Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure

Delays in commitment and treatment court proceedings worsen psychiatric and other medical conditions

OBJECTIVE

Adversarial hearings in hospital commitment and de novo treatment proceedings, or court hearings, delay psychiatric treatment in many jurisdictions. In Massachusetts, the "treatment over objection" process requires a court petition. For state hospital patients, the delay to treatment is an initial 34 day waiting period in addition to continuances of court hearings that extend treatment delays. This study examined the frequency of adverse medical events due to delayed court hearings within a forensic state hospital in the US.

METHODS

The study reviewed all (n = 355) treatment petitions filed by a Massachusetts forensic hospital from 2015 and 2016. The incidence and nature of adverse events (e.g. patient/staff assaults, milieu disruptions) and acute medical symptoms (e.g. catatonia, acute psychosis), before and after the Court granted a petition for treatment, were analyzed by two raters. Adverse events included patient and staff assaults, acute psychiatric symptoms, and milieu problems.

RESULTS

82.6 % of treatment petitions led to involuntary treatment, 16.6 % were withdrawn by the medical petition filer, and only 0.8 % petitions were denied by the judge. Adversarial hearings occasioned an average delay of 41 days from treatment petition filing to receipt of standing treatment in addition to statute required delays. Once treatment was court-approved, all types of adverse events were significantly reduced.

CONCLUSIONS

Results established that the court treatment hearing scheme exacerbates health and safety risks to patients with serious mental illness. Increasing physician and court personnel awareness of these risks is likely key to enhancing a patient-focused, rights-oriented approach to these matters. This and other recommendations is proposed for jurisdictions that deal with this problem around the world.

Canada Should Retain Its Reservation on the United Nation's Convention on the Rights of Persons with Disabilities

The United Nations adopted the Convention on the Rights of Persons with Disabilities (CRPD) in 2006. When Canada ratified the CRPD, it reserved the right to continue using substitute decision making schemes even if the CRPD was 'interpreted as requiring their elimination'. This was a prescient decision because the CRPD Committee, which is tasked with overseeing the interpretation and implementation of the CRPD, subsequently opined that all legislation supporting substitute decision making schemes contravene the CRPD and must be revoked. The CRPD Committee insists that every person can make decisions with sufficient support and that if a person lacks capacity to make a decision, we must rely on their 'will and preferences'. Many international legal scholars have called this interpretation unrealistic. We agree and, in this article, describe how this unrealistic approach would result in extensive harm and suffering for people with severe cognitive or psychotic disorders. The reader should also be aware that the CRPD Committee also calls for the elimination of all mental health acts and the United Nations Commissioner for Human Rights for the abandonment of the not criminally responsible (NCR) defence.

Refusal of prescribed drugs in a psychiatric hospital

Aims and methods

A survey of recorded refusal of drug administration to patients in a psychiatric hospital over a six-month period in 1996 was made using drug administration records. For comparison 150 patients were randomly selected from the 1975 drug sheets and instances of drug refusal noted.

Results

Eighteen per cent of patients refused drugs on at least one occasion, and of those over 65 years of age 26.2% refused drugs. All the main diagnostic categories and groups of drugs were involved. of the 150 patients studied from 1975 only four refused drugs.

Clinical implications

Doctors should be alert to the possibility of refusal of drug treatment in a wide range of psychiatric conditions. When refusal occurs interventions are likely to be necessary, including a review of drug treatment.

Why don't patients take their medicine? Reasons and solutions in psychiatry

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

Involuntary psychiatric admission: how the patients are detected and the general practitioners' expectations for hospitalization. An interview-based study

BACKGROUND

In Norway, it is usually GPs that refer patients to involuntary admission. A high proportion of such referrals come from out-of-hours clinics. Little is known about who first initiate the contact between the patients and the referring doctors and which expectations the referring doctors have with respect to the involuntary admissions. The aim of the study was to examine who first detected the patients who were subsequently involuntarily admitted, and to examine the referring doctors' expectations for the admissions.

METHODS

Semi-structured interviews with 74 doctors that had referred patients for involuntary admission at a psychiatric hospital.

RESULTS

Patients who were involuntarily admitted were detected by other branches of the health service (52 %, n = 39), family (25 %, n = 19), and the police (17 %, n = 13). The doctors mentioned these expectations for the admission (more than one expectation could be given): start treatment with neuroleptics: 58 % (n = 43), take care of the patient: 45 % (n = 34), extensive changes to the treatment regime: 37 % (n = 28), solve an acute situation: 35 % (n = 26), and clarify the diagnosis: 22 % (n = 17). Female doctors significantly more often expected that the patients would be examined and treated, while the male doctors significantly more often expected that the patients would be cared for.

