Mental health care in Athens: Are compulsory admissions in Greece a one-way road?

Factors that influence hospitalization stress in patients with chronic schizophrenia: A cross-sectional study in psychiatric hospitals

WHAT IS KNOWN ON THE SUBJECT?: Patients with chronic schizophrenia become vulnerable to stress when admitted to psychiatric wards, lacking the abilities to independently cope with stress. Therefore, it is crucial to focus on the stress associated with hospitalization. Stress increases when interpersonal functioning is impaired due to schizophrenia symptoms. Social support acts as a protective factor against stress, boosting coping skills and problem-solving abilities.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Interpersonal relationships, marital status, having cohabited before hospitalization and hospitalization type were associated with hospitalization stress in patients with chronic schizophrenia. Patients with chronic schizophrenia continue aging (mean 55.73 ± 11.14) within closed psychiatric hospitals due to their long-term hospitalizations (mean 14.24 ± 11.37). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses need to use a standardized nursing assessment including interpersonal relationships, family support system and hospitalization type that may affect hospitalization stress in patients with chronic schizophrenia. Mental health nurses should develop tailored interventions to reduce hospitalization stress for long-stay patients with chronic schizophrenia that consider aging, illness duration, and length of hospital stay, as well as psychiatric symptoms. Mental health nurses need to make efforts to help the families of patients with schizophrenia solidify an important support system by participating in treatment plans and intervention programs, checking on the patients' condition, and spending time with them.

ABSTRACT

INTRODUCTION: Patients with chronic schizophrenia in psychiatric hospitals often experience increased stress due to living in closed spaces and frequently lack the coping skills necessary for independent stress management.

AIM

To explore interpersonal relationships, social support and hospitalization stress, and identify the factors associated with hospitalization stress in patients with chronic schizophrenia in psychiatric hospitals.

METHOD

This cross-sectional study included 135 patients who had been diagnosed with schizophrenia for over 2 years, recruited from two psychiatric hospitals in City B, South Korea through convenience sampling. We conducted descriptive statistics and quantile regression.

RESULTS

Interpersonal relationships, marital status, cohabiting before hospitalization, and voluntary admission were significant factors influencing the hospitalization stress at the 90th percentile.

DISCUSSION

Standardized nursing assessment, active family support, and tailored stress management programs including interpersonal relationships are needed to reduce hospitalization stress in patients with chronic schizophrenia.

IMPLICATIONS FOR PRACTICE

To identify the 90th percentile group for hospitalization stress among patients with chronic schizophrenia, it is essential to consider interpersonal relationships, marital status, pre-hospitalization cohabitation, type of hospitalization, as well as aging and prolonged hospitalization. Mental health nurses should develop and implement family therapy-based interpersonal relationship programs to reduce hospitalization stress in patients with chronic schizophrenia and actively involve families in the process.

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.

Outcome of Involuntary Mental Health Assessment in a Psychiatric Department in Greece

Despite their controversiality, involuntary admissions in psychiatric departments remain a central issue in mental health care. The present study aims to identify demographic and clinical factors possibly associated with emergency involuntary psychiatric assessment and its outcome in Greece. This study was carried out in the psychiatric department of the University General Hospital of Alexandroupolis (UGHA) from 1 March 2018 to 28 February 2019. The sample included 191 individuals who had been psychiatrically assessed without their consent following a prosecutorial order. The majority of the involuntary assessments resulted in hospitalization (71%), with 51% of them resulting in involuntary hospitalization. Almost all patients diagnosed with "F20-29 schizophrenia, schizotypal and delusional disorders" were subsequently admitted to the psychiatric department of the UGHA (77 of 81, 66 of them involuntarily). Higher admission rates were recorded among those who had been referred from the Prosecutor's Office of regions that are located far from the psychiatric department of UGHA (Fisher's exact test, p-value = 0.045). In multivariate logistic regression, prior contact with psychiatric services and having an "F20-29 schizophrenia, schizotypal and delusional disorders" diagnosis was statistically significant with admission to the hospital as an outcome variable. Our study suggests an increased risk of involuntary admission among patients with psychosis, patients who had visited a psychiatric service prior to their assessment as well as those living further away from the main psychiatric services of the hospital. Better organization of community psychiatric services in remote places from hospital central services may lead to fewer prosecutorial referrals and coercive measures.

