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

Length of hospital stay in involuntary admissions in Greece: a 10-year retrospective observational study

PURPOSE

The treatment of mental disorders has shifted from inpatient wards to community-based settings in recent years, but some patients may still have to be admitted to inpatient wards, sometimes involuntarily. It is important to maintain the length of hospital stay (LoS) as short as possible while still providing adequate care. The present study aimed to explore the factors associated with the LoS in involuntarily admitted psychiatric patients.

METHODS

A ten-year retrospective chart review of 332 patients admitted involuntarily to the inpatient psychiatric ward of the General University Hospital of Ioannina, Northwestern Greece, between 2008 and 2017 was conducted.

RESULTS

The mean LoS was 23.8 (SD = 33.7) days and was relatively stable over the years. Longer-stay hospitalization was associated with schizophrenia-spectrum disorder diagnosis, previous hospitalizations and the use of mechanical restraint, whereas patients in residential care experienced significantly longer LoS (52.6 days) than those living with a caregiver (23.5 days) or alone (19.4 days). Older age at disease onset was associated with shorter LoS, whereas no statistically significant differences were observed with regard to gender.

CONCLUSION

While some of our findings were in line with recent findings from other countries, others could not be replicated. It seems that multiple factors influence LoS and the identification of these factors could help clinicians and policy makers to design more targeted and cost-effective interventions. The optimization of LoS in involuntary admissions could improve patients' outcomes and lead to more efficient use of resources.

[Cantonal Differences in The Implementation of Involuntary Admission in Switzerland]

OBJECTIVE

To examine sociodemographic and clinical characteristics of persons hospitalized in five psychiatric hospitals from regions with different structural characteristics compared with persons hospitalized voluntarily.

METHODS

Descriptive analyses of routine data on approximately 57000 cases of 33000 patients treated for a primary ICD-10 psychiatric diagnosis at one of the participating hospitals from 2016 to 2019.

RESULTS

Admission rates, length of stay, rates of further coercive measures, sociodemographic and clinical characteristics of the affected persons differ between the different regions.

CONCLUSION

There are considerable regional differences between regulations and implementation of the admission procedures and the sample. Causal relationships between regional specifics and the results cannot be inferred.

Predictors for early and long-term readmission in involuntarily admitted patients

BACKGROUND

It is a common aim to reduce psychiatric readmissions. Although risk factors for readmissions were described, specific data in the group of patients with potentially aversively experienced involuntary admissions are lacking. To better understand underlying mechanisms, it is important to identify factors that are linked to readmissions in this specific patient group, which is the purpose of the current paper.

METHODS

A four-year cohort of N = 3575 involuntary admissions (IA) was followed-up for subsequent re-hospitalization. Demographic, administrative and clinical factors associated with short- (within 30 days) or long-term (> 30 days) readmissions were examined using logistic regression modelling.

RESULTS

Almost half of all IA cases were readmitted within the observation period, whereof every fifth readmission was within the first month after discharge from the involuntary index hospitalization. Adjusted regression modelling revealed problematic substance use at admission and assisted living or homelessness as risk factors for readmission, while high functioning at discharge, anxiety disorders, no subsequent treatment after discharge or IA due to danger to others were negatively associated with readmission. Factors specifically linked to short-term readmission were substance use and personality disorders, abscondence or discharge by initiation of the clinic, as well as being discharged to any place except the patient's home. There were no specific risk-factors for long-term readmission.

CONCLUSIONS

To prevent readmissions after IA, especially for patients at risk, the aim of treatment strategies should be to focus on intensive discharge planning, enable continuous treatment in the outpatient setting, and provide social support.

