Internamiento involuntario vs. Retención ilegal en pacientes contrastorno mental grave / Involuntary internment vs. Illegal retention in patients with serious mental disorder

Aunque una buena actitud hacia la terapia y el cumplimiento de la misma son claves para el éxito del tratamiento, en ciertas situaciones el uso de medidas coercitivas en personas con trastornos mentales es la única forma de prevenir daños graves al paciente y a otras personas. La decisión de utilizar estas medidas, como el internamiento involuntario, es un desafío para los médicos, ya que tienen que lidiar no solo con la voluntad del paciente y de sus familiares, que se encuentran en una situación emocional desbordada, sino también con el conocimiento de la normativa vigente, especialmente complejas. Para proteger los derechos del paciente en estas situaciones difíciles y del personal clínico, es esencial que el mismo conozca los límites de su actuación en el marco del procedimiento legal. Por ello, se necesitan más estudios en la materia, que ofrezcan conclusiones contrastadas con respecto a las diferencias entre el internamiento involuntario y la retención ilegal.(AU)

Even though a good attitude towards therapy and adherence are key to an effective treatment, in certain circumstances the use of coercive actions in people with mental disorders is the only way to prevent serious harm to the patient and to others. The choice to use coercive measures, such as involuntary internment, is a challenge for doctors, since not only do they have to deal with the patient and their relatives who are in a highly emotional situation, but there are also complex legal regulations. To defend the rights of patients in these difficult situations, and to avoid legal consequences for clinical staff due to illegal acts, it is essential that staff are familiar with all of the relevant legal rules and procedures. Further studies are warranted to obtain clear conclusions regarding differences between involuntary internment and illegal retention.(AU)

Clinical and Ethical Dilemmas in the Involuntary Treatment of Anorexia Nervosa.

LEARNING OBJECTIVES: After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. ABSTRACT: Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.

Psychiatric patients' attitudes towards being hospitalized: a national multicentre study in Norway.

BACKGROUND: The aim of the study was to explore patients' attitudes towards voluntary and involuntary hospitalization in Norway, and predictors for involuntary patients who wanted admission. METHODS: A multi-centre study of consecutively admitted patients to emergency psychiatric wards over a 3 months period in 2005-06. Data included demographics, admission status (voluntary / involuntary), symptom levels, and whether the patients expressed a wish to be admitted regardless of judicial status. To analyse predictors of wanting admission (binary variable), a generalized linear mixed modelling was conducted, using random intercepts for the site, and fixed effects for all variables, with logit link-function. RESULTS: The sample comprised of 3.051 patients of witch 1.232 (40.4%) were being involuntary hospitalised. As expected 96.5% of the voluntary admitted patients wanted admission, while as many as 29.7% of the involuntary patients stated that they wanted the same. The involuntary patients wanting admission were less likely to be transported by police, had less aggression, hallucinations and delusions, more depressed mood, less use of drugs, less suicidality before admission, better social functioning and were less often referred by general practitioners compared with involuntary patients who did not want admission. In a multivariate analysis, predictors for involuntary hospitalization and wanting admission were, not being transported by police, less aggression and less use of drugs. CONCLUSIONS: Almost a third of the involuntary admitted patients stated that they actually wanted to be hospitalized. It thus seems to be important to thoroughly address patients' preferences, both before and after admission, regarding whether they wish to be hospitalized or not.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry.

BACKGROUND: Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. MAIN BODY: The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002-2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. CONCLUSION: Ross Upshur's principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

District nurses' attitudes towards involuntary treatment in dementia care at home: A cross-sectional study.

One in two persons living with dementia (PLWD) at home receive care which they resist to and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in the use of involuntary treatment. However, little is known how their attitudes and opinions influence the use of involuntary treatment. This cross-sectional study aims to investigate the attitudes of district nurses towards the use of involuntary treatment in dementia care at home, determinants and their opinion about its restrictiveness and discomfort. Results show that district nurses perceive involuntary treatment as regular part of nursing care, having neither positive nor negative attitude towards its appropriateness. They consider involuntary treatment usage as moderately restrictive to PLWD and feel moderately uncomfortable when using it. These findings underscore the need to increase the awareness of district nurses regarding the negative consequences of involuntary treatment use to PLWD at home.

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 involuntary alcohol treatment and subsequent emergency department visits and hospitalizations: a Bayesian analysis of treated patients and matched controls.