CONCLUSIONS

Involuntary admissions are typically complex processes involving different people and services and patients with various needs. More knowledge about the events preceding hospitalization is needed in order to develop alternatives to involuntary admissions.

A comparison of treatment adherence in individuals with a first episode of psychosis and inpatients with psychosis

In predicting treatment compliance in individuals with severe mental illness, research has focused on variables such as substance abuse, personality, history of child abuse, and symptomatology, although these relationships have not been investigated in great detail in individuals at the onset of mental illness. To better understand these correlates of treatment compliance, two samples were examined: a sample of 117 individuals presenting with a first episode of psychosis and a more chronic forensic sample of 65 participants recruited from a psychiatric hospital. These samples were investigated for service engagement in terms of violence history, substance abuse, symptom severity, psychopathic traits and history of childhood abuse. Linear regressions performed for the first episode sample revealed that childhood physical abuse was the strongest predictor of poor service engagement, followed by problems with alcohol, a history of physical violence, any history of violence and higher psychopathic traits. Linear regression revealed for the forensic group that a lower level of service engagement was most strongly predicted by a history of childhood abuse and a higher score on the Brief Psychiatric Rating Scale (BPRS). Results are presented in light of the existing literature and clinical implications are discussed.

Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study

PURPOSE

This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries.

METHODS

Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect.

RESULTS

The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model.

CONCLUSIONS

The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

Reducing seclusion through involuntary medication: a randomized clinical trial

The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention. Patients admitted to an acute psychiatric ward were randomly allocated to two groups. In Group 1, involuntary medication was the intervention of first choice for dealing with agitation and risk of violence. In Group 2, seclusion was the intervention of first choice. Patients' characteristics between the groups were compared by Pearson χ(2) and two-sample t-tests; the incidence rates and risk ratios (RRs) were calculated to examine differences in number and duration of coercive incidents. In Group 1, the relative risk of being secluded was lower than in Group 2, whereas the risk of receiving involuntary medication was higher. However, the mean duration of the seclusion incidents did not differ significantly between the two groups; neither did the total number of coercive incidents. Although the use of involuntary medication could successfully replace and reduce the number of seclusions, alternative interventions are needed to reduce the overall number and duration of coercive incidents. A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met.

Conflict and containment events in inpatient psychiatric units

AIMS AND OBJECTIVES

To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns.

BACKGROUND

Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours.

DESIGN

A cross-sectional survey of conflict and containment events.

METHODS

Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively.

RESULTS

Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict.

CONCLUSIONS

This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours.

RELEVANCE TO CLINICAL PRACTICE

Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.

Event sequencing of forced intramuscular medication in England

In most inpatient psychiatric care systems it is permissible in certain situations for staff to forcibly inject patients with psychotropic medication. The aim of this study is to describe what precedes and follows a coerced intramuscular injection within a nursing shift. Data were collected on the sequence of conflict (aggression, absconding, etc.) and containment (seclusion, restraint, etc.) for the first 2 weeks of 522 acute admissions on 84 wards in 31 UK hospitals. Injections were given to 9% of patients. Aggression, regular medication refusal and pro re nata (PRN) medication refusal preceded injections. The giving of coerced medication concluded most crises. Coerced medication effectively resolves crises in the short term. Staff should offer oral PRN as an alternative, unless this is unsafe. Where only verbal violence has occurred staff should try to resolve the crisis without enforcing medication. More research on the best way to respond to inpatients' medication refusal is required.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

A narrative review of studies of refusal of psychotropic medication in acute inpatient psychiatric care

This paper offers a narrative review of the 22 studies of medication refusal in acute psychiatry. Because of varied definitions of medication refusal, diverse methodologies and few rigorous studies, it has not been possible to draw firm conclusions on the average rate of refusal of psychotropic medications in acute psychiatry. However, it is clear that medication refusal is common and leads to poor outcomes characterized by higher rates of seclusion, restraint, threats of, and actual, assaults and longer hospitalizations. There are no statistically significant differences between refusers and acceptors in gender, marital status and preadmission living arrangements. Although no firm conclusions on the influence of ethnicity, status at admission and diagnosis on refusal, the refusers are more likely to have higher number of previous hospitalizations and history of prior refusal. The review indicates that staff factors such as the use of temporary staff, lack of confidence in ward staff and ineffective ward structure are associated with higher rates of medication refusal. Comprehensive knowledge of why, and how, patients refuse medication is lacking. Research on medication refusal is still fragmented, of variable methodological quality and lacks an integrating model.

