Compulsory admissions in a London borough: I. Social and clinical features and a follow-up

Comparing mental health and mental capacity law data across borders: Challenges and opportunities

The island of Ireland is partitioned into Northern Ireland and the Republic of Ireland. In both jurisdictions, there have been important developments in mental health and mental capacity law, and associated policies and services. This includes an emphasis on developing more comprehensive approaches to collecting data on outcomes and so there is an opportunity to align these processes to enable comparison and shared learning across the border. This article explores: legal and policy developments; international approaches to mental health outcomes; and the type of data that would be helpful to collect to better understand the use of mental health and mental capacity laws. It is argued that an inclusive strategy to developing a comprehensive, integrated and aligned approach to collecting and analysing data would benefit citizens, policy makers and professionals.

Systematic review of involuntary hospitalisation and long-term compliance

INTRODUCTION

Involuntary hospitalisation denies autonomy and freedom of decision-making and is frequent in psychiatric clinical practice. However, there is still a lack of knowledge of long-term compliance after Involuntary commitment.

METHODS

We conducted a systematic review of published studies reporting people compliance after involuntary hospitalisation and people compliance after voluntary admission. Two investigators independently searched PubMed, PsycINFO, EMBASE and CINAHL up to December 17th, 2021 to identify eligible studies. The study is registered with PROSPERO number CRD42022299437.

RESULTS

Ten independent studies analysing the main indicators of compliance, engagement with services and medication adherence, were included. Three studies show that compliance is worse in people that have been involuntary hospitalised and in the others no association is found. Just two of the ten studies show an association with improved compliance. Outcomes are assessed from the first follow-up appointment after discharge up to 96 months.

CONCLUSIONS

Although evidences carried out so far are weak, the data do not show a trend of improvements and do not seem to exclude the possibility of worse compliance after compulsory hospitalisation. More appropriate methodologies and reliable assessment are needed in future research to provide scientific evidence on involuntary admission health effects.

Symptomatic, functional and service utilization outcomes of migrants with a first episode of psychosis

BACKGROUND

Certain migrant groups have been identified as being at increased risk of developing a psychotic disorder, but there is limited research on the outcomes for migrants who develop a first episode of psychosis (FEP). We investigated symptomatic outcomes (remission and relapse rates), functional outcomes (occupational status and relationships) and service utilization (hospital admission and engagement).

METHODS

Young people, aged between 15 and 24, who presented with FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen between 01.01.11 and 31.12.16 were included. Place of birth was recorded at the time of presentation. To determine remission, symptoms were scored at three-month intervals using the short-form Scale for the Assessment of Positive Symptoms.

RESULTS

A total of 1220 young people presented with FEP over the six-year period (mean age = 19.6 ± 2.8). Of these, 58.1% were male and 24.0% were first-generation migrants. While there was no difference in overall rates of admission after presentation, migrants were more likely to have an involuntary admission after presentation (31.4% vs. 24.6%, aHR = 1.54, 95% CI [1.19, 2.01]) and this risk was greatest for African migrants (HR = 1.98, 95% C.I. [1.37, 2.86]. The rates of remission and relapse were similar in migrants and those born in Australia and there was no difference in functional outcomes, such as employment rates at follow-up.

DISCUSSION

The outcomes for migrants who experience FEP appear to be largely similar to those for the Australian-born population. Our finding that a greater rate of involuntary admission for migrants at presentation supports existing literature and needs further exploration to improve clinical care.

Determinants of compulsory admissions in a state psychiatric hospital-Case control study

OBJECTIVE

Compulsory admissions are against the patient's will and are presumably due to diverse reasons. There has been a rise in compulsory admissions world over. The objective of the study was to determine the risk factors for compulsory admissions in a state psychiatric hospital.

METHODS

A case control study was conducted at the state psychiatric hospital, Trivandrum, Kerala. Cases were involuntary non-legal admissions while controls were voluntary admissions. Putative risk factors studied included social support, severity of psychopathology etc., in addition to the socio-demographic variables.

RESULTS

Risk factors for compulsory admissions were higher age, 30-49 years, OR=1.98, 95% CI [1.03-3.81]; >50years, OR=2.2, 95% CI [1.03-4.72], being from an urban locale,OR=1.99, 95% CI [1.13-3.52], living in joint & extended families OR=2.12, 95% CI [1.3-3.4], homelessness OR=2.24, 95% CI [1.32-3.79] and poor social support, OR=4.45 [2.53-7.81]. The type of illness, its duration, diagnosis, or symptom severity were not significantly related to compulsory admissions, but past compulsory admissions OR=5.36, 95% CI [2.09-13.75], poor functioning OR=2.54, 95% CI [1.31-4.91] and poor compliance to medication OR=1.78, 95% CI [1.05-3.01] were associated with compulsory admission. Poor social support, past involuntary admissions and poor functional status retained their association after multivariate analysis.