BACKGROUND AND AIMS: Many nations have provisions for involuntary treatment of alcohol dependence where the person is at serious risk of harm to themselves. To date, there has been little thorough evaluation of its effectiveness. This study aimed to determine if there were differences between involuntary and voluntary treatment for alcohol dependence on subsequent emergency and hospital care. DESIGN: A retrospective cohort design using linked routinely collected administrative data on health-care utilization. SETTING: Hospital and community-based alcohol treatment, New South Wales, Australia. PARTICIPANTS: A total of 231 patients who were involuntarily treated for alcohol dependence and 231 matched controls who received treatment as usual within the period May 2012 to April 2018. INTERVENTION AND COMPARATOR: Involuntary treatment comprised a 28-day mandated hospital admission which included supervised withdrawal, comprehensive assessment, rehabilitation and support followed by voluntary aftercare support for up to 6 months. Treatment as usual comprised three not mutually exclusive forms of intensive voluntary alcohol treatment: withdrawal management, rehabilitation and pharmacotherapies for alcohol dependence. MEASUREMENTS: Outcome measures: changes in the number of emergency department (ED) visits and number of unplanned hospital admissions 12 months before and 12 months after completion of index treatment. FINDINGS: Both groups showed a reduction in ED visits (incidence rate ratio (IRR) = 0.56, 95% credible intervals (CrI) = 0.39-0.78) and unplanned hospital admissions (IRR = 0.49, 95% CrI = 0.37-0.65). There was no statistically significant difference between the two groups (IRR = 0.77, 95% CrI = 0.58-1.03 for ED visits and IRR = 0.79, 95% CrI = 0.62-1.01 for hospital admissions). The Bayes factors were 0.925 and 0.936 for ED visits and unplanned hospital admissions, respectively, interpreted as weak evidence in support of the null hypothesis of no difference between the interventions. CONCLUSIONS: Involuntary treatment of alcohol dependence was associated with reduced health service utilization in the year following treatment, and the outcomes did not differ from those of a matched control group.

[Involuntary Psychiatric Hospitalizations: From request to a call center to hospitalization]. / Admission en soins psychiatriques a la demande d'un tiers : de l'appel au SAMU a l'hospitalisation.

BACKGROUND: Involuntary psychiatric hospitalization (IPH) is a heavy and complex psychiatric exception measure. In the Seine-Saint-Denis department (low medical density), the evaluation of the patient in psychiatric decompensation is the responsibility of the out-of-hours general practitioners (GP) mandated by the call center. Their feeling is the non-achievement of the procedure once the patient arrives at the emergency room. We aimed to evaluate the outcome of patients following a request for IPH from these GP. METHODS: We conducted a retrospective study based on all requests for IPH received during 2016 at the Seine-Saint-Denis emergency medical call center. The characteristics of the call and the patient, as well as the decisions of the regulator and the GP were collected. The decision of hospitalization in the emergency room was sought for patients referred for IPH. RESULTS: Of the 7541 calls for decompensation, 539 were for an IPH. These calls occurred during non-working hours in 55 % of cases. A GP was involved in more than two-thirds of the cases and requested an IPH for 240/304 (79 %) patients. Patients were male in 56 % of cases with an average age of 40 (±16) years. IPH was confirmed for 132 (61 %) patients. This rate did not differ from the 65 % reported in the literature (Z-test, P=0.26). Voluntary hospitalization was performed for 37 (17 %) other patients. DISCUSSION: The IPH rate for patients referred by GP mandated by the call center was comparable to that following the requests of the attending physicians, validating their intervention in this critical context.

Compulsory treatment of physical illness under MHA 1983.

Taken together, Sections 145 and 63 of the Mental Health Act 1983 (MHA) provide for treatment without consent of physical illness ancillary to the mental disorder with which a patient presents. On a daily basis, clinicians make both the decision that the Act's authority can be applied to their patient's case, and that it should be applied. But in the unusual circumstances where there is uncertainty as to the applicability of the MHA to the ancillary treatment of physical illness, the assistance of a court may be sought. In so doing, the law (and thence the courts) may justify compulsion but never prescribes it; the clinician is presented with authority that he or she could use but is left to decide whether it should be employed. This paper explores how the clinical question is set before the court, and whether the distinction between symptom, manifestation and consequence is sufficiently understood. This has important consequences in the context of self-neglect and its close cousin self-harm: the question whether the relevant ailment was attributable to or exacerbated by neglect or self- inflicted harm will determine whether compulsion under the MHA is applicable; and furthermore, whether or not compulsion is clinically acceptable.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients.

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

A Quasi-experimental study on prevention and reduction of involuntary treatment at home (PRITAH) in people with dementia.

