Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff.

BACKGROUND: Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS: During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS: The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS: The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018.

INTRODUCTION: Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018. METHOD: We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender. RESULTS: Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%). CONCLUSION: Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

Clinical determinants of involuntary psychiatric hospitalization: A clinical profile approach.

OBJECTIVES: The study examines the clinical determinants of involuntary psychiatric hospitalization. Specifically, it investigates whether distinct clinical profiles of hospitalized patients can be discerned, what other characteristics they are linked with, and which profiles predict involuntary admission. METHODS: In this cross-sectional multicentre population study, data were collected for 1067 consecutive admissions in all public psychiatric clinics of Thessaloniki, Greece, during 12 months. Through Latent Class Analysis distinct patient clinical profiles were established based on Health of the Nation Outcome Scales ratings. The profiles were then correlated with sociodemographic, other clinical, and treatment-related factors as covariates and admission status as a distal outcome. RESULTS: Three profiles emerged. The "Disorganized Psychotic Symptoms" profile, combining positive psychotic symptomatology and disorganization, included mainly men, with previous involuntary hospitalizations and poor contact with mental health services and adherence to medication, indicating a deteriorating condition and chronic course. Τhe "Active Psychotic Symptoms" profile included younger persons with positive psychotic symptomatology in the context of normal functioning. The "Depressive Symptoms" profile, characterized by depressed mood coupled with nonaccidental self-injury, included mainly older women in regular contact with mental health professionals and treatment. The first two profiles were associated with involuntary admission and the third with voluntary admission. CONCLUSIONS: Identifying patient profiles allows the examination of the combined effect of clinical, sociodemographic, and treatment-related characteristics as risk factors for involuntary hospitalization, moving beyond the variable-centered approach mainly adopted to date. The identification of two profiles associated with involuntary admission necessitates the development of interventions tailored to chronic patients and younger persons suffering from psychosis respectively.

Caregivers' perceptions of compulsory treatment of physical illness in involuntarily psychiatric hospitalization.

BACKGROUND: Physical morbidity is rife among patients with serious mental illness. When they are involuntarily hospitalized and even treated, they may still refuse treatment for physical illness leading clinicians to wonder about the ethics of coercing such treatments. RESEARCH AIM: This survey study explored psychiatric caregivers' perceptions on whether compulsory treatment of physical illness is legal and whether it is justifiable in patients with serious mental illness and under what circumstances. RESEARCH DESIGN: A questionnaire that included two case vignettes of an involuntarily hospitalized psychiatric patient with diabetes refusing treatment with insulin for various reasons. The cases differed in terms of diabetes severity. Participants answered questions regarding the appropriateness of involuntary treatment. PARTICIPANTS AND RESEARCH CONTEXT: Psychiatric medical doctors and nurses working in a mental health center. (N = 89, 50 female, ages 26-66). ETHICAL CONSIDERATIONS: The study was approved by the Medical Centre Institutional Review Board (IRB) and the University Ethics Committee. The respondents' anonymity was kept. Participation was voluntary and consent was obtained. RESULTS: The severity of the patient's medical condition and their reason for refusing treatment were associated with participants' willingness to give insulin despite patient objection [(F(1, 87) = 49.41, p < .01; (F(1, 87) = 33.44, p < .01), respectively]. Participants were more inclined to support compulsory treatment if the patient's refusal was "illness-oriented" (i.e. directly related to psychiatric illness). Participants presented diverse views regarding the perceived legality of compulsory treatment of physical illness in such situations (illegal 63.09%; legal 23.8%; 13% unsure). The majority (53.5%-55.3%) of those who thought it was illegal supported compulsory treatment in high-severity, illness-oriented refusal situations. CONCLUSIONS: The severity of the medical condition and the reason for treatment refusal influence psychiatric caregivers' willingness to provide compulsory treatment for physical illness in involuntary hospitalized psychiatric patients. Beyond the legal framework, ethical guidelines for these situations are warranted, while decisions should be made on a case-by-case basis.

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.

Involuntary psychiatric admission in Cyprus: A descriptive correlational study.

