Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis

Police-referred psychiatric emergency presentations during the first and second wave of COVID-19 in Berlin, Germany: a retrospective chart review

BACKGROUND

Literature on psychiatric emergency services (PES) presentations during the COVID-19 pandemic showed heterogeneous results regarding patients brought in by police (BIBP). This is the first study primarily focusing on patients BIBP in a PES during the COVID-19-period.

METHODS

Case documentation records during the first and second wave of the COVID-19 pandemic in a PES in Berlin, Germany were analyzed using descriptive data analysis and binomial logistic regression analysis to detect factors that predict presentations BIBP.

RESULTS

5440 PES presentations: 20.4% BIBP during the first wave vs. 16.3% during its control period; second wave: 17.6% BIBP vs. 14.9% during its control period. In both waves, absolute increases in presentations BIBP were seen compared to control (p = .029, p = .028, respectively). COVID-19-period was a predictor for presentations BIBP during the first and the second wave. The following factors also predicted presentations BIBP: younger age, male gender, aggressive behavior, suicide attempt prior to presentation and diagnosis of psychotic or substance use disorders; depressive disorders were negatively associated.

CONCLUSIONS

During the two first waves of the COVID-19 pandemic, there was an increase in presentations BIBP in a PES in Berlin. Regression analysis shows that the pandemic itself was a predictor of presentations BIBP. The underlying factors of this association need to be further elucidated in future research. Additionally, general factors predicting PES presentations BIBP are reported that replenish the present literature.

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

BACKGROUND

A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning.

METHODS

We analysed registry data for 2008-2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission.

RESULTS

In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls.

CONCLUSION

There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Position Paper: fragmented youth healthcare services in the Netherlands endanger treatment of teenage boys with psychiatric disorders

For children who show strongly deviant behaviour in the Netherlands, a distinction is made between behavioural problems and psychiatric problems. As a result, two different domains have emerged over time, each with its own legal frameworks and inclusion and exclusion criteria. Consequently, there is no well-organized, coherent system for youth mental health care in the Netherlands. This strong dichotomy raises the question whether patients are being admitted to facilities where they are receiving appropriate care. In addition, referral bias can arise, because the type of complaint with which a young person presents is often dependent on the type of coping of the individual and thus, in turn, the gender of the patient. In this Position Paper, we examined the gender distribution at a youth psychiatric high and intensive care (HIC-Y) and other streams of youth care in the Netherlands to explore possible inequities in access to psychiatric care among children and adolescents. Results show that girls are significantly more likely than boys to be admitted to the HIC-Y for suicidal thoughts, self-harm and emotional dysregulation. In fact, girls account for 80% of all admissions, while boys account for only 20%. In contrast, regional and national reports from youth services and probation show a majority of boys being admitted (56-89%). The way care is organized (lack of cross-domain collaboration and the interplay between gender-dependent coping and exclusion criteria) seems to play a role in the underrepresentation of boys in acute psychiatry and their overrepresentation in secure youth care. Based on our research results, the concern is raised whether boys have a greater chance of undertreatment for psychiatric problems. Further research is needed to better understand the underlying factors that contribute to gender bias in psychiatric admissions, and to develop interventions that promote gender equality in healthcare.

SARS-CoV-2 and Adolescent Psychiatric Emergencies at the Tübingen University Hospital: Analyzing Trends, Diagnoses, and Contributing Factors

Psychiatric emergencies have increased in recent decades, particularly with the onset of the SARS-CoV-2 pandemic, and far too little is known about the backgrounds of these emergencies. In this study, we investigated the extent to which the number of psychiatric emergencies changed during and in the aftermath of the SARS-CoV-2 pandemic at the Child and Adolescent Psychiatry (CAP) Tübingen. We considered age and psychiatric diagnoses. Additionally, we evaluated the backgrounds of the emergencies. We applied a mixed- (quantitative and qualitative) methods approach to data on emergency presentations at the CAP Tübingen from the pre-SARS-CoV-2 pandemic period (October 2019-January 2020) to Restriction Phase 1 (October 2020-January 2021), Restriction Phase 2 (October 2021-January 2022), and endemic phase (October 2022-January 2023). The total number of emergencies and those with eating disorders and affective disorders increased, while obsessive-compulsive disorders, expansive disorders and anxiety disorders decreased. The patients presenting in the pre-SARS-CoV-2 pandemic period were younger than those in the subsequent periods. We content-coded the reasons behind the emergency presentations. We also identified four areas of stressors and personality characteristics associated with the emergency presentations. In light of the increasing number of psychiatric emergencies, the long-term aim should be to meet the growing demands and create options for prevention.