AIM AND OBJECTIVES: To examine the implementation (reach, dose, fidelity, adaptations, satisfaction), mechanisms of impact (attitude, subjective norm, perceived behavioural control and intention) and context of the PRITAH intervention. BACKGROUND: Involuntary treatment, defined as care provided against one's will, is highly prevalent in home care. The PRITAH intervention comprises policy, workshops, coaching and alternative measures for professional caregivers to prevent and reduce involuntary treatment in home care. DESIGN: Quasi-experimental study. METHODS: Eight home care teams from two care organisations participated in this study. Guided by the Theory of Planned Behavior, the mechanisms of impact were evaluated with questionnaires. Implementation and context were assessed using attendance lists, evaluation questionnaires, focus groups and logbooks. The study adhered to the TREND checklist. RESULTS: 124 of 133 eligible professional caregivers participated (93%). All four components were delivered with minor deviations from protocol. Participants' subjective norms and perceived behavioural control changed over time in favour of the intervention group. No effects were seen for attitude and intention. Barriers included an unclear policy and lack of communication between stakeholders. The multidisciplinary approach and possibility to discuss involuntary treatment with the specialised nurse were described as facilitators. CONCLUSIONS: Prevention and reduction of involuntary treatment at home is feasible in home care practice and contributes to changing professional caregivers' subjective norms and perceived behavioural control, prerequisites for behavioural change in order to prevent and reduce involuntary treatment. A follow-up study on the effectiveness of PRITAH on actual use, prevention and reduction of involuntary treatment in home care is needed. Future studies should emphasise the role of family caregivers and GPs and actively involve them in the prevention and reduction of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE: Involuntary treatment is commonly used in dementia home care and professional and family caregivers need to be supported in prevention and reduction of involuntary treatment in people with dementia.

Caregiver decision-making concerning involuntary treatment in dementia care at home.

BACKGROUND: Dementia care at home often involves decisions in which the caregiver must weigh safety concerns with respect for autonomy. These dilemmas can lead to situations where caregivers provide care against the will of persons living with dementia, referred to as involuntary treatment. To prevent this, insight is needed into how family caregivers of persons living with dementia deal with care situations that can lead to involuntary treatment. OBJECTIVE: To identify and describe family caregivers' experiences regarding care decisions for situations that can lead to involuntary treatment use in persons living with dementia at home. RESEARCH DESIGN: A qualitative descriptive interview design. Data were analysed using the Qualitative Analysis Guide of Leuven. PARTICIPANTS AND RESEARCH CONTEXT: A total of 10 family caregivers providing care for 13 persons living with dementia participated in in-depth semi-structured interviews. Participants were recruited by registered nurses via purposive sampling. ETHICAL CONSIDERATION: The study protocol was approved by the Ethics Committee of the University Hospitals Leuven and the Medical Ethical Test Committee Zuyderland. FINDINGS: Family caregivers experience the decision-making process concerning care dilemmas that can lead to involuntary treatment as complicated, stressful and exhausting. Although they consider safety and autonomy as important values, they struggle with finding the right balance between them. Due to the progressive and unpredictable nature of dementia, they are constantly seeking solutions while they adapt to new situations. Family caregivers feel responsible and experience social pressure for the safety of persons living with dementia. They may be blamed if something adverse happens to the persons living with dementia, which increases an already stressful situation. Their experience is influenced by characteristics of the care triad (persons living with dementia, professional and family caregivers) such as practical and emotional support, knowledge, and previous experiences. DISCUSSION AND CONCLUSION: To prevent involuntary treatment, professionals need to proactively inform family caregivers, and they need to support each other in dealing with complex care situations.

Involuntary treatment in dementia care at home: Results from the Netherlands and Belgium.