CONCLUSIONS

By addressing the modifiable factors like poor social support, poor functional status, and poor compliance to medication, compulsory admissions could be prevented. Since it is found that compulsory admissions are likely to repeat, such patients form a high risk group requiring specific interventions.

The Local use of Section 136

Recent attention has been focused on divergent practices in the implementation of Section 136, problems in its practice encountered by the police, and possible means of improving the service and reducing unnecessary detention. In these studies, doubts have been raised about the justness of the section, both in principle and in practice, and about the efficiency and efficacy of its implementation. In the context of the closure of the large psychiatric institutions it seems probable that these issues will become increasingly acute. The purpose of our brief study was therefore to investigate the trends of admissions to Friern Hospital, not only of patients under Section 136, but of all patients accompanied by the police.

Ethnicity and outcome of appeal after detention under the Mental Health Act 1983

Aims and Method

There is insufficient research into the relationship between ethnicity and appeals against detention under mental health legislation. We sought to identify rates and success of appeals in different ethnic groups through a retrospective analysis of all detentions under the Mental Health Act 1983 over 1 year.

Results

We found high rates of appeals overall, with substantial differences between ethnic groups (36 (39%) White British compared with 71 (63%) Black Caribbean (P = 0.0001) and 21 (68%) White Irish (P = 0.01) individuals (Yates corrected chi-squared)). Success rates on appeal were very low in all groups.

Clinical Implications

There are significant ethnic differences in appeals against detention under the Mental Health Act.

Section 136 and the Police

Section 136 of the Mental Health Act 1983 is a controversial section. It authorises a police constable, often with no psychiatric training, to take a mentally disordered person from a public place to a place of safety, usually a hospital or a police station, so that he or she may be assessed by a doctor and a social worker within a 72 hour period. There have been several studies looking at this section from the point of view of psychiatrists, social workers, and other interested parties, in particular MIND. The aim of this study was to find out from the police whether or not problems arose during their dealings with people whom they had placed on section 136.

A prospective, quantitative study of mental health act assessments in England following the 2007 amendments to the 1983 act: did the changes fulfill their promise?

BACKGROUND

In 2008, the Mental Health Act (MHA) 2007 amendments to the MHA 1983 were implemented in England and Wales. The amendments were intended to remove perceived obstacles to the detention of high risk patients with personality disorders (PDs), sexual deviance and learning disabilities (LDs). The AMEND study aimed to test the hypothesis that the implementation of these changes would lead to an increase in numbers or proportions of patients with these conditions who would be assessed and detained under the MHA 2007.

METHOD

A prospective, quantitative study of MHA assessments undertaken between July-October 2008-11 at three English sites. Data were collected from local forms used for MHA assessment documentation and patient electronic databases.

RESULTS

The total number of assessments in each four month period of data collection varied: 1034 in 2008, 1042 in 2009, 1242 in 2010 and 1010 in 2011 (n = 4415). Of the assessments 65.6% resulted in detention in 2008, 71.3% in 2009, 64.7% in 2010 and 63.5% in 2011. There was no significant change in the odds ratio of detention when comparing the 2008 assessments against the combined 2009, 2010 and 2011 data (OR = 1.025, Fisher's exact Χ 2 p = 0.735). Only patients with LD and 'any other disorder or disability of the mind' were significantly more likely to be assessed under the MHA post implementation (Χ2 = 5.485, P = 0.018; Χ2 = 24.962, P > 0.001 respectively). There was no significant change post implementation in terms of the diagnostic category of detained patients.

CONCLUSIONS

In the first three years post implementation, the 2007 Act did not facilitate the compulsory care of patients with PDs, sexual deviance and LDs.

Rehospitalization risk of former voluntary and involuntary patients with schizophrenia

BACKGROUND

The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization.

METHODS

In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %) involuntarily. Follow-up assessments were conducted half-yearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a random-effect logit model and a random-effect tobit model.

RESULTS

After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer.

CONCLUSIONS

Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients.

Procedures for involuntary admission to public and private psychiatric facilities

Objective: The aims of this study were to assess the procedures for involuntary admission to both public and private psychiatric hospitals as determined by the Mental Treatment Act, 1945 which is one of the oldest pieces of mental health legislation in the EC. Method: Over a prospective five month period all involuntary admissions to both a public and a private hospital in Dublin were studied. Social-demographic data and clinical features of 54 involuntary admissions were recorded and analysed. Results: 11.2% of public admissions were involuntary as were 3.4% of admissions to the private hospital. The most common diagnoses were schizophrenia and mania. 74.1% of the patients had been previously admitted. 81.5% of the patients were detained in hospital for less than three months although they were committed for a potential six months. There was no formal method of decertification. Conclusions: There appears to be little need nowadays for differentiating between legislation for public and private patients. The duration of the initial reception order should be reduced from six months to a period of forty-eight hours for initial assessment and treatment. If necessary this could be extended to three months. Formal methods for decertification are required. Mental health legislation in Ireland needs to be modernised.