Nursing staff numbers and their relationship to conflict and containment rates on psychiatric wards-a cross sectional time series poisson regression study

BACKGROUND

The link between positive outcomes and qualified nurse staffing levels is well established for general hospitals. Evidence on staffing levels and outcomes for mental health nursing is more sparse, contradictory and complicated by the day to day allocation of staff resources to wards with more seriously ill patients.

OBJECTIVE

To assess whether rises in staffing numbers precede or follow levels of adverse incidents on the wards of psychiatric hospitals.

DESIGN

Time series analysis of the relationship between shift to shift changes over a six month period in total conflict incidents (aggression, self-harm, absconding, drug/alcohol use, medication refusal), total containment incidents (pro re nata medication, special observation, manual restraint, show of force, time out, seclusion, coerced intramuscular medication) and nurse staffing levels.

SETTINGS

32 acute psychiatric wards in England.

METHODS

At the end of every shift, nurses on the participating wards completed a checklist reporting the numbers of conflict and containment incidents, and the numbers of nursing staff on duty.

RESULTS

Regular qualified nurse staffing levels in the preceding shifts were positively associated with raised conflict and containment levels. Conflict and containment levels in preceding shifts were not associated with nurse staffing levels.

CONCLUSIONS

Results support the interpretation that raised qualified nurse staffing levels lead to small increases in risks of adverse incidents, whereas adverse incidents do not lead to consequent increases in staff. These results may be explicable in terms of the power held and exerted by psychiatric nurses in relation to patients.

Wards features associated with high rates of medication refusal by patients: a large multi-centred survey

OBJECTIVE

This article aimed to explore the relationship of medication-related conflict [refusal of regular medication, refusal of pro re nata (prn) medication, demanding prn medication] to other conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff demographics and staff group variables.

METHOD

The Patient-staff Conflict Checklist (PCC-SR), an end-of-shift report completed by nurses on the frequency of conflict and containment events, was collected for a 6-month period on 136 acute mental health wards in 67 hospitals within 26 NHS Trusts in England, in 2004-2005. Multilevel modelling was used to assess associations with medication-related conflict rates.

RESULTS

The mean daily rate (at ward level, standardised to 20 beds) of incidents of regular medication refusal was 0.89 (S.D. 0.52), prn medication refusal 0.30 (S.D. 0.19) and demanding prn medication 1.09 (S.D. 0.63). The frequency of these events was found to be associated with passive resistant patient behaviours, higher levels of containment (specifically locking the main ward door, the use of special observation, and time out) and unstable staffing profiles.

CONCLUSION

It may be possible to achieve greater medication concordance amongst patients in acute mental health wards through a more consensual approach to care. Paradoxically, fewer restrictions may promote better treatment acceptance and safer outcomes. Consistent nurse staffing and therefore better staff-patient relationships are also likely to improve cooperation and outcomes.

International human rights for mentally ill persons: the Ontario experience

This article is part of a working project which assesses Ontario's mental health legislation and practice vis-à-vis international human rights standards. The paper focuses on procedural safeguards provided by the major international human rights instruments in the field of mental health law such as the UN Principles for the Protection of Persons with Mental Illness (MI Principles) and the European Convention on Human Rights as interpreted by the European Human Rights Court. In analysing Ontario's compliance with international standards, the paper will explore some problems arising from the implementation of the legislation with which the author is familiar with from his experience as counsel for the Consent and Capacity Board. The paper aims to generate discussion for potential reforms in domestic legal systems and to provide a methodology to be used as a tool to assess similar mental health legislation in other local contexts.

Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.

