and linguistic diversity increases the likelihood of compulsory community treatment.

BACKGROUND: People from culturally and linguistically diverse (CALD) backgrounds are over-represented in compulsory admissions to hospital but little is known about whether this also applies to community treatment orders (CTOs). AIMS: We investigated any differences between Australian- and foreign-born patients in the likelihood of CTO placement using state-wide databases from Western Australia. METHODS: Cases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Logistic regression was then used to identify potential predictors of a CTO. We also assessed if any differences in CTO placement between Australian- and foreign-born patients had effects on bed-days or community contacts in the subsequent year. RESULTS: We identified 2958 CTO cases and controls from November 1997 to December 2008 (total n=5916). Of these, 74% had schizophrenia or other non-affective psychoses. Patients who were born in New Zealand, the United Kingdom or Ireland had very similar rates of CTO placement compared to those who were Australian-born. By contrast, there was a gradient of increasing risk of CTO placement for people born in Continental Europe (ORadj=1.36; 95% CI=1.07-1.71, p=0.01) and then the Rest of the World (ORadj=1.61; 95% CI=1.31-1.97, p<0.001). However, there was no evidence of additional benefit in terms of health service use in the following year. CONCLUSIONS: In common with other coercive treatments, people from culturally and linguistically diverse (CALD) backgrounds are more likely to be placed on CTOs. Further research is needed to establish if this is for similar reasons.

Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis.

BACKGROUND: The increasing rate of compulsory admission to psychiatric inpatient beds in England is worrying. Studying variation between places and services could be key to identifying targets for interventions to reverse this trend. We modelled spatial variation in compulsory admissions in England using national patient-level data and quantified the extent to which patient, local-area, and service-setting characteristics accounted for this variation. METHODS: This study is a cross-sectional, multilevel analysis of the 2010-11 Mental Health Minimum Data Set (MHMDS). Data from eight provider trusts were excluded, including three independent provider trusts that lacked spatial identification codes. We excluded patients detained under sections of the Mental Health Act concerned only with conveyance to, or assessment in, a registered Place of Safety, or for short-term (≤72 h) assessment only, as these do not in themselves necessarily mean that the person will be admitted to an inpatient mental health bed. MHMDS contained reasonably complete data for a limited number of patient characteristics, namely age, sex, and ethnicity; however, several patient-level variables could not be included in our analysis because of high levels of missing data. Multilevel models were applied with MLwiN to estimate variation in compulsory admission, starting with null (unconditional) models that partitioned total variance in compulsory admission between each level in the model. The primary outcome was compulsory admission to a psychiatric inpatient bed, compared with people admitted voluntarily or receiving only community-based care. FINDINGS: Data were available for 1 238 188 patients, covering 64 National Health Service provider trusts (93%) and 31 865 census lower super output areas (LSOAs; 98%). 7·5% and 5·6% of the variance in compulsory admission occurred at LSOA level and provider trust levels, respectively, after adjusting for patient characteristics. Black patients were almost three times more likely to be admitted compulsorily than were white patients (odds ratio [OR] 2·94, 95% CI 2·90-2·98). Compulsory admission was greater in more deprived areas (OR 1·22, 1·18-1·27) and in areas with more non-white residents (OR 1·51, 1·43-1·59), after adjusting for confounders. INTERPRETATION: Rates of compulsory admission to inpatient psychiatric beds vary significantly between local areas and services, independent of patient, area, and service characteristics. Compulsory admission rates seem to reflect local factors, especially socioeconomic and ethnic population composition. Understanding how these factors condition access to, and use of, mental health care is likely to be important for developing interventions to reduce compulsion. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme.

Factors Affecting the Agreement Between Emergency Psychiatrists and General Practitioners Regarding Involuntary Psychiatric Hospitalizations.

Important discrepancies exist between physicians in deciding when to perform involuntary hospitalization measures (IHMs). The factors underlying these differences are poorly known.We conducted a two-year single-center retrospective study in France on patients who were referred to the emergency department (ED) with an IHM certificate written by a private-practice General Practitioner (GP). For each consultation, the official IHM motive was categorized into four groups: Suicide; Psychosis, Mania, or Melancholia (PMM); Agitation; and Other. The alcohol status of the patient was also noted. The factors underlying the ED psychiatrists' confirmation of the use of IHMs were determined using a logistic regression model. One hundred eighty-nine cases were found (165 patients; 44.2 ± 16 years, 41.3% women). The ED psychiatrists confirmed the use of IHMs in 123 instances (65.1% agreement rate). Multivariate analyses found that IHM disagreement was significantly associated with patient alcohol status and the reason for referral. Specifically, there was an increased risk of IHM disagreement when the patient had an alcohol-positive status (OR = 15.80; 95% CI [6.45-38.67]; p < 0.0001) and when the motive for IHM was "agitation" compared with "suicide" (OR = 11.44; 95% CI[3.38-38.78]; p < 0.0001). These findings reflect significant disparities between GPs and ED psychiatrists regarding the decision to proceed to an IHM.

Rate of community treatment orders and readmission orders following reconfiguration of community mental health services.

OBJECTIVES: Community treatment orders (CTOs) are a controversial practice as they extend the practice of involuntary treatment into the community. This study aimed to determine whether there was a difference in the rate of CTOs and revocation (readmission) orders following the implementation of a recovery-orientated model across four adult mental health services. METHODS: A retrospective cohort study was conducted prior to and after the reconfiguration of services. Population data for those aged 15 to 65 were obtained from a census and rate rates were calculated. RESULTS: Prior to the reconfiguration, there were 893 individuals subject to a CTO and 136 of these individuals had a revocation of their CTO (i.e. were involuntarily readmitted). This represented a rate of 100.8 individuals on CTOs per 100,000 population and a rate of 15.4 revocations per 100,000 population. Following the reconfiguration, the rate of CTOs increased by 10% and there was a trend for the rate of revocation orders to have decreased by 17%. CONCLUSIONS: Rates of CTOs and readmissions varied across services and further research is warranted to identify factors associated with these increased rates. Additionally, the very high rate of CTOs in the catchment areas warrants further examination.