Patient perspectives and the risk of compulsory admission: the Amsterdam Study of Acute Psychiatry V

OBJECTIVE

Compulsory admission to a psychiatric hospital is associated with a three- to fourfold increase in the risk of another compulsory admission. Given the rising numbers of civil detentions in The Netherlands and other European countries, it is important to understand the mechanism behind this association. Our aim is to study the links between opinions about prior psychiatric treatment, insight, service engagement and the risk of (new) civil detentions.

METHODS

We took a random sample of 252 from the 2,682 patients consecutively coming into contact with two psychiatric emergency teams in Amsterdam between September 2004 and September 2006. We recorded socio-demographic and clinical characteristics, and information about prior involuntary admissions. We interviewed the patients using the Verona Service Satisfaction Scale (Verona-EU), the Birchwood Insight Scale and the Service Engagement Scale. During a two-year follow-up period we noted their use of mental health care facilities.

RESULTS

Patients with a satisfactory score on the Verona-EU had significantly lower odds for civil detentions during follow-up compared to patients with a dissatisfactory score on this scale (OR = 0.3). Level of insight did not influence the risk of detention during follow-up. Furthermore, of the 131 patients admitted involuntarily the year before, one-third looked back on their involuntary admission with unambiguous satisfaction.

CONCLUSION

More satisfaction with prior treatment seems to reduce the risk of civil detention remarkably. Low levels of satisfaction seem to be mainly dependent on a history of previous involuntary admission. These findings seem to open up a new perspective for diminishing the risk of (new) civil detention by trying to enhance satisfaction with treatment, especially for patients under detention.

Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion

PURPOSE

The purpose of the study was to examine the long-term influence of involuntary hospitalization on medication adherence, engagement in out-patient treatment and perceived coercion to treatment participation.

METHODS

In a naturalistic observational multi-centre study, 290 voluntarily and 84 involuntarily hospitalized patients with schizophrenia or schizoaffective disorder had been followed up over a period of 2 years with half-yearly assessments. Assessments included self-rated medication adherence, externally judged medication adherence by blood levels, engagement in treatment and perceived coercion. The statistical analyses were based on multilevel hierarchical modelling of longitudinal data. Level and development of the outcome was controlled for involuntariness, for sociodemographic characteristics and clinical history.

RESULTS

Involuntariness of the index-hospitalization did not have an effect on the development of treatment engagement or medication adherence judged by blood levels in the course of the follow-up period when the models were controlled for sociodemographic variables and clinical history. It was associated, though, with a continuously lower self-rated medication adherence. Moreover, former involuntarily hospitalized patients more often felt coerced in several treatment aspects at the follow-up assessments. Yet, there was no difference between the voluntary and involuntary group with regard to the development of the levels of adherence or coercion experiences over time.

CONCLUSIONS

Involuntary hospitalization does not seem to impair future treatment engagement in patients with schizophrenia, but formerly involuntarily hospitalized patients continue to be more sensitive to subjective or real coercion in their treatment and more vulnerable to medication non-adherence. Hereby, their risk of future involuntary hospitalization might be increased.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Patients' views and readmissions 1 year after involuntary hospitalisation

BACKGROUND

Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals.

AIMS

To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes.

METHOD

Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year.

RESULTS

At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission.

CONCLUSIONS

Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.

Involuntary vs. voluntary hospital admission. A systematic literature review on outcome diversity

This article systematically reviews the literature on the outcome of acute hospitalization for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily. Inclusion and exclusion criteria qualified 41 out of 3,227 references found in Medline and PSYNDEXplus literature searches for this review. The authors independently rated these articles on six pre-defined indicators of research quality, carried out statistical comparisons ex-post facto where not reported, and computed for each adequate result the effect size index d for the comparison of means, and the Phi- or contingency coefficient for cross-tabulated data. Methodological quality of the studies, coming mostly from North American and European countries, showed significant variation and was higher concerning service-related than clinical or subjective outcomes. Main deficits appeared in sample size estimation, lack of clear follow-up time-points, and the absence of standardized instruments used to assess clinical outcomes. Length of stay, readmission risk, and risk of involuntary readmission were at least equal or greater for involuntary patients. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. Further, involuntary patients demonstrated lower levels of social functioning, and equal levels of general psychopathology and treatment compliance; they were more dissatisfied with treatment and more frequently felt that hospitalization was not justified. Future methodologically-sound studies exploring this topic should focus on patient populations not represented here. Further research should also clarify if the legal admission status is sufficiently valid for differentiating the outcome of acute hospitalization.

Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study

BACKGROUND

Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African-Caribbean and Black African patients with a psychotic illness.

AIMS

To establish whether African-Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres.

METHOD

All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (AESOP) study. For this analysis we included all White British, other White, African-Caribbean and Black African patients from the AESOP sampling frame. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.

RESULTS

African-Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African-Caribbean men were the most likely to be compulsorily admitted.

CONCLUSIONS

These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African-Caribbean and Black African patients.

Social exclusion and risk of emergency compulsory admission. A case-control study

BACKGROUND

Emergency detentions under section 4 of the Mental Health Act 1983 are more frequent in socially deprived areas of England and Wales. However, it is not clear whether individual socio-economic disadvantage increases likelihood of emergency detention. Therefore, this study tests the hypothesis that a higher proportion of people who are socially excluded will be admitted to hospital under section 4 than those who are not.

METHODS

A total of 300 mental health act assessments in two London boroughs with different rates of section 4 admissions were studied by retrospective case note review in a case-control design. An index of social exclusion was created and piloted for this study.

RESULTS

The logistic regression analysis discovered four risk factors for section 4 admissions: presenting with a risk to self or others at the mental health act assessment, bi-polar affective disorder, non-White British ethnicity and low social support. There were no significant differences between the two boroughs on these variables. Risk factors for any compulsory admission were: presenting with a risk, psychosis and non-White British ethnicity.

CONCLUSION

This study found low social support to be the only social exclusion indicator that increases likelihood of admission under section 4. While individual-level variables explain some of the variation in section 4 rates, it is likely that, as indicated by other studies, different configurations of mental health services affect rates to a greater degree.

The role of engagement with services in compulsory admission of African/Caribbean patients

BACKGROUND

High rates of compulsory admission of African/Caribbean patients have been reported. Several factors have been associated with this finding. The roles of some factors related to engagement with services have not been empirically evaluated.

AIMS

The aim of this study was to assess the role of engagement factors in compulsory admission of African/Caribbean patients.

METHOD

A systematic case-note review was made of the admission process of 100 compulsorily and 100 voluntarily admitted patients; each group containing 50 randomly selected African/Caribbean and White British patients. Information about socio-demographic and engagement factors was collected and the findings compared.

RESULTS

Compulsorily admitted African/Caribbean patients had more factors indicative of poor engagement with services than patients in the other groups. Prior to admission, they were less likely to keep their appointments, comply with their medication, contact their GPs and were more likely to present late. Furthermore, they had more history of multiple compulsory admissions. The compulsorily admitted patients, irrespective of ethnicity, also engaged poorly with services.

CONCLUSIONS

Poor engagement with primary care and secondary mental health services of African/Caribbean patients appears to be contributing to their high rates of compulsory admission. This aspect of ethnic factors and compulsory admission requires further studies.

Clinical predictors of admission status in first episode schizophrenia

Having a diagnosis of schizophrenia is a risk factor for involuntary admission to psychiatric inpatient care, but we have a limited understanding of why some patients and not others require involuntary admission. We aimed to identify the predictors of involuntary admission in first episode schizophrenia. We used validated instruments to assess clinical and socio-demographic variables in all patients (n = 78) with first episode schizophrenia from a defined geographical area admitted to a Dublin psychiatric hospital over a 4-year period. Involuntary patients (n = 17) could not be distinguished from voluntary patients (n = 61) on the basis of age, gender, living status, marital status, drug abuse or duration of untreated psychosis. Neither positive nor negative symptoms were useful predictors of admission status. Lack of insight was a strong predictor of involuntary status.

Epidemiology of involuntary placement of mentally ill people across the European Union

BACKGROUND

Despite the tendency for harmonisation of strategies for mental health care delivery, rules and regulations for involuntary placement or treatment of mentally ill persons still differ remarkably internationally. Rapid European integration and other political developments require valid and reliable international overviews, sound studies and profound analyses of this controversial issue.

AIMS

To give an overview of compulsory admission data from official sources across the European Union (EU).

METHOD

Data on the legal frameworks for involuntary placement or treatment of people with mental illness and their outcomes were provided and assessed by experts from all EU member states.

RESULTS

Total frequencies of admission and compulsory admission rates vary remarkably across the EU. Variation hints at the influence of differences in legal frameworks or procedures. Time series suggest an overall tendency towards more or less stable quotas in most member states.

CONCLUSIONS

Further research is greatly needed in this field. Common international health reporting standards are essential to the compilation of basic data.