AIMS AND OBJECTIVES: To gain insight into the request, use and associated factors of involuntary treatment in people with dementia (PwD) receiving professional home care in the Netherlands and Belgium. BACKGROUND: Most of the PwD remain living at home as long as possible. Due to complex care needs, this can result in an increased risk for care provided against the wishes of the client and/or to which the client resists, referred to as involuntary treatment. DESIGN: Secondary data analyses of two cross-sectional surveys. METHODS: Dementia case managers and district nurses filled in a questionnaire for each PwD in their caseload. This study included data of 627 PwD receiving professional home care in the Netherlands and 217 in Belgium. The same methodology (questionnaire and variables) was used in both samples. Descriptive statistics and multi-level logistic regression analyses were used to analyse the data. The study adhered to the STROBE checklist. RESULTS: More than half of the PwD (50.7%) living at home received involuntary treatment (Belgium 68.2% and the Netherlands 44.7%). Nonconsensual care (82.7%) was the most common, followed by psychotropic medication (40.7%) and physical restraints (18.5%). Involuntary treatment use was associated with living alone, greater ADL dependency, lower cognitive ability, higher family caregiver burden and receiving home care in Belgium versus the Netherlands. Involuntary treatment was most often requested by family caregivers. CONCLUSIONS: Involuntary treatment is often used in PwD, which is in line with previous findings indicating dementia as a risk factor for involuntary treatment use. More research is needed to gain insight into variations in prevalence across other countries, which factors influence these differences and what countries can learn from each other regarding prevention of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE: To provide person-centred care, it is important to study ways to prevent involuntary treatment in PwD and to stimulate dialogue between professional and family caregivers for alternative interventions.

Involuntary psychiatric hospitalization among migrants in Italy: A matched sample study.

BACKGROUND: Immigrants in Europe appear to be at higher risk of psychiatric coercive interventions. Involuntary psychiatric hospitalization poses significant ethical and clinical challenges. Nonetheless, reasons for migration and other risk factors for involuntary treatment were rarely addressed in previous studies. The aims of this study are to clarify whether immigrant patients with acute mental disorders are at higher risk to be involuntarily admitted to hospital and to explore clinical and migratory factors associated with involuntary treatment. METHODS: In this cross-sectional matched sample study, we compared the rates of involuntary treatment in a sample of first-generation immigrants admitted in a Psychiatric Intensive Care Unit of a large metropolitan academic hospital to their age-, gender-, and psychiatric diagnosis-matched native counterparts. Clinical, sociodemographic, and migratory variables were collected. The Brief Psychiatric Rating Scale-expanded (BPRS-E) and the Clinical Global Impression-Severity (CGI-S) scale were administered. McNemar test was used for paired categorical variables and a binary logistic regression analysis was performed. RESULTS: A total of 234 patients were included in the analysis. Involuntary treatment rates were significantly higher in immigrants as compared to their matched natives (32% vs. 24% respectively; p < .001). Among immigrants, involuntary hospitalization was found to be more frequent in those patients whose length of stay in Italy was less than 2 years (OR = 4.2, 95% CI [1.4-12.7]). CONCLUSION: Recently arrived immigrants appear to be at higher risk of involuntary admission. Since coercive interventions can be traumatic and negatively affect outcomes, strategies to prevent this phenomenon are needed.

[Changes in the Practice of Involuntary Hospitalization During the COVID-19 Pandemic - Experiences and Opinions of Chief Psychiatrists]. / Veränderungen in der psychiatrischen Unterbringungspraxis während der COVID-19-Pandemie.

OBJECTIVE: To collect experiences and opinions of chief psychiatrists in relation to changes in the practice of involuntary hospitalization during the COVID-19 pandemic. METHODS: Online survey among members of the Association of Chief Physicians for Psychiatry and Psychotherapy in North Rhine-Westphalia (LLPP) and analysis of protocols of LLPP board meetings. RESULTS: Changes in the practice of involuntary hospitalization have been perceived in contexts with and without direct reference to COVID-19. These changes have affected, among other things, judicial hearings as well as decisions about the use of coercive measures. CONCLUSION: Procedural standards for involuntary hospitalization must be maintained and coercive measures may only be used if they meet the applicable ethical and legal requirements. It must be ensured that people with mental disorders are not treated unequally both when taking and withdrawing restrictive measures to contain the pandemic.

[The role of patient competence in the new Dutch statute concerning involuntary treatment in psychiatry]. / De rol van wilsbekwaamheid in de Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: In the new Compulsory Mental Health Care Act (Wvggz), patient competence has a more central position. AIM: To describe the new position of patient competence in the Wvggz and to reflect on related moral questions. METHOD: Discussion of relevant legal texts and publications. RESULTS: In case of incompetency of a patient, a surrogate decision-maker has to attempt what decision the patient would make if he or she were competent. A new element in the Wvggz is that grandparents and grandchildren can also act as surrogate decision-makers. A competency judgment is mandatory in every decision on involuntary treatment, with the exception of involuntarily commitment. Competent refusal of care has to be respected, unless the patient is in a life threatening situation or there is a risk of other people getting harmed. CONCLUSION: The question is whether the changed position of patient competence in the new law will contribute to the aim of maintaining and enhancing patients' autonomy. Due care in competency judgments is complex and remains important.