Beyond Patient Characteristics: A Narrative Review of Contextual Factors Influencing Involuntary Admissions in Mental Health Care

Variations in the rates of involuntary admission (IA) reflect the influence of unexplained contextual variables that are typically too heterogeneous to be included in systematic reviews. This paper attempts to gather and analyze factors unrelated to the patients that have been linked to IA. The articles included in this review were selected by iteratively searching four electronic databases (PubMed, PsychINFO, EMBASE, and Web of Science). A total of 54 studies from 19 different countries and regions, including 14 European countries, the United States, Canada, China, Vietnam, and Taiwan, were selected. The factors were categorized as service-related factors, impactful events, seasonal and temporal factors, mental health legislation, staff factors, and public attitudes. The factors rarely act in isolation but rather interact and reinforce each other, causing a greater influence on IA. This paper explains how these factors present opportunities for robust and sustainable interventions to reduce IAs. The paper also identifies future directions for research, such as examining the effects of economic recessions. Enhancing global reporting standards is essential to validate future research and support further in-depth studies. The complexity of the factors influencing IA and the implicit role of society suggest that resolving it will require social change.

Involuntary psychiatric treatment during the COVID-19 pandemic. An international qualitative study

Background

During the COVID-19 pandemic, studies report that in the first few months of the lockdown there was a decrease in requests for mandatory psychiatric treatment, while, in contrast, following the second wave, the number of cases increased. This study investigates the use of compulsory psychiatric treatments internationally in the first and subsequent phases of the pandemic.

Methods

Sixteen key people were interviewed: eight mental health care professionals and eight scholars in Italy, Greece, China and Chile. Participants were asked to discuss their experience of the motivations, diagnoses and management of patients undergoing an involuntary psychiatric hospitalization.

Results

The analysis through Grounded Theory highlighted four themes: (a) the culture of psychiatric care services, (b) the effect of the pandemic on involuntary hospitalizations, (c) exceptional management of hospitalization, and (d) policies and suggestions for more inclusive mental health treatments.

Conclusion

During the first wave, respondents reported a decrease in the use of involuntary treatments, while a gradual increase was seen in the following months. Italy extended compulsory psychiatric treatment to a group of new users, including young people and adolescents with acute crises; in other contexts, the main users are chronic psychiatric patients.

Who is coercively admitted to psychiatric wards? Epidemiological analysis of inpatient records of involuntary psychiatric admissions to a University General Hospital in Greece for the years 2008-2017

BACKGROUND

Involuntary psychiatric admissions are a widely used practice despite ethical concerns about coercion. There are particular concerns that vulnerable groups, such as single, unemployed or racial minorities, may be more subjected to such practices.

AIM

We aimed to investigate the social patterns of involuntary psychiatric admissions from 2008 to 2017 at University General Hospital in Ioannina, Greece.

METHOD

We retrospectively assessed inpatient records from 2008 to 2017 of patients admitted to the Department of Psychiatry of the Ioannina University General Hospital, Northwestern Greece. Alternative patients of alternative years were selected for inclusion; this yielded 332 patients involuntarily admitted, corresponding to 28.5% of total involuntary psychiatric admissions.

RESULTS

Over the 10-year period, the overall numbers of annual involuntary psychiatric admissions remained relatively stable, as did the length of hospital stay (mean = 23.8 days). The most common disorder upon admission was schizophrenia spectrum disorders, accounting for approximately two-thirds of all admissions, followed by mood disorders (about 20%). There was evidence that people who lacked social support or experienced financial hardship were more greatly represented among those admitted: 70.2% of admitted patients were single and 64.8% were unemployed. Most patients had been admitted to the psychiatric ward in the past (64.2%).