A prospective survey of section 136 in rural England (Devon and Cornwall)

The Mental Health Act 1983 gives the police the power to remove those persons who appear to be mentally disordered from a public place to a place of safety. Previous studies have shown conflicting results concerning its use and there have not been any previous studies in a rural area. This study is a prospective survey of the use of Section 136 in SW England and was carried out between October and December 2000 in six custody centres in SW England. Each detainee had a study form completed to examine how the section was being applied, specifically looking at the time taken for the assessment to be complete and the outcome. The results showed that there were 178 detentions under Section 136 over the three-month study period. It took 25 minutes for detainees to arrive at a police custody unit and the assessments took about 8 hours to complete. The longest delay was for the approved social worker to arrive at the custody centre, (3h 25m) which was significantly longer than the arrival time of the Section 12 doctor (2h 10m). After assessment 32% of Section 136 detainees were admitted to hospital. There were differences between the conversion rates between the six custody centres although these were not significant. This study's conclusions suggest that although rural areas meet the statutory maximum time limits for completing Section 136 assessments, greater distances than in inner city areas lead to substantial delays in completing assessments. Also this study found a much lower rate of hospital admission after assessment than has been found previously and this may reflect the differing needs and characteristics of a rural population compared with the inner city populations.

Section 136 use in the London borough of Haringey

A retrospective one-year study of the use of Section 136 of the Mental Health Act was undertaken in Haringey between 1995 and 1996 to ascertain behaviours resulting in detention, and their admission rate. Data were extracted from police Section 136 forms, Emergency Assessment Centre records and patient notes. Of 90 people assessed under Section 136, the majority were male and lived locally, with the largest ethnic group being Afro-Caribbean. Each category of presenting behaviour recorded by the police was a high predictor of admission, with an overall admission rate of 82%. Behavioural categories with an admission rate of less than 79% were threats or acts of deliberate self-harm and 'confusion' or disorientation (57% and 67% admission rates), which both warrant police referral for specialized assessment. The three most common presenting behaviours were violent threats/acts, abnormal form or stream of speech, and walking/lying/running in the road. The police did not appear to over use Section 136. Section 136 data were incomplete, in keeping with previous studies. This should be rectified by the introduction of both a national data collection standard and a requirement for a defined local data collection point for all instances of Section 136.

Sociodemographic and clinical characteristics of psychiatric patients coercively brought to hospitals

In order to clarify the sociodemographic and clinical characteristics of psychiatric patients with poor motivation for treatment, we examined patients who were coercively brought to hospitals. Sociodemographic and clinical data on 287 inpatients from two private psychiatric hospitals in Japan were retrospectively analyzed. All patients were in the hospitals on 1 April 1997 and had received treatment prior to this admission. Of these inpatients, 67 (23.3%) were coercively brought to hospitals. Multiple logistic regression was performed on the data of these patients to identify the factors associated with their resistance to visiting the hospital. From the results of multivariate analysis, four characteristics were associated with patients coercively brought to hospitals, namely medication compliance, receiving regular outpatient treatment or not, a history of self-aggression or aggressive behavior towards others, and living arrangements. For patients who had lived with relatives before hospitalization, the primary caregiver being a parental caregiver was associated with patients coercively brought to hospitals, although it was not statistically significant. In addition, agitation was associated with patients not coercively brought to the hospital according to multivariate analysis. The present results suggest that psychiatric patients with poor motivation are more likely to have poor medication compliance, to have not received regular outpatient treatment, to have a history of aggressive behavior and to live alone. For patients who lived with their caregivers prior to hospitalization, poorly motivated patients tended to have parental caregivers and were less likely to be agitated.

[Decision making process for compulsory admission: study of a group of psychiatrists of Sardinia, Italy]

OBJECTIVE

The aim of the study was to investigate the attitudes in the decision making process for admitting patients compulsorily under the Italian Law 180/78.

SETTING

A group of psychiatrists (n = 81) working in the area of Cagliari (Sardinia, Italy).

MAIN OUTCOME MEASURES

Three case-vignettes describing different hypothetical clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. Each vignette was followed by a list of 11 factors reported in the literature as important in the decision to admit compulsorily (current mental state, severity of the disease, dangerousness to self or others, psychiatric history, likely response of the mental state to the medical treatment, age and gender of the patient, owning a home, occupational status, social support available). Psychiatrists were asked: a) whether they would admit the patient compulsorily; and b) to rate 11 factors from the most to the least important in their decision.

RESULTS

We obtained responses from 57 psychiatrists (26 males and 31 females). The most important factors for deciding to detain a patient compulsorily were: current mental state, diagnosis, severity of the illness and possible contribution of medical treatment. Perceived dangerousness to self and others was considered the most important factor by 23% of the sample.

CONCLUSIONS

Our results confirm that, in three different hypothetical situations, there is agreement in the factors perceived as the most important in the decision to admit compulsorily, although their application is highly subjective. The factors correspond to those recommended by the Italian Law 180. The need for protection of the patient or others has an important role in the decision and may take precedence over the current mental state of the patients [corrected].