Psychiatric Emergencies in the Community: Characteristics and Outcome in Switzerland

Psychiatric emergencies occur frequently in the community setting, e.g. the patient's home or public places. Little is known about the characteristics and outcome of these situations. This study describes psychiatric emergencies in the canton of Zurich, Switzerland, and examines determinants of their outcome. We retrospectively analyzed 620 medical records of consultations classified as psychiatric emergencies of a 24/7 service of community-based emergency physicians. Information on sociodemographic, clinical and situational factors was extracted. The observation period was 6 months in 2017. Binary logistic regression was used to examine predictors for involuntary admissions. Most emergency consultations (64.5%) took place at the patient's home, followed by police stations (31.0%), public places (3.2%), and somatic hospitals (1.3%). Patient characteristics and reasons for consultation varied considerably between the locations. The first involved person was commonly a relative. Of all consultations, 38.4% resulted in involuntary admissions, mainly in patients with psychosis, suicidality, aggression, refusal of necessary treatment and previous involuntary admissions. Situation-related factors and the involvement of relatives were no significant predictors of the outcome. Psychiatric emergencies occur in different places and in patients with a variety of psychiatric symptoms. Although half of the emergency situations were resolved in the community, the rate of involuntary admissions was still high. For additional reduction, the further development of quickly available alternatives to psychiatric inpatient treatment is required. These should be specifically geared towards acute situations in patients with the described risk factors. Additionally, the role of relatives during psychiatric emergencies should be further studied.

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

BACKGROUND

Involuntary admissions can be detrimental for patients. Due to legal, ethical and clinical considerations, they are also challenging for referring physicians. Nevertheless, not much is known about the subjective perceptions of those who have to decide whether to conduct an involuntary admission or not.

AIMS

This study aimed at answering the question whether psychiatrists' perceptions of confidence during psychiatric emergency situations and consecutive involuntary admissions differ from those of physicians without a psychiatric training.

METHOD

We assessed the professional background and subjective perceptions during psychiatric emergency situations in physicians who executed involuntary admissions to the University Hospital of Psychiatry Zurich. We used one-way analysis of variance (ANOVA) with Bonferroni-adjusted post hoc tests and chi-square tests to compare the responses of 43 psychiatrists with those of 64 other physicians.

RESULTS

Psychiatrists felt less time constraints compared with non-psychiatric residents. The latter also had more doubts on the necessity of the involuntary admission issued. Psychiatrists considered themselves significantly more experienced in handling psychiatric emergency situations and in handling the criteria for involuntary admissions than other physicians. Psychiatrists and other physicians did not differ in their satisfaction concerning course and results of psychiatric emergency situations which was overall high. About half of all participants felt pressure from third parties.

CONCLUSION

Psychiatric emergency situations are challenging situations not only for patients but also for the involved physicians. Physicians with a specialized training might be more confident in the handling of psychiatric emergency situations and exertion of involuntary admissions. Non-psychiatric physicians might benefit from specialized training programs.

Clinical and socio-demographic characteristics associated with involuntary admissions in Switzerland between 2008 and 2016: An observational cohort study before and after implementation of the new legislation

BACKGROUND

Involuntary admission (IA) for psychiatric treatment has a history of controversial discussions. We aimed to describe characteristics of a cohort of involuntarily compared to voluntarily admitted patients regarding clinical and socio-demographic characteristics before and after implementation of the new legislation.

METHODS

In this observational cohort study, routine data of 15'125 patients who were admitted to the University Hospital of Psychiatry Zurich between 2008 and 2016 were analyzed using a series of generalized estimating equations.

RESULTS

At least one IA occurred in 4'560 patients (30.1%). Of the 31'508 admissions 8'843 (28.1%) were involuntary. In the final multivariable model, being a tourist (OR = 3.5) or an asylum seeker (OR = 2.3), having a schizophrenic disorder (OR = 2.1), or a bipolar disorder (OR = 1.8) contributed most to our model. Male gender, higher age, prescription of neuroleptics (all OR < 2.0) as well as having a depressive disorder, prescription of psychotherapy, prescription of antidepressants and admission after implementation of the new legislation (all OR > 0.6) were also weakly associated with IA.

CONCLUSIONS

Besides schizophrenic or bipolar disorders, a small group of patients had an increased risk for IA due to non-clinical parameters (i.e. tourists and asylum seekers). Knowledge about risk factors should be used for the development of multi-level strategies to prevent frequent (involuntary) hospitalizations in patients at risk. On the organizational level, we could show that the new legislation decreased the risk for IA, and therefore may have succeeded in strengthening patient autonomy.