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.

Umbrella Review: Atlas of the Meta-Analytical Evidence of Early-Onset Psychosis

OBJECTIVE

Early-onset psychosis (EOP) refers to the development of psychosis before the age of 18 years. We aimed to summarize, for the first time, the meta-analytical evidence in the field of this vulnerable population and to provide evidence-based recommendations.

METHOD

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant, pre-registered (PROSPERO: CRD42022350868) systematic review of several databases and registers to identify meta-analyses of studies conducted in EOP individuals to conduct an umbrella review. Literature search, screening, data extraction, and quality assessment were carried out independently. Results were narratively reported, clustered across core domains. Quality assessment was performed with the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool.

RESULTS

A total of 30 meta-analyses were included (373 individual studies, 25,983 participants, mean age 15.1 years, 38.3% female). Individuals with EOP showed more cognitive impairments compared with controls and individuals with adult/late-onset psychosis. Abnormalities were observed meta-analytically in neuroimaging markers but not in oxidative stress and inflammatory response markers. In all, 60.1% of EOP individuals had a poor prognosis. Clozapine was the antipsychotic with the highest efficacy for overall, positive, and negative symptoms. Tolerance to medication varied among the evaluated antipsychotics. The risk of discontinuation of antipsychotics for any reason or side effects was low or equal compared to placebo.

CONCLUSION

EOP is associated with cognitive impairment, involuntary admissions, and poor prognosis. Antipsychotics can be efficacious in EOP, but tolerability and safety need to be taken into consideration. Clozapine should be considered in EOP individuals who are resistant to 2 non-clozapine antipsychotics. Further meta-analytical research is needed on response to psychological interventions and other prognostic factors.

STUDY PREREGISTRATION INFORMATION

Early Onset Psychosis: Umbrella Review on Diagnosis, Prognosis and Treatment factors; https://www.crd.york.ac.uk/PROSPERO/; CRD42022350868.

Emergency-related inpatient admissions in child and adolescent psychiatry: comparison of clinical characteristics of involuntary and voluntary admissions from a survey in Bavaria, Germany

Emergency inpatient admissions of children and adolescents are more difficult if the patient is admitted involuntarily and/or the caregivers or custodians of institutional care are absent. The present study aimed to clinically characterize involuntary versus voluntary admissions by examining the reasons for presentation and associated factors. We retrospectively analyzed patients who presented to the emergency department of a hospital for child and adolescent psychiatry in Bavaria, Germany, and were admitted as inpatients for crisis intervention in the 4th quarter of 2014-2018. Reasons for presentation, clinical and sociodemographic characteristics, and type of admission (voluntary versus involuntary) were analyzed for 431 emergency inpatient admissions. A total of 106 (24.6%) patients were involuntarily admitted. In a binominal logistic regression, presentation due to alcohol consumption, deviant social behavior, and psychosocial burden was positively associated, whereas difficulties at school and depression were negatively associated, with the likelihood of involuntary admission. 58.5% of the 123 unaccompanied patients were admitted involuntarily. Reasons for the presentation of unaccompanied and voluntary inpatient admissions were suicidal thoughts, psychosocial burden, and externalized aggression. A substantial number of child and adolescent psychiatric admissions represent emergency admissions. Involuntarily admitted patients and unaccompanied children/adolescents represent a non-negligible proportion of clinical routine and the clinical and legal background factors need to be further clarified in future studies. This study is registered in the German Clinical Trials Register (24 September 2019, DRKS00017689).