CONCLUSION

Our study indicates potentially worrisome evidence that patients who are in vulnerable positions are at elevated likelihood of being involuntarily admitted to psychiatric wards. Future research is needed to evaluate the socio-demographic patterning of involuntary admissions in other European countries.

Effectiveness of a Community-Based Crisis Resolution Team for Patients with Severe Mental Illness in Greece: A Prospective Observational Study

This prospective observational study evaluated the effectiveness of a crisis resolution team (CRT) for outpatient treatment of psychiatric patients experiencing an acute episode of severe mental disorder. The effectiveness of the CRT (n = 65) was assessed against the care-as-usual [CAU group (n = 65)]. Patients' clinical state, overall functioning, quality of life and satisfaction were respectively evaluated at baseline, post intervention and three-month post-intervention.CRT patients compared to the CAU group, had significantly improved outcomes concerning clinical state and patient satisfaction at post intervention phase. Statistically significant improvement was also recorded for the dimensions of environment, physical and psychological health related to quality of life. No significant differences were observed between the two groups regarding overall functioning.On the basis of these results, reforming of existing crisis-management services, in Greece, using the CRT model may improve substantially the services offered to psychiatric patients.

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.

Determinants of compulsory hospitalisation at admission and in the course of inpatient treatment in people with mental disorders-a retrospective analysis of health records of the four psychiatric hospitals of the city of Cologne

BACKGROUND

We aimed to identify differences in predictors of involuntary psychiatric hospitalisation depending on whether the inpatient stay was involuntary right from the beginning since admission or changed from voluntary to involuntary in the course of in-patient treatment.

METHODS

We conducted an analysis of 1,773 mental health records of all cases treated under the Mental Health Act in the city of Cologne in the year 2011. 79.4% cases were admitted involuntarily and 20.6% were initially admitted on their own will and were detained later during the course of in-patient stay. We compared the clinical, sociodemographic, socioeconomic and environmental socioeconomic data (ESED) of the two groups. Finally, we employed two different machine learning decision-tree algorithms, Chi-squared Automatic Interaction Detection (CHAID) and Random Forest.

RESULTS

Most of the investigated variables did not differ and those with significant differences showed consistently low effect sizes. In the CHAID analysis, the first node split was determined by the hospital the patient was treated at. The diagnosis of a psychotic disorder, an affective disorder, age, and previous outpatient treatment as well as the purchasing power per 100 inhabitants in the living area of the patients also played a role in the model. In the Random Forest, age and the treating hospital had the highest impact on the accuracy and decrease in Gini of the model. However, both models achieved a poor balanced accuracy. Overall, the decision-tree analyses did not yield a solid, causally interpretable prediction model.

CONCLUSION

Cases with detention at admission and cases with detention in the course of in-patient treatment were largely similar in respect to the investigated variables. Our findings give no indication for possible differential preventive measures against coercion for the two subgroups. There is no need or rationale to differentiate the two subgroups in future studies.

Outcome of Voluntary vs Involuntary Admissions in Greece over 2 years after Discharge: A Cohort Study in the Psychiatric Hospital of Attica "Dafni"

The increasing rates of involuntary hospitalization constitute a major ethical issue in psychiatric practice. The present cohort study endeavours to investigate the relationship between patients' legal status (involuntary vs voluntary) and the outcome of their hospitalization, over 2 years after discharge. All individuals admitted in the 3rd Psychiatric Department of the Psychiatric Hospital of Attica during February 2015-February 2017 took part in the study. 64.7% of patients were compulsory admitted. Findings indicate a statistically significant improvement in global functioning and symptomatology levels from admission to discharge for all treated patients, independently of their legal status. However, readmission rates over 2 years after discharge were high (34.8% vs. 21.9% in voluntary and involuntary patients, respectively). In conclusion, psychiatric admission, irrespectively of legal status leads to clinical improvement.