Use of the Mental Health Act criteria in the decision-making process for compulsory admissions: a study of psychiatrists in South London

This study investigates the decision-making process for admitting patients compulsorily under the Mental Health Act 1983 of England and Wales. We used three case-vignettes describing different clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. The vignettes were administered to a group of psychiatrists working at the Bethlem Royal and Maudsley Hospitals in South London. The psychiatrists were asked to rate 11 factors from the most to the least important in their decision to admit the individual compulsorily. Three factors resembled the criteria considered in the Mental Health Act 1983 for compulsory admission: current mental state; severity of the disease; and dangerousness to self or others. Three were other clinical features of the patient: diagnosis; psychiatric history; and likely response of the mental state to the medical treatment. The remaining five were sociodemographic features of the patient: age and gender; owning a home; occupational status; and social support available. The psychiatrists were not given the option that the patient would accept a voluntary admission to hospital. We obtained responses from 42 psychiatrists (25 males and 17 females). The most important factor for deciding to detain a patient compulsorily was perceived dangerousness to self and others. The current mental state of the patient and the severity of the illness were the next two important factors. Our results confirm that the criteria recommended by the Mental Health Act 1983 of England and Wales were applied consistently in three different hypothetical situations. The need for protection of the patient or others may take precedence over the current mental state of the patient or the severity of the illness, a finding that warrants further investigation in view of the current debate on the responsibility of psychiatrists in deciding to detain subjects affected by personality disorder.

Dangerousness and disability as predictors of psychiatric patients' legal status

In a sample of patients admitted to two state psychiatric facilities, discriminant analyses were used to predict (1) legal status at admission (voluntary versus emergency detention), and (2) the subsequent decision to commit patients initially admitted under an order of emergency detention (court commitment versus release). Measures of preadmission dangerousness, followed by variables reflecting degree of disability or impairment, accounted for most of the variance in legal status at admission. Personal resources and demographic characteristics added little to the discrimination. Measures of disability accounted for most of the variance in the later decision to commit, whereas indices of dangerousness, personal resources, and demographics added little to discrimination of discharged and court-committed patients. These findings reflect the gap between legal standards and the practice of civil commitment, and support the argument that degree of disability plays a more important role than dangerousness in decisions to extend the hospitalization of involuntary patients.

Homelessness, mental illness and the law

One major difficulty that faces both researchers and practitioners who work with the homeless is the lack of definitions and frameworks that assist better understanding of such people's problems and society's response to them. This article reviews the legislation dealing with homeless people's social, civil and legal problems. We tried to give this legislation's historic and social background, including a section on psychiatric disorders in this group because of their relevance to current debate on homeless offenders. We then reviewed the legislation relevant to homeless people in general and the homeless mentally ill in particular, including the recently introduced court diversion schemes.

The Camden schizophrenia surveys. II. High prevalence of schizophrenia in an inner London borough and its relationship to socio-demographic factors

BACKGROUND

Investigation of the geographical distribution of schizophrenia and its relationship to socio-demographic factors is useful for planning services.

METHOD

Individuals with schizophrenia (n = 980) were identified by key informants within an inner London borough and point prevalence calculated for broad, Feighner and DSM-III-R schizophrenia. The distribution of cases was tested for significant variation using the Poisson process model. Regression models using the Jarman-8 score and its component variables were tested for their ability to predict the prevalence of schizophrenia.

RESULTS

A high point prevalence of schizophrenia (5.3 per 1000 resident population) was demonstrated. Case distribution showed a marked and significant variation associated with socio-demographic factors. The prediction of prevalence was more accurate for broad than for narrower definitions of schizophrenia; unemployment rate performed best.

CONCLUSIONS

Unemployment rates and Jarman-8 scores may provide crude estimates for resource allocation in planning mental health services, highlighting the need for additional services in deprived inner city areas.

Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London

OBJECTIVE

To compare the risk of detention under the Mental Health Act 1983 in a representative group of people with psychotic disorders from different ethnic groups.

SETTING

Two defined geographical areas in south London.

DESIGN

Annual period prevalent cases of psychosis were identified in 1993 in the study areas from hospital and community data. Standardised criteria were applied to case notes to establish diagnosis and detention under the act.

SUBJECTS

535 patients were identified, of whom 439 fulfilled ICD-10 criteria for psychosis.

MAIN OUTCOME MEASURES

Risk of ever having been detained under the Mental Health Act 1983, risk of detention under specific sections of the act during the study year, and risk of contact with forensic services for the different ethnic groups.