INTRODUCTION: Studies on the clinical and socio-demographic characteristics of those involuntarily admitted to psychiatric settings could help professionals and researchers to develop effective, targeted interventions, alternative to compulsory psychiatric care. AIM: The association between socio-demographic and clinical characteristics in adults under involuntary hospitalization for psychiatric treatment in the Republic of Cyprus was assessed. METHOD: This was a descriptive, cross-sectional and correlational study. Data collection was achieved (December 2016 to February 2018) via a census sampling method. Socio-demographic and clinical data of individuals involuntarily admitted to the reference psychiatric hospital of Cyprus with psychotic symptomatology were recorded. RESULTS: The sample encompassed 144 females and 262 males. The most frequent diagnosis was schizophrenia or a relevant psychotic disorder (72.9%). The most frequent cause of admission was "Disorganized behaviour" along with non-adherence to pharmacotherapy (53.7%). Approximately 42.8% of the participants confirmed positive substance use history, which was more frequently reported in males than in females (88.5% vs. 11.5%, respectively, p < 0.001). Additionally, males were more frequently admitted due to Disorganized behaviour with substance use compared to females (31.3% vs. 4.9%, respectively, p < 0.001), while females were more frequently admitted due to d"Disorganized behaviour with non-adherence to pharmacotherapy (70.1% vs. 44.7%, respectively, p < 0.001). Also, males were more frequently involuntarily hospitalized due to suicidal/self-harming behaviour compared to females (12.2% vs. 5.6%, respectively, p = 0.031). CONCLUSION: Gender differences were noted in relation to clinical characteristics of the participants, highlighting the need for gender-specific interventions to decrease compulsory psychiatric care, including enhancement of adherence to therapy.

[Involuntary psychiatric care for incarcerated people: a descriptive study of 73 consecutive judge-ordered discharges from psychiatric hospitalisation in France]. / Soins psychiatriques sans consentement pour les personnes détenues : une étude descriptive de 73 mainlevées consécutives en unité hospitalière spécialement aménagée.

INTRODUCTION: The procedure of involuntary psychiatric hospitalization has been recently modified in France. Indeed, since 2011, a liberty and custody judge is appointed for each measure, to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. As a result, if procedural errors are noted, the liberty and custody judge may order the immediate ending of the psychiatric hospitalization. To date, only two studies described the reasons for judiciary discharge from involuntary psychiatric hospitalizations, but no study has been conducted in forensic psychiatric units for incarcerated people. The objective of the current study was to describe the main reasons judges use to decide on the irregularity of the hospitalization (against the opinion of psychiatrists) for detained patients, and to compare these reasons with those for patients in the community psychiatric unit. METHODS: We included all the discharges ordered between 2011 and 2018 in two units of the same hospital: a forensic psychiatric unit for incarcerated people and a community involuntary psychiatric unit. We extracted sociodemographic characteristics and judiciary information such as date of discharge, resason fordischarge, presence of the patient at the hearing. We analyzed the judge-ordered discharge rate (corresponding to the number of discharges divided by the number of involuntary psychiatric hospitalizations) for each year. Then, we examined the reason of discharge for each measure. RESULTS: One hundred and forty-seven discharges were analyzed: 73 in the psychiatric forensic unit and 73 in the community psychiatric unit. Rates of discharges were 6.7% and 8.8% for the forensic unit and the general psychiatric unit, respectively. Several reasons for the discharges were common for the two units (failure to inform the patient, lack of physical examination), but others were specific to the forensic unit, such as the impossibility for the patients to communicate with their lawyer, or the lack of immediate dangerousness for the person or for the others. CONCLUSION: This study highlights the specific aspects of involuntary psychiatric hospitalizations for people in prison in France. Future studies are needed to assess the impact of these judge-ordered discharge on patient's mental health, particularly for incarcerated patients.

Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care.