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review

Mental illness heightens risk of medical emergencies, emergency hospitalisation, and readmissions. Innovations for integrated medical-psychiatric care within paediatric emergency settings may help adolescents with acute mental disorders to get well quicker and stay well enough to remain out of hospital. We assessed models of integrated acute care for adolescents experiencing medical emergencies related to mental illness (MHR). We conducted a systematic review by searching MEDLINE, PsychINFO, Embase, and Web of Science for quantitative studies within paediatric emergency medicine, internationally. We included populations aged 8-25 years. Our outcomes were length of hospital stay (LOS), emergency hospital admissions, and rehospitalisation. Limits were imposed on dates: 1990 to June 2021. We present a narrative synthesis. This study is registered on PROSPERO: 254,359. 1667 studies were screened, 22 met eligibility, comprising 39,346 patients. Emergency triage innovations reduced admissions between 4 and 16%, including multidisciplinary staffing and training for psychiatric assessment (F(3,42) = 4.6, P < 0.05, N = 682), and telepsychiatry consultations (aOR = 0.41, 95% CI 0.28-0.58; P < 0.001, N = 597). Psychological therapies delivered in emergency departments reduced admissions 8-40%, including psychoeducation (aOR = 0.35, 95% CI 0.17-0.71, P < 0.01, N = 212), risk-reduction counselling for suicide prevention (OR = 2.78, 95% CI 0.55-14.10, N = 348), and telephone follow-up (OR = 0.45, 95% CI 0.33-0.60, P < 0.001, N = 980). Innovations on acute wards reduced readmissions, including guided meal supervision for eating disorders (P = 0.27), therapeutic skills for anxiety disorders, and a dedicated psychiatric crisis unit (22.2 vs 8.5% (P = 0.008). Integrated pathway innovations reduced readmissions between 8 and 37% including family-based therapy (FBT) for eating disorders (X2(1,326) = 8.40, P = 0.004, N = 326), and risk-targeted telephone follow-up or outpatients for all mental disorders (29.5 vs. 5%, P = 0.03, N = 1316). Studies occurred in the USA, Canada, or Australia. Integrated care pathways to psychiatric consultations, psychological therapies, and multidisciplinary follow-up within emergency paediatric services prevented lengthy and repeat hospitalisation for MHR emergencies. Only six of 22 studies adjusted for illness severity and clinical history between before- and after-intervention cohorts and only one reported socio-demographic intervention effects.

Emergency examination authorities in Queensland, Australia

OBJECTIVE

In Queensland, where a person experiences a major disturbance in their mental capacity, and is at risk of serious harm to self and others, an emergency examination authority (EEA) authorises Queensland Police Service (QPS) and Queensland Ambulance Service (QAS) to detain and transport the person to an ED. In the ED, further detention for up to 12 h is authorised to allow the examination to be completed. Little published information describes these critical patient encounters.

METHODS

Queensland's Public Health Act (2005), amended in 2017, mandates the use of the approved EEA form. Data were extracted from a convenience sample of 942 EEAs including: (i) patient age, sex, address; (ii) free text descriptions by QPS and QAS officers of the person's behaviour and any serious risk of harm requiring urgent care; (iii) time examination period commenced; and (iv) outcome upon examination.

RESULTS

Of 942 EEA forms, 640 (68%) were retrieved at three 'larger central' hospitals and 302 (32%) at two 'smaller regional' hospitals in non-metropolitan Queensland. QPS initiated 342 (36%) and QAS 600 (64%) EEAs for 486 (52%) males, 453 (48%) females and two intersexes (<1%), aged from 9 to 85 years (median 29 years, 17% aged <18 years). EEAs commonly occurred on weekends (32%) and between 2300 and midnight (8%), characterised by 'drug and/or alcohol issues' (53%), 'self-harm' (40%), 'patient aggression' (25%) and multiple prior EEAs (23%). Although information was incomplete, most patients (78%, n = 419/534) required no inpatient admission.

CONCLUSIONS

EEAs furnish unique records for evaluating the impacts of Queensland's novel legislative reforms.

Factors associated with children and young people's mental health in the English-speaking Caribbean region: Systematic review and narrative synthesis

BACKGROUND

Studies conducted in regions consisting of low and middle income and developing countries often report high prevalence of mental health problems among children and young people (CYP). To identify some of the contributing factors we examined the available evidence from research in one such setting.

METHODS

Multiple academic databases and grey literature sources were searched until January 2022. We then identified primary research focusing on CYP's mental health in the English-speaking Caribbean region. Data was extracted and summarized to form a narrative synthesis of the factors associated with CYP's mental health. The synthesis was then organised according to the social-ecological model. The Joanna Briggs Institute's critical appraisal tools were used to examine the quality of the reviewed evidence. The study protocol was registered with PROSPERO, CRD42021283161.

RESULTS

From 9684 records, 83 publications representing CYP ages 3 to 24 years from 13 countries met our inclusion criteria. The evidence was varied in quality, quantity and consistency for 21 factors associated with CYP's mental health. Adverse events and negative peer to peer and sibling relationships were consistently associated with mental health problems, while helpful coping strategies were associated with better mental health. There were mixed findings for age, sex/gender, race/ethnicity, academic level, comorbidity, positive affect, health risks behaviours, religion/prayer, parent history, parent to parent and parent to child relationships, school/employment, geography and social status. There was also some limited evidence for associations between sexuality, screen time and policies/procedures and CYP's mental health. At least 40% of the evidence contributing to each of the factors was judged as high quality.