Involuntary admission for psychiatric treatment: Compliance with the law and legal considerations in referring physicians with different professional backgrounds

BACKGROUND

Involuntary admission (IA) for psychiatric treatment is a massive restriction of human rights. Therefore, its execution is regulated by law. During executing IAs referring physicians find themselves in a dual role: support of patients in the recovery process but also safe-keeper of society. In Zurich, Switzerland the law stipulates that physicians regardless of their medical specialization may admit patients who suffer from a mental disorder, mental disability or severe neglect involuntarily if care cannot be provided otherwise, regardless of their decision-making capacity. The referring physician is obliged to examine the patients, hear their views on the IA, inform them about the following steps and about their right of appeal at the civil court. We aimed to assess whether referring physicians can comply with those legal requirements for an IA. Additionally, we examined whether legal considerations differed according to the physicians` professional backgrounds and attitudes towards coercion in general.

METHODS

We invited physicians from different in- and outpatient settings who executed IAs to the University Hospital of Psychiatry Zurich to participate in a newly developed online survey. We used correlation analysis, chi-square and t-tests to analyze the responses of 43 psychiatrists with those of 64 other physicians.

RESULTS

In about 1/3 of the IAs referring physicians were not able to hear the patients' views on the IA, to inform the patients about the following steps and about their right of appeal. Psychiatrists felt more certain with the legal basis of IA compared to physicians other than psychiatrists. Nevertheless, the latter stated that the assessment of the risk for suicide and danger should not be restricted only to psychiatrists. Both groups differed in their attitudes towards coercion with psychiatrists being more critical.

CONCLUSIONS

Interventions should be developed to facilitate a compliance with legal requirements during IA. Physicians who execute IAs must have a thorough knowledge of the clinical and legal basis for their actions. We recommend specialized consultation teams for the assessment of PES and regular training including ethical discussions, especially for physicians other than psychiatrists.

Characteristics of Psychiatric Emergency Situations and the Decision-Making Process Leading to Involuntary Admission

Introduction: Involuntary admissions to psychiatric hospitals, regardless of their beneficial effects, violate the patients' autonomy. To keep such measures at a minimum and develop less restricting and coercive alternatives, a better understanding of the psychiatric emergency situations which end up in involuntary admissions is needed. This descriptive and exploratory study investigates the consultations leading to involuntary admission and the decision-making process of the referring physicians. Methods: We developed an online questionnaire to collect data on the characteristics of the consultation leading to an involuntary admission, including influencing factors from the referring physicians' perspective, as well as their professional background. We included 107 physicians who completed the questionnaire after they had referred patients for involuntary admission to one major psychiatric hospital in Switzerland. Results: The referring physicians were heterogeneous regarding their medical background and experience with psychiatric emergency situations. The consultations were time consuming and took place in various locations. Clinical findings, third-party anamnesis and a known psychiatric diagnosis contributed strongest to the decision to admit involuntarily. "Protection from danger to self" was named most frequently as purpose of the admission. Discussion: This study emphasizes the variety of psychiatric emergency situations leading to involuntary admissions. In most cases, several parties are involved and influence the decision together with medical and social factors. To reduce the number of involuntary admissions, alternatives for patients with a high symptom load and at risk of harming themselves are needed. Possible approaches to achieve that reduction and recommendations for further research are provided.

Cross-Cultural Notions of Risk and Liberty: A Comparison of Involuntary Psychiatric Hospitalization and Outpatient Treatment in New York, United States and Zurich, Switzerland

Involuntary hospitalization is a frequently discussed intervention physicians must sometimes execute. Because this intervention has serious implications for the citizens' civil liberties it is regulated by law. Every country's health system approaches this issue differently with regard to the relevant laws and the logistical processes by which involuntary hospitalization generally is enacted. This paper aims at analyzing the regulation and process of involuntary hospitalization in New York (United States) and Zurich (Switzerland). Comparing the respective historical, political, and economic backgrounds shows how notions of risk and liberty are culture-bound and consequently shape legislation and local practices. It is highly relevant to reconsider which criteria are required for involuntary hospitalization as this might shape the view of society on psychiatric patients and psychiatry itself. Furthermore, this article discusses the impact that training and experience of the person authorized to conduct and maintain an involuntary hospitalization has on the outcome.