[THE EFFICACY OF THE DECISIONS OF TREATING PHYSICIANS VS. DISTRICT PSYCHIATRIC COMMITTEES IN REGARD TO THE DISCHARGE OF COMMITTED PSYCHIATRIC PATIENTS: A REGIONAL STUDY].

ABSTRACT

BACKGROUND: The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized can be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. This study attempts to compare the variance between the TP and the DPC decisions in different geographical regions in Israel. METHODS: We examined the outcomes of decisions made by the DPC using readmission data - an internationally recognized indicator of the quality of hospital care - and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were taken from the Israel National Register. We also collected information regarding all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in fewer than 30 days, involuntary civil readmission in fewer than 180 days, and involuntary readmission under court order in less than 1 year. RESULTS: The re-hospitalization pattern was compared in the two groups of patients discharged from psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the success rates of the various regional DPCs and the hospital TP groups, with the TP average (74.5% national success rate) success significantly better than the DPC groups (66.7% national success rate). Moreover, the variance between the decisions made in the different geographical regions in the two groups was also statistically significant (σ2 variance was 80.4 and 27.1 for the DPC and TP groups, respectively). CONCLUSIONS: The results we present indicate that the variance of decision "failure" (readmission) and "success" across the various geographical regions was found to be significantly better in the TP group than in the DPC group. We consider it likely that whereas TPs discharge IPH patients in accordance with well-accepted clinical approaches, the DPC's decisions are based on interpretations of the law (regarding, e.g., the patient posing a physical threat) and on the DPC's understanding of what is meant by the patient's "best interests." We suggest introducing more formal psychiatric training for the legal staff of the DPCs and building a structured and standardized method for reviewing the patient. Moreover, we propose using "soft paternalism" as an approach, which would justify limitations on individual liberties for the benefit of persons being restricted, provided that they are unable to make a choice that would be consistent with their own interests. This is often an appropriate and perhaps a more practical approach, one that the DPC could adopt in place of the present conservative approach, which requires a specific standard of "proof" of major illness to qualify as insanity requiring hospitalization.