PURPOSE: Few studies have focused on the experience of involuntary psychiatric hospitalization among youth, especially the impact of these experiences on engagement with mental health services post-discharge. In this study, we contribute to a deeper understanding of youth experiences of involuntary hospitalization (IH) and its subsequent impacts on trust, help-seeking, and engagement with clinicians. METHODS: The study utilized a grounded theory approach, conducting in-depth interviews with 40 youth and young adults (ages 16-27) who had experienced at least one prior involuntary hospitalization. RESULTS: Three quarters of the youth reported negative impacts of IH on trust, including unwillingness to disclose suicidal feelings or intentions. Selective non-disclosure of suicidal feelings was reported even in instances in which the participant continued to meet with providers following discharge. Factors identified as contributing to distrust included perceptions of inpatient treatment as more punitive than therapeutic, staff as more judgmental than empathetic, and hospitalization overall failing to meet therapeutic needs. Conversely, participants reporting more mixed experiences of hospitalization and simultaneously strong indirect benefits, including greater family support, diminished family judgement members and greater access to care. CONCLUSION: Findings draw attention to the ways in which coercive experiences may impact youth pathways to and through care. Additional research is needed to understand the impact of these experiences across larger samples, and their influence on downstream outcomes including engagement and long-term wellbeing. Finally, these data may inform the development and testing of inpatient and post-discharge interventions designed to mitigate potential harm.

Compulsory treatments in eating disorders: a systematic review and meta-analysis.

INTRODUCTION: The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes. METHODS: Relevant articles were identified following the PRISMA guidelines by searching the following terms: "treatment refusal", "forced feeding", "compulsory/coercive/involuntary/forced treatment/admission", "eating disorders", "feeding and eating disorders", "anorexia nervosa", "bulimia nervosa". Research was restricted to articles concerning humans and published between 1975 and 2020 in English. RESULTS: Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies). CONCLUSIONS: Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option. LEVEL OF EVIDENCE: Level I, systematic review and meta-analysis.

Do no harm in due process - a historical analysis of social determinates of institutionalization in the USA.

Involuntary hospitalization has been a fundamental function of psychiatric care for mentally ill persons in the USA for centuries. Procedural and judicial practices of inpatient psychiatric treatment and civil commitment in the USA have served as a by-product of socio-political pressures that demanded constant reform throughout history. The origin of modern commitment laws can best be understood through the lens of cultural paradigms that led to their creation and these suggest caution for future legislative amendments.

[Pupil Mariela, what do an Orphanage and a Hospital have in common?] / Niña Mariela ¿qué tienen en común un Hogar y un Hospital?

In Argentina, the National Mental Health Law (No. 26.657), from 2010, indicates that a specific budget is available to carry out particularly significant changes in the institutions where patients are admitted for mental health reasons. Voluntary or involuntary hospitalization in general hospitals is promoted throughout the country, while the closure of specialized mental health hospitals is anticipated. However, some demographic characteristics and the marked lack of accessibility to specialized resources throughout the country allow to locate a well-founded doubt to said proposal, even if the indicated resources were available and even more so, if it is intended to preserve the valuable rights that are in the spirit of the Law. Especially with regard to clinically involuntary hospitalizations outside the big cities. This article aims to illustrate and substantiate this position clinically -with the case of the girl Mariela-, in relation to mental health patients of all ages and to criticize this aspect of the Law, pointing out the risk for users of not creating increasingly complex public mental health systems accessible to the entire population of the country.

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 hospitalization: A survey of liberty and custody judges]. / Soins psychiatriques sans consentement : une enquête auprès des juges des libertés et de la détention.

The procedure of involuntary hospitalization in France has been recently modified by the law of 5 July 2011. Since that time, a liberty and custody judge has been appointed to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. Currently, for one involuntary hospitalization in ten a release is decided by the liberty and custody judge although psychiatrists consider that psychiatric care is necessary. In order to improve our understanding of the role of liberty and custody judges, and how they make their decisions, we conducted a qualitative survey of liberty and custody judges in the Tribunal de Grande Instance of Lille. Three judges were questioned, based on a semi-structured interview. Judges' responses have highlighted the need for psychiatrists to strictly respect the legal procedures and to accurately describe the clinical signs and symptoms that justify the procedure of involuntary hospitalization in the medical certificates. The intervention of liberty and custody judges for patients with psychiatric disorders represents a breakthrough for patients' rights in France, reflecting that they are considered as citizens, with the same rights as others. Nonetheless, this new mission needs a progressive learning, based on mutual exchanges with doctors and caregivers.

International standards for application of compulsory medical measures.