RESULTS

439 patients with a psychotic illness were identified. Nearly half of the white patients had been detained under the act compared with 70% and 69% of black Caribbean and black African patients, respectively. Black Caribbean and black African patients were more likely than white patients to have been involuntarily detained (adjusted odds ratio 3.67; 95% confidence interval 2.07 to 6.50 and 2.88; 1.04 to 7.95, respectively). Rates of use of sections 2, 3 and 136 in the study year were higher for black than for white patients, and black patients were more likely than white patients to have been admitted to a psychiatric intensive care facility or prison.

CONCLUSION

Independent of psychiatric diagnosis and sociodemographic differences, black African and black Caribbean patients with psychosis in south London were more likely than white patients to have ever been detained under the Mental Health Act 1983.

Personality disorder and police section 136 in Westminster: a retrospective analysis of 65 assessments over six months

Section 136 of the 1983 Mental Health Act empowers the police to detain those suspected of being mentally ill in public places. The current study is a retrospective analysis of those occurring within Westminster, London, over a six-month period. A high rate of referral was found. In those individuals assessed, schizophrenia was the commonest diagnosis, but personality disorder provided the largest number of assessments. This was due to the propensity of the latter individuals to present on multiple occasions. Those with personality disorders were significantly less likely to be placed under further sections of the Mental Health Act, less likely to be admitted to hospital and more likely to re-present under a further section 136. The inability of the current system to address these individuals' needs is a cause for concern.

Mortality and suicide rates of involuntarily committed patients

The mortality and suicide rates for involuntarily committed patients in Denmark are presented. Two cohorts of psychiatric patients committed to a mental hospital from January 1, 1971 to December 31, 1975 (8322 people) and January 1, 1981 to December 31, 1985 (5253 people) have been followed. The standard mortality rate (SMR) in relation to the total Danish population were 4.9 (4.5-5.4) and 5.2 (4.7-5.8), respectively, for the two cohorts, during the first year after involuntarily commitment to a mental hospital. During the same period, the SMR for suicide among the committed patients were 44.9 (37.1-53.9) and 30.9 (24.2-38.9), respectively. The crude suicide rates among the committed patients during the first year after the commitment were 14.3 and 14.0, respectively, per 1000 years, unchanged between the cohorts. Short length of stay in hospital (< 14 days), a nonpsychotic main diagnosis, male sex, and age 35 years or more were equally related to high risk of suicide in the 1971 cohort as evaluated to proportional hazard methods (Cox regression), and short length of stay and commitment on the danger indication provided the most information in relation to high suicidal risk in the 1981 cohort. Methodological problems and the reasons for the results are discussed.

Police may underuse Section 136

A one-year prospective study comparing Section 136 patients (39) and the severe Section 2 or 4 patients (29) of the Mental Health Act 1983 in a hospital with inner London catchment areas. The assessments were clinical, nurses' ratings and socio-demographic. The results showed that clinical and nursing ratings did not differentiate the two groups. Most social/demographic data showed similar trends with both groups being disadvantaged but Section 136 patients slightly more so. The differences were smaller than anticipated, suggesting a recent shift of patients admitted under Section 2 or 4 towards a more socially disadvantaged position. In conclusion, police did not overuse Section 136. Our comparison suggests: (a) police may underuse Section 136, and (b) Section 136 acts as a valuable 'back-up' for those patients who would otherwise fail to benefit from the Mental Health Act.

Compulsory admission of psychiatric patients--an international comparison

The frequency of compulsory admissions to psychiatric hospitals varies considerably between countries and regions. However, the differences are partly artificial, as the figures available are not fully comparable; this is mainly owing to differing definitions of "compulsory" and the methodological shortcomings of most studies in this field. In addition, there are also clear real differences, most of which result from different legislation and administrative regulations. Characteristics of the patient that influence the risk of compulsory admission include diagnosis and certain sociodemographic and social factors. Most studies, however, are based on highly selected populations. Furthermore, the results depend heavily on the commitment frequency of a country and therefore eventually also on the restrictiveness of legislation. The lack of methodologically sound studies, internationally comparable data and internationally published information is regrettable, as international comparison and discussion would certainly be valuable, especially for countries that are in the process of re-evaluating their commitment criteria and mental health legislation.

Diversion from custody. II: Effect on hospital and prison resources

Two hundred and one referrals to a psychiatric assessment scheme based at two inner-London magistrates' courts were followed up to assess the effect of the scheme on hospital and prison resources. Of the 65 hospital admissions, 50 (77%) derived some or marked benefit from psychiatric treatment. Those who did badly were more likely to be of no fixed abode, and had higher rates of criminality and previous compulsory admission to hospital. Absconding was the largest management problem; 30 (46%) of those admitted did so. Twelve months after admission, all patients except one had been discharged; 10 (15%) had been readmitted to hospital. The scheme generated an extra 21 (64%) hospital admissions per annum from the two courts, compared with the three years before its introduction. The saving in remand time to the prison was approximately double the increased admission time to hospital. However, the overall effect of early diversion on hospital and prison resources was small.