Decrease of Hospitalizations and Length of Hospital Stay in Patients with Schizophrenia Spectrum Disorders or Bipolar Disorder Treated in a Mobile Mental Health Service in Insular Greece

In recent years serious mental health issues, such as schizophrenia spectrum disorders and bipolar disorder, have been treated in the community by community-based mental health services. In the present study our goal was to estimate the modification in the number of hospitalizations and duration of admissions in either psychotic patients or patients with bipolar disorder, treated by a Mobile Mental Health Unit in the islands of Kefalonia, Zakynthos and Ithaca (MMHU-KZI). Data were collected from a total of 108 patients with schizophrenia spectrum disorders and bipolar disorder. For each patient comparison was made for the same time interval prior and after engagement to treatment with the MMHU-KZI and not for the total hospitalizations that patients had in their history. There was a statistically significant reduction (45.9%) in hospitalizations after treatment engagement with the MMHU-KZI, as the Wilcoxon signed ranks test indicated. Furthermore, a major decrease (54.5%) of hospitalization days was noted after treatment engagement with the unit. This pattern of mental health provision may be beneficial for the reduction of the number and duration of psychiatric hospitalizations. Despite the beneficial contribution of community-based mental health units, hospital based treatment should always be available, since severe relapses are better treated in inpatient setting.

Insights into involuntary hospital admission procedures for psychiatric patients: A 3-year retrospective analysis of police records

The procedure of involuntary hospitalization has been an ongoing subject of study. Its implementation requires the systematic co-ordination between the Justice and Health Care systems around the globe. In the case of Greece, the procedure under discussion is regulated by Law 2071/1992, which designates the Police as the agent that links the aforementioned systems together. The present study aims to shed light upon the procedure of involuntary hospitalizations, regarding the preparatory stage and the Police involvement up to the individuals' admission to the on-call hospital for a mental health assessment (MHA). The entry data of two police stations in Athens was recorded by the respective Duty Officer responsible for each case. The police records were retrospectively inspected and information on socio-demographic, clinical and parametric characteristics was extracted. The data collection took place between March and July 2020 and included 324 cases, 80.3% of which referred to involuntary hospitalizations; 17.6% of sample cases did not meet the criteria of the procedure, as opposed to 1.9% of the cases in which the patients eventually ended up being voluntarily admitted and afterwards hospitalized for treatment. There was a statistically comparison of socio-demographic, clinical and parametric variables in relation to the status of hospitalization groups (involuntary, voluntary and no hospitalization). Additionally, statistical comparisons were made between parametric and clinical variables in relation to the type of prosecution order (written: standard route, oral: emergency route). Acute mental health deterioration accounted for around 45% of the total data and it has been identified as the main factor for informing the Hearings Prosecutor office mainly by the patient's family and subsequently proceeding to the issuance of an order (in either written or oral form) to the Police. This enables the Police to escort the individuals and lead them to a psychiatric unit for mental health assessment (MHA) and based on this, for involuntary hospitalization if deemed necessary. In 87.9% of the cases, the individual was transported by police vehicles over a time span ranging from the very same day to 22 days. In total, the written prosecution orders (63.6%) outnumbered the oral ones (36.7%). The findings of the present study demonstrate that the Prosecution order type varies significantly depending on the causes that instigated the involuntary hospitalization procedure. The psychiatric decision whether there should be hospitalization or outpatient therapy also significantly varies depending on the diagnosis. Lastly, the results point out that the need for improvement and further clarification of the aforementioned Greek Law is absolutely essential.