OBJECTIVE: Introduction: The study of the international standards of compulsory medical measures' (CMM) application to persons who have committed socially dangerous acts is relevant problematics of medical law. The aim: of the research is to define international standards for the implementation of CMM, as well as assessing the state of their implementation in Ukrainian law and medical practice. PATIENTS AND METHODS: Materials and methods: The study is based on international acts, ECHR decisions, legislation of Ukraine and foreign countries, scientific articles in the fields of law and psychiatry as well as empirical materials that illustrate application of CMM in Ukraine. Dialectical, comparative-legal, statistical, induction and deduction, legal modeling, sociological research were used in this research. CONCLUSION: Conclusions: As a result of the research the concept of the international standards of CMM application is defined, their scope in the law-enforcement and medical practice of Ukraine is determined, the system and meaning of these standards are formulated.

The Medical Incapacity Hold: A Policy on the Involuntary Medical Hospitalization of Patients Who Lack Decisional Capacity.

BACKGROUND: Medically hospitalized patients who lack decisional capacity may request, demand, or attempt to leave the hospital despite grave risk to themselves. The treating physician in this scenario must determine how to safeguard such patients, including whether to attempt to keep them in the hospital. However, in many jurisdictions, there are no laws that address this matter directly. In this absence, psychiatrists are often called upon to issue an involuntary psychiatric hold (civil commitment) to keep the patient from leaving. Yet, civil commitment statutes were not intended for, and generally do not address, the needs of the medically ill patient without psychiatric illness. Civil commitment is permitted for patients who pose a danger to themselves or others, or who are gravely disabled, specifically as the result of a mental illness, and allows the transport of such individuals to facilities for psychiatric evaluation. It does not permit detention for medical illnesses nor the involuntary administration of medical treatments. Therefore, the establishment of hospital policies and procedures may be the most appropriate means of detaining medically hospitalized patients who lack capacity to understand the risks of leaving the hospital, in addition to mitigating the potential tort risk faced by the physician for acting in a manner that protects the patient. OBJECTIVE: The purpose of this article is to identify the array of clinical and medical-legal concerns in these scenarios, and to describe the development of a "medical incapacity hold" policy as a means of addressing this unresolved issue.

[Involuntary psychiatric care for inmates in France: Only for "dangerous" patients?] / Les soins psychiatriques sans consentement en milieu pénitentiaire sont-ils réservés aux patients « dangereux ¼ ?

The unités hospitalières spécialement aménagées (UHSA) are full-time inpatient psychiatric units for inmates in France. Their creation has been associated with several advances in access to psychiatric care for inmates in recent years. However, there is still only one means of involuntary hospitalization for prisoners in France: care by decision of a representative of the state (les soins sur décision d'un représentant de l'état [SDRE]). Interestingly, for SDRE to be recognized as legal by the French judge, the patient must be "a danger to himself or to the others". Thus, there is a major difference with involuntary hospitalization outside the prison, and there are specific criteria for involuntary psychiatric hospitalization for inmates in France. This situation questions the general framework of involuntary psychiatric care and is very inconsistent with French law. Indeed, the goal of the loi no 94-43 du 18 janvier 1994 relating to public health and social protection is to ensure equivalent care for all patients, incarcerated or not.

Taking the Role of the Family Seriously in Treating Chinese Psychiatric Patients: A Confucian Familist Review of China's First Mental Health Act.

This essay argues that the Chinese Mental Health Act of 2013 is overly individualistic and fails to give proper moral weight to the role of Chinese families in directing the process of decision-making for hospitalizing and treating the mentally ill patients. We present three types of reactions within the medical community to the Act, each illustrated with a case and discussion. In the first two types of cases, we argue that these reactions are problematic either because they comply with the law but undermine the patient's interests by refusing the family's request to have the patient hospitalized, or violate the law by hospitalizing patients in response to the real concerns of their families. In the third type of situation, psychiatrists inappropriately encourage families to produce evidence of the patient's behavior that is harmful to self or others in order legally to commit the patient. Each of these problems, we conclude, should be tackled by supplementing Article 30 of the Act with the stipulation that a psychiatrist may authorize the involuntary hospitalization of a patient, who is not at risk of causing physical harm to self or others, with the consent of all major family members. Drawing on the deeply culturally embedded moral traditions of Confucian medical familism, this proposal would facilitate the proper treatment of a significant number of Chinese mentally ill patients under the care of their families.