Mental health, race and ethnicity: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit

A retrospective case-note study of 152 discharged psychiatric patients (77 subjects of ethnic minority origin and 75 whites) examined for details of follow-up arrangements on discharge, compliance rate with out-patient appointments and details on length of stay, status on admission, employment status, record of illicit drug taking and diagnosis. The results show that in the areas of diagnosis, possible illicit drug involvement, status on admission and length of stay, there are significant differences between Afro-Caribbean subjects and others.

'Mentally disordered persons found in public places'. Diagnostic and social aspects of police referrals (Section 136)

A survey over 2 years of all Police Referrals (Section 136 of the Mental Health Act 1983) in an inner-city health district identified 163 cases, with a core group of repeat referrals. Previous psychiatric admissions, a diagnosis of schizophrenia, social deprivation, and a bias towards young men of Afro-Caribbean ethnicity were key features. The difficulty of obtaining clear data and uncertainties within the law rebound unfairly on patients, police and psychiatrists. Section 136, while not inappropriate diagnostically, can be seen as highlighting unmet social and medical needs in the context of community care. The requirement for coordinated resources, including acute in-patient services sufficient for deprived populations and legal provision for treatment beyond a hospital's boundaries, seems paramount.

Compulsory psychiatric treatment in the community. II. A controlled study of patients whom psychiatrists would recommend for compulsory treatment in the community

Several English consultant psychiatrists were asked to identify which patients currently under their care they would recommend for treatment with a community treatment order, if such a provision existed. The psychiatrists were asked to match each such 'nominated' patient for age, sex and diagnosis with one or two control patients, not considered to require compulsory treatment in the community. From specific data collected, it was found that: the two groups did not differ in their 'lifetime' histories of psychiatric admissions, substance misuse, criminal charges or dangerousness; 65-72% of the total sample had a history of serious dangerousness; but in the 12 months before nomination, the 'nominated' patients were significantly less likely than the controls to have complied with psychiatric treatment, and more likely to have defaulted from follow-up. The results indicate that a psychiatrist's decision to recommend a patient for treatment with a community treatment order will depend predominantly on specific criteria related to the patient's recent past.

Factors influencing compulsory admission of psychiatric patients

From 1 January 1984 until 30 June 1986 all 517 compulsorily admitted psychiatric patients of a well-defined mixed rural-urban catchment area in Baden-Württemberg, a southern State of the German Federal Republic, were compared with all 10,232 voluntarily admitted patients. Because of the very low frequency of compulsory admissions this population can be regarded as a 'core group' of committed patients. In a logit analysis the characteristics distinguishing involuntary from voluntary patients can be reduced to three main factors: the diagnosis 'schizophrenia/paranoid disorder', 'masculine gender' and the compound indicator 'not owning a home', the latter being mainly associated with youth, masculine gender and low occupational status. The strong association of these characteristics with the criteria 'severity of disease' and 'danger to oneself and others', both pre-requisites for compulsory admission according to the laws of most countries, is discussed.

Ethnic factors in voluntary and compulsory admissions

Socio-demographic and clinical aspects of compulsory and informal admissions to general adult psychiatry wards over a two-year period are compared. In addition, Afro-Caribbean patients are compared with white UK-born patients. Relative rates of admission are examined. The study confirms other reports of greater than expected compulsory admissions of Afro-Caribbean patients and pays particular attention to the circumstances preceding compulsory entry to hospital and the persons and agencies involved in that process.

Section 136 and African/Afro-Caribbean minorities

Social, demographic and clinical information was collected retrospectively on all 99 people referred to a South London hospital in 1986 under Section 136 of the Mental Health Act (1983), this being the last complete year before local changes in the procedure for assessment of Section 136 cases were initiated. An over-representation of Afro-Caribbeans was confirmed and this seemed to be accounted for largely by young men under the age of 30 who with Africans had very high rates of previous Section 136 referral, were more likely to be perceived as threatening, incoherent and disturbed but less clearly diagnosed with a mental illness, and were more likely than the Caucasian sample to be living in stable accommodation. The implications of these results are discussed.

The effect of a nurses' industrial action on psychiatric hospital admissions

The socio-demographic and clinical characteristics of patients admitted to a large psychiatric hospital during a six month period of industrial action by nurses are described and compared with those from a similar period in the previous year. During the industrial action, the nursing staff agreed only to accept "emergency cases" for admission. The way that medical and social work practices were affected by the restricted conditions are discussed. The admission threshold was raised across all diagnostic categories, although the level of violence and social isolation was markedly less than expected. Chronic patients with a duration of illness of ten years or more were least likely to be admitted during the action. It is probable that some patients were admitted under a compulsory order to facilitate access to in-patient treatment.