Mental Health and Well-Being During the First vs. Second COVID-19 Pandemic Lockdown in Cyprus

Abstract. Introduction: Following the onset of the COVID-19 pandemic, most countries imposed strict governmental lockdowns. Research investigating the psychological impact of pandemic-induced lockdowns is accumulating, though to date no study has examined the psychological health and associated parameters of well-being in countries that underwent additional lockdowns as the pandemic continued into resurgence “waves.” Aim: The present study provides an overview of the psychological impact of COVID-19 across the two lockdowns in the Cypriot population. Methods: In total, 957 participants completed an online survey during the first lockdown, 134 of whom completed a similar survey again during the second lockdown. The outcomes assessed included stress, positive and negative affect, and well-being. Results: The results indicated no population-wide severe reactions in the participants. Repeated measures analyses showed similar mental health levels during both the first and the second lockdowns. Further inspection of participants’ scores indicated that, for all mental health variables, approximately half of the participants improved, while the other half deteriorated. Discussion: Perceived social support and psychological flexibility predicted most psychological outcomes during both lockdowns. Further research is necessary to understand the continuing effects of the pandemic and associated lockdowns on mental health.

Locked versus open ward environments and restrictive measures in acute psychiatry in Greece: Nursing students' attitudes and experiences

PURPOSE

To examine student nurses' attitudes and experiences of door policies and restrictive measures in acute psychiatric care.

METHODS

A mixed-method study with 274 third-year students.

RESULTS

Participants' attitudes towards door locking and other containment measures appeared to be more a matter of custom, practice and tradition at particular units. The therapeutic benefits of open doors was the central organizing element in open units experiences while locked doors appeared to be "invisible" when the locked unit was perceived as a caring environment.

PRACTICAL IMPLICATIONS

Exploring student nurses' attitudes towards crucial and debatable aspects of mental health practice contributes in cultivating a critical and analytical attitude towards the service they provide necessary for supporting a recovery mental health model and building a strong professional identity.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.

Methods

Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.

Results

An increment of involuntary hospitalizations was associated with male gender [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively].

Conclusions

The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Economic Distress in Families with a Member Suffering from Severe Mental Illness: Illness Burden or Financial Crisis? Evidence from Greece

The present study aims to explore the economic distress and pertinent coping strategies in families with a member suffering from a severe mental illness. Furthermore it endeavors to gauge the impact of illness burden and that of the Greek recession on economic distress, while disentangling their contribution. In total, 190 key relatives of people with severe mental illness were recruited from community mental health services in the region of Attica. Relatives completed a self-reported questionnaire consisting of the Index of Personal Economic Distress, the Family Burden scale and the Family Rituals scale. Information on financial strategies for tackling recession and income loss due to the recession was also gleaned. Regarding economic distress, only 15% had frequent difficulty meeting routine financial demands in their household. The preponderant strategy was spending savings (56.8%). Income category and spending less on basic needs were the main predictors of economic distress. Objective poverty indices rather than burden predicted economic distress to a greater extent.

Socio-Demographic and Clinical Characteristics of Adults With Psychotic Symptomatology Under Involuntary Admission and Readmission for Compulsory Treatment in a Referral Psychiatric Hospital in Cyprus