[Involuntary hospitalization under the Act of July 5th 2011: A study of patients' experience and understanding of their hearing with the judge ruling on civil detention cases]. / Étude du vécu et de la compréhension par les patients hospitalisés sans consentement de l'audience devant le juge des libertés et de la détention.

OBJECTIVE: To assess involuntary admitted patients' experience and understanding of their hearing with the judge ruling on civil detention cases according to the Act of July 5th 2011. METHODS: The evaluation was conducted through face-to-face interviews, from a semi-structured questionnaire, with 48 involuntary admitted patients under psychiatric care admission on a third party request (ASPDT) or on state representative decision (ASPDRE) (participation rate=96%). RESULTS: Few participants knew the name of the hearing place (13%) and the judge's exact title (21%). About 58% of them had benefited from lawyer services. During the hearing, half of the patients contested the need for hospitalization. The judge was perceived as clear (79%), listening (69%) and benevolent (58%), but only 46% of patients believed that he/she was impartial and 35% that he/she was independent from medical decisions. More than half of the patients disagreed with the judge's decision (56%). However, only 19% of them planned to appeal. Three out of four were in favour of a judicial review of involuntary hospitalization. A feeling of protection was more common in people with a higher educational level (65% versus 35%, Chi(2) (1) = 3.9, P = 0.05) and who suffered from mood disorders (75% versus 46%, Chi(2) (1) = 3.8, P = 0.05). A feeling of being accused was more frequent in persons with hospitalization under psychiatric care admission on state representative decision (ASPDRE) than on a third party request (ASPDT) (37% vs 10%, Chi(2) (1) = 4.9, P = 0.03). Persons under guardianship were also more likely to report such feelings (32% versus 10%, Chi(2) (1) = 3.4, P=0.06). The feeling that "everything was preordained" was more common in younger patients (m = 36.4 years [SD = 13.9] vs m = 46.2 years [SD = 17.8], t-test [46] = 2.01, P = 0.04), as well as among those who used the advice of a lawyer, with an association at a trend level (73% versus 46%, Chi(2) (1) = 3.5, P = 0.06). CONCLUSION: Systematic judicial review of involuntary hospitalization represents a major evolution in the patients' rights field. This study shows that their experience and understanding of the hearing with the judge ruling on civil detention cases are quite mixed. In clinical practice, informing the patient about the upcoming hearing may allow the physician who initiates the hospitalization to reassure him/her as the intervention of a third party will be required to confirm the legality of involuntary admission. Furthermore, such information about the judicial intervention might avoid unproductive confrontation between the patient and the physician when the person remains opposed to the hospitalization. However, some patients may be disappointed as they are heavily invested in the preparation of their "defence" and have high hopes in the intervention of a judge who most often maintains the hospitalization.

Do Suicide Attempters Have a Right Not to Be Stabilized in an Emergency?

The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life-sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients' level of decisional capacitation-among other relevant information-in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs-the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness.

No-Restraint Committed General Hospital Psychiatric Units (SPDCs) in Italy-A Descriptive Organizational Study.

This study describes and explores the application of no-restraint policies in General Hospital Psychiatric Units (GHPUs) in Italy, a country pioneering in deinstitutionalization and psychiatric reform. The research aims to assess the organizational characteristics and effectiveness of no-restraint practices, contributing to the global discourse on humane psychiatric care. Following a purposive sampling approach, a nationwide descriptive study was conducted involving a detailed online survey distributed to 24 GHPUs actively engaged in or aspiring toward no-restraint practices. The survey, comprising 60 items across seven sections, gathered comprehensive data on the structural, organizational, and operational dimensions of the units, along with the prevalence and management of restraint episodes. Results reveal a significant commitment to no-restraint policies, with 14 GHPUs reporting zero restraint incidents in 2022. Despite variations in infrastructure and staffing, a common thread was the implementation of systematic procedures and risk management training aimed at reducing coercive practices. The study identified a correlation between the use of exclusive garden spaces and an increased incidence of restraints, suggesting nuanced factors influencing restraint practices. The findings underscore the viability and ethical alignment of no-restraint practices within psychiatric care, highlighting the crucial role of organizational protocols and training. This research adds empirical weight to the advocacy for restraint-free environments in mental health settings, signaling a paradigm shift toward more humane and rights-respecting psychiatric care.