CONCLUSION

Individual, relationship, community and societal factors may influence CYP's mental health outcomes in the English-speaking Caribbean. Knowledge of these factors is useful to inform early identification and early interventions. More research is needed to explore inconsistent findings and understudied areas.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

Comparison of adolescent referred involuntarily or voluntarily to psychiatric hospitalization

PURPOSE OF THE STUDY

To study in an adolescent clinical inpatient population how clinical, background and psychological factors differ between adolescents referred voluntarily or involuntarily.

METHODS

In this prospective cohort study, we compared adolescents (age 13-17 years, n = 206) who had been referred to psychiatric hospitalization for the first time in their life either voluntarily (n = 144) or involuntarily (n = 62). We gathered from clinical records data on the source, mode and reason for referral as well as on whether after referral the subjects were admitted to the hospital voluntarily or not, and whether they were committed to involuntary hospitalization after the observation period. Diagnostics was based on Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) interview, supplemented by information from clinical records. Structured self-reports provided information on family background, depressive symptoms, substance use, defense styles, self-image and perceived social support.

RESULTS

The majority of referrals due to psychotic symptoms were involuntary, whereas self-harm was the primary reason for involuntary and voluntary referrals in comparable extent. After diagnostic evaluation, no significant difference in psychotic disorders was observed between the two groups, but anxiety disorders were more prevalent among inpatients referred voluntarily than involuntarily. Among adolescents referred involuntary, parents were more often unemployed and had mental health problems. In self-assessments, mature defense style and more positive self-image were associated with adolescents referred involuntarily compared with those referred voluntarily.

CONCLUSIONS

Not only psychiatric but also psychological and social factors were associated with involuntary referral for psychiatric hospitalization in adolescents.

Indigeneity and Likelihood of Discharge to Psychiatric Hospital in an Australian Deliberate Self-Poisoning Hospital-Treated Cohort

Hospital-treated self-harm rates for Aboriginal and Torres Strait Islander (Indigenous) people are at least double those for other Australians. Despite this, limited research has explored the relationship between Indigeneity and the clinical management of hospital-treated deliberate self-harm. A retrospective clinical cohort study (2003-2012) at a regional referral centre (NSW) for deliberate self-poisoning was used to explore the magnitude and direction of the relationship between Indigeneity and discharge destination (psychiatric hospital vs. other) using a series of logistic regressions. There were 149 (4%) Indigenous and 3697 (96%) non-Indigenous deliberate self-poisoning admissions during the study period. One-third (31%) were referred to the psychiatric hospital at discharge; Indigenous 21% (n = 32) vs. non-Indigenous 32% (n = 1175). Those who identified as Indigenous were less likely to be discharged to the psychiatric hospital, OR 0.59 (0.40-0.87) at the univariate level, with little change after sequential adjustment; and AOR 0.34 (0.21-0.73) in the fully adjusted model. The Indigenous cohort had a lower likelihood of psychiatric hospital discharge even after adjustment for variables associated with discharge to the psychiatric hospital highlighting the need for further investigation of the reasons accounting for this differential pattern of clinical management and the effectiveness of differential after-care allocation.

[Association between substance use and coercive measures on psychiatric wards]

OBJECTIVE

The intention to minimize coercive measures requires a comprehensive understanding of the influencing factors. The aim of the present work was to examine the association between substance use and the use of coercive measures.

METHODS

All coercive measures carried out on acute psychiatric wards of the Charité Campus Mitte in 2019 were examined, with a particular focus on the association with substance use disorders.

RESULTS

In 106 cases (92 patients) out of a total of 1232 cases (1131 patients), coercive measures were used, mainly admissions according to PsychKG (94) and BGB (21), more rarely isolation (23) or mechanical restraint (18). Acute intoxication was present in approximately one third of cases with coercive measures and a history of substance use disorder in two thirds, most often with alcohol and/or cannabis. In contrast, 9% of 1232 treatment cases presented with acute intoxication and 36% with substance use disorders in general.

CONCLUSION

The present work delivers empirical data confirming the clinically known association between intoxication and the use of coercive measures.