Socio-demographic and clinical characteristics of adults under compulsory psychiatric treatment, have not been reported adequately in Southern European countries. We investigated the socio-demographic and clinical characteristics of adults with psychotic symptomatology who were involuntarily treated in the acute Mental Health Services in Cyprus. A descriptive cross-sectional study was applied. Data collection (December 2016 to February 2018) achieved via a structured questionnaire including demographic and clinical variables. Census sampling was applied in Cyprus referral center for compulsory psychiatric treatment. The sample included 406 individuals (262 males, 144 females). Approximately 86.2% were single, 77.6% were unemployed, and 24.9% held a bachelor's degree. The most frequent clinical diagnosis was schizophrenia or a relevant psychotic disorder (86.4%). The most frequent admission cause was non-adherence to pharmacotherapy along with disorganized behavior (agitation and/or self-care deficit, and/or aggressive behavior, and/or suicidal behavior) (53.6%). Moreover, 70.7% of the sample reported a positive personal history of mental health problems, while 42.1% reported a positive family history of mental health disorders. Half of the participants (52%) were previously involuntarily admitted for compulsory treatment. Adjusted associations of readmission status were reported with Cypriot ethnicity (OR: 4.40, 95%CI: 2.58-7.50), primary education only (OR: 3.70, 95%CI: 1.64-8.37), readmission due to disorganized behavior along with non-adherence to pharmacotherapy (OR: 10.84, 95%CI: 2.69-43.72), as well as along with substance use (OR: 6.39, 95%CI: 1.52-26.82). Readmission was almost five times more likely to occur due to suicidal behavior (OR: 5.01, 95%CI: 1.09-22.99) compared to disorganized behavior not otherwise specified. Additionally, those with a diagnosis of schizophrenia were more than 12 times more frequently readmitted for compulsory treatment compared to other diagnoses (OR 12.15, 95%CI: 1.04-142). Moreover, the participants with higher secondary education had 54.6% less odds to be involuntarily re-admitted compared to Bachelor degree holders (OR 0.442, 95%CI: 0.24-0.79). A high percentage of involuntary treatment was noted due to non-adherence to pharmacotherapy and substance use. Re-evaluation of the effectiveness of relevant community interventions is suggested, as well as implementation of structured educational programs on therapy adherence during psychiatric hospitalization.

Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

BACKGROUND

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

AIMS

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

METHOD

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

RESULTS

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

CONCLUSIONS

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients' admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Mental Health Professionals' Attitudes to Severe Mental Illness and Its Correlates in Psychiatric Hospitals of Attica: The Role of Workers' Empathy

To describe mental health workers' attitudes to severe mental illness and to explore its socio-demographic and professional correlates, including the influence of empathy. A total of 127 mental health staff working on the psychiatric hospitals of Attica participated in the study. Stigma was assessed with the Attitudes to Severe Mental Illness scale (ASMI) and the Greek Social Distance scale; whilst Empathy with the Interpersonal Reactivity Index. Participants' unfavourable attitudes to severe mental illness were limited to pessimism about recovery, difficulty in viewing people with mental illness as similar to other people and desire to keep distance in intimate encounters. Professional group and personal experience with mental illness were found to predict stigma. Only perspective taking was associated with both stigma measures; while Fantasy was positively correlated with social distance. Anti-stigma interventions in mental healthcare should prioritize nurses and psychiatrists and aim at enhancing perspective taking.

Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis

BACKGROUND

Use of involuntary psychiatric hospitalisation varies widely within and between countries. The factors that place individuals and populations at increased risk of involuntary hospitalisation are unclear, and evidence is needed to understand these disparities and inform development of interventions to reduce involuntary hospitalisation. We did a systematic review, meta-analysis, and narrative synthesis to investigate risk factors at the patient, service, and area level associated with involuntary psychiatric hospitalisation of adults.

METHODS

We searched MEDLINE, PsycINFO, Embase, and the Cochrane Controlled Clinical Register of Trials from Jan 1, 1983, to Aug 14, 2019, for studies comparing the characteristics of voluntary and involuntary psychiatric inpatients, and studies investigating the characteristics of involuntarily hospitalised individuals in general population samples. We synthesised results using random effects meta-analysis and narrative synthesis. Our review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is registered on PROSPERO, CRD42018095103.

FINDINGS

77 studies were included from 22 countries. Involuntary rather than voluntary hospitalisation was associated with male gender (odds ratio 1·23, 95% CI 1·14-1·32; p<0·0001), single marital status (1·47, 1·18-1·83; p<0·0001), unemployment (1·43, 1·07-1·90; p=0·020), receiving welfare benefits (1·71, 1·28-2·27; p<0·0001), being diagnosed with a psychotic disorder (2·18, 1·95-2·44; p<0·0001) or bipolar disorder (1·48, 1·24-1·76; p<0·0001), and previous involuntary hospitalisation (2·17, 1·62-2·91; p<0·0001). Using narrative synthesis, we found associations between involuntary psychiatric hospitalisation and perceived risk to others, positive symptoms of psychosis, reduced insight into illness, reduced adherence to treatment before hospitalisation, and police involvement in admission. On a population level, some evidence was noted of a positive dose-response relation between area deprivation and involuntary hospitalisation.

INTERPRETATION

Previous involuntary hospitalisation and diagnosis of a psychotic disorder were factors associated with the greatest risk of involuntary psychiatric hospitalisation. People with these risk factors represent an important target group for preventive interventions, such as crisis planning. Economic deprivation on an individual level and at the population level was associated with increased risk for involuntary hospitalisation. Mechanisms underpinning the risk factors could not be identified using the available evidence. Further research is therefore needed with an integrative approach, which examines clinical, social, and structural factors, alongside qualitative research into clinical decision-making processes and patients' experiences of the detention process.

FUNDING

Commissioned by the Department of Health and funded by the National Institute of Health Research (NIHR) via the NIHR Mental Health Policy Research Unit.

An association of economic hardship with depression and suicidality in times of recession in Greece

The interplay between objective and subjective measures of economic hardship on influencing mental health has not been explored during a period of enduring recession. The present study aims to fill this gap by investigating the relationship between income and economic difficulties in evoking major depression and suicidality in Greece, while taking into consideration gender differences. A random and representative sample of 2188 adults participated in a telephone survey in 2013 (response rate = 81%). Major depression and suicidality were assessed with the pertinent modules of SCID-IV; while financial difficulties were measured by the Index of Personal Economic Distress. Information on confounder variables was also gleaned. Income exerted an independent effect on major depression (OR = 0.37, 95%CI = 0.22-0.63), which was more pronounced among men than women. On the contrary, financial difficulties exerted a strong and independent effect on depression (OR = 1.16, 95%CI = 1.13-1.2). Income was found to bear a strong association with suicidality only among men; whereas financial difficulties were unrelated in both genders. Subjective and objective indices of economic hardship exert a differential impact on mental health outcomes amid recession. Gender-sensitive policies and interventions should be geared towards softening the social effects of the recession in the country.

Manic episode, aggressive behavior and poor insight are significantly associated with involuntary admission in patients with bipolar disorders

Objectives

Serious mental illnesses, such as bipolar disorders and schizophrenia, are closely associated with involuntary admission. Many studies have focused on involuntary admission in people with schizophrenia, but little is known about the factors associated with involuntary admission in Chinese patients with bipolar disorders. This study aimed to investigate socio-demographic and clinical factors associated with involuntary admission in Chinese patients with bipolar disorders.

Methods

In this multi-center cross-sectional survey in China, a total of 155 newly admitted patients with bipolar disorders were consecutively recruited from 16 psychiatric institutions from 15 March to 14 April, 2013. Patients' socio-demographic and clinical data were collected from their medical records. The Modified Overt Aggression Scale and the Insight and Treatment Attitudes Questionnaire were used to measure patients' level of aggression and insight of current psychiatric illness.

Results

The prevalence of involuntary admission was 52% in this sample of Chinese inpatients with bipolar disorders. In multiple logistic regression, a high level of aggression (odds ratio (OR) = 2.48), diagnosis of manic episode (OR = 3.65), poor insight (OR = 7.52), and a low level of education (OR = 3.13) were significantly associated with involuntary admission.

Conclusion

Manic episode, aggressive behavior, and poor insight were the significant contributing factors to involuntary admission in Chinese patients with bipolar disorders.

A retrospective analysis of determinants of involuntary psychiatric in-patient treatment

BACKGROUND

The purpose of our study was to identify predictors of a high risk of involuntary psychiatric in-patient treatment.

METHODS

We carried out a detailed analysis of the 1773 mental health records of all the persons treated as in-patients under the PsychKG NRW (Mental Health Act for the state of North Rhine-Westphalia, Germany) in a metropolitan region of Germany (the City of Cologne) in 2011. 3991 mental health records of voluntary in-patients from the same hospitals served as a control group. We extracted medical, sociodemographic and socioeconomic data from these records. Apart from descriptive statistics, we used a prediction model employing chi-squared automatic interaction detection (CHAID).

RESULTS

Among involuntary patients, organic mental disorders (ICD10: F0) and schizophrenia and other psychotic disorders (ICD10: F2) were overrepresented. Patients treated as in-patients against their will were on average older, they were more often retired and had a migratory background. The Exhaustive CHAID analysis confirmed the main diagnosis to be the strongest predictor of involuntary in-patient psychiatric treatment. Other predictors were the absence of outpatient treatment prior to admission, admission outside of regular service hours and migratory background. The highest risk of involuntary treatment was associated with patients with organic mental disorders (ICD 10: F0) who were married or widowed and patients with non-organic psychotic disorders (ICD10: F2) or mental retardation (ICD10: F7) in combination with a migratory background. Also, referrals from general hospitals were frequently encountered.

CONCLUSIONS

We identified modifiable risk factors for involuntary psychiatric in-patient treatment. This implies that preventive measures may be feasible and should be implemented to reduce the rate of involuntary psychiatric in-patient treatment. This may include efforts to establish crisis resolution teams to improve out-patient treatment, train general hospital staff in deescalation techniques, and develop special programs for patients with a migratory background.

Does Involuntary Admission With Bipolar Disorder Differ From Involuntary Admission With Schizophrenia and Related Disorders? A Report From the Dublin Involuntary Admission Study (DIAS)

BACKGROUND

While involuntary psychiatric admission and treatment are common, little is known about what impact different diagnoses have on specific features of involuntary admission and on how involuntary status is terminated (eg, by psychiatrists or tribunals, which are independent, court-like bodies reviewing involuntary admissions).

METHODS

We studied 2940 admissions, 423 (14.4%) of which were involuntary, at 3 psychiatry units covering a population of 552,019 individuals in Dublin, Ireland.

RESULTS

Involuntary patients were more likely than voluntary patients to be male and unmarried. The median length of stay for involuntary patients was 27 days compared with 10 days for voluntary patients (P<0.001). Schizophrenia (and related disorders, including schizoaffective disorder) and bipolar disorder accounted for 58.6% and 17.3% of involuntary admissions, respectively, compared with 20.1% and 12.4% of voluntary admissions (P<0.001). Psychiatrists revoked the majority of involuntary orders for both patients with bipolar disorder (85.3%) and those with schizophrenia (and related disorders) (86.6%); in contrast, tribunals did not revoke any involuntary admission orders for patients with bipolar disorder and revoked orders for 3.8% of patients with schizophrenia (and related disorders) (P=0.034). On the basis of multivariable testing, increased age among patients with bipolar disorder was the only characteristic among those studied (sex, age, marital status, occupation, involuntary admission criteria, length of stay, method of involuntary order revocation, location) that independently distinguished involuntary patients with bipolar disorder from those with schizophrenia (and related disorders) (P=0.028).

CONCLUSIONS

Involuntary admission of patients with bipolar disorder is similar in most respects to that of patients with schizophrenia (and related disorders). Consequently, it is important that measures aimed at reducing the need for involuntary admission (eg, patient advance statements/advance directives) are implemented equally across all diagnostic groups associated with involuntary care.

The impact of the long-lasting socioeconomic crisis in Greece

Since 2009, Greece has experienced a long-lasting socioeconomic crisis that has had substantial consequences on the health and mental health of the population. Unemployment, financial hardship and income loss constitute the hallmarks of the socioeconomic landscape. Consequently, a substantial decline in health and mental health has been documented. Converging evidence corroborates a deterioration of self-rated health, an alarming rise in suicide rates and a gradual increase in the prevalence of major depression. Concomitantly, the healthcare system is on the verge of collapse and the mental healthcare system is incapable of addressing the emerging needs. Therefore, a multifaceted and concerted effort is urgently needed to mitigate the mental health effects of the recession.

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.