Use of restraint in a general hospital psychiatric unit in Japan

Few analyses have been carried out in Japan concerning factors contributing to physical restraint of patients. We compared demographic data for 241 inpatients who were restrained during a 4-year period with data for 1093 inpatients who were not restrained in a general hospital psychiatric unit in Japan. Increased likelihood of restraint use was associated with older age, male gender, off-hours admission, involuntary hospitalization, transfer from other departments of the hospital, frequent hospitalization, absence of previous treatment, physical complications, history of suicide attempts, organic mental disorders, mental and behavioral disorders from psychoactive substance use, schizophrenia, schizotypal and delusional disorders. Importantly, physical complications not only were more prevalent among restrained than unrestrained patients, but additionally in restrained patients physical complications were associated with more prolonged hospitalization and periods under restraint than were associated with assaultive behavior or periods of unconsciousness. In conclusion, general hospital psychiatric units in Japan often treat patients with psychiatric disorders or symptoms that were associated with physical problems. Particular caution is needed in deciding whether such patients should be restrained since hospitalization may be prolonged or functional status compromised.

Disruptive and dangerous behaviour by patients on acute psychiatric wards in three European centres

BACKGROUND

The disturbed behaviour of acute in-patients can have serious consequences, and methods of management are contentious and vary between countries. Little is known about this variation and its relationship to the characteristics of in-patient populations.

AIM

The aim of this study was to compare rates and patterns of disturbed behaviours and containment methods in acute psychiatric wards in three centres in the United Kingdom, Italy and Greece.

METHOD

A retrospective survey of medical and nursing records (n=838) at seven hospitals for the first 2 weeks of patients' admissions was done using a structured data collection tool.

RESULTS

Nearly all types of disruptive behaviour varied by centre, with rates being generally higher in the UK and lowest in Italy. Specific relationships between different behaviours were replicated across all three centres. Ethnic minority patients were more likely to be subject to containment measures in all centres, even when their behaviours did not differ from the majority. Rates of containment method use were only partially related to the frequency of disturbed behaviour.

CONCLUSIONS

More research is required to discover the efficacy of varying containment methods, with a view to minimising their use. Gross international and inter-hospital variation demands large samples rather than single site studies. Clinicians need to reflect upon containment rates that may be, in some places, excessive and incorrectly targeted.

Combining clinical and actuarial methods to assess and manage risk in a New South Wales forensic psychiatric setting

OBJECTIVE

This paper describes the risk assessment (RA) approach in a maximum security forensic psychiatric unit in New South Wales, Australia. The literature in relation to violence and mental illness is briefly reviewed and discussed and the process of RA is described. Emphasis is placed on the importance of combining clinical and actuarial methods to engage in comprehensive RA.

CONCLUSION

It is concluded that a combination of actuarial and clinical assessment completed by a multidisciplinary team of mental health professionals with clinical knowledge of the patient being assessed is proving to be an efficient and effective method. Further directions are highlighted and a cautionary note in relation to the potential for unintended outcomes is made.

Fifteen years of research with the Staff Observation Aggression Scale: a review

OBJECTIVE

Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

METHOD

Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.

RESULTS

Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4-33.2 incidents (mean = 9.3).

CONCLUSION

Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Involuntary medication in psychiatric inpatient treatment

The aim of this study was to examine involuntary medication in psychiatric inpatient treatment. A retrospective chart review of 1543 consecutive admissions of working aged civil patients from well-defined catchment areas to three psychiatric centres were evaluated regarding events of involuntary medication. 8.2% of the admissions included involuntary medication episode(s). Involuntary medication was associated with a diagnosis of schizophrenia, involuntary legal status and having previously been committed. One of the studied centres used less involuntary medication than the other two, even if patients with schizophrenia were over-represented in that centre. Although involuntary medication mainly takes places in the treatment of patients who are conceptualised most ill and perhaps resist treatment most, treatment culture obviously also plays a role. In future, it is important to study the aspects of treatment culture to fully understand the use of involuntary medication in psychiatry.

The right to refuse psychiatric treatment

The right to refuse psychiatric treatment has become an important clinical and legal issue in the last twenty-five years. This article briefly reviews the clinical, administrative, and legal aspects of the right to refuse psychiatric treatment, especially medication. Emphasis is placed on the clinical issues including the reasons for treatment refusals, and the management of treatment refusal. Empirical data are provided to illustrate the rights driven and treatment driven models of involuntary psychotropic medication administration.

Is rehospitalization a measure of the efficacy of neuroleptics in the treatment of schizophrenia?

This study was undertaken to evaluate the efficacy of standard neuroleptic treatment versus depot neuroleptic treatment. The major criterion for evaluation was the number of patients hospitalized. Patients were chosen on the basis of their rating by the ICD-10 classification for schizophrenic disorders. The first study period was defined as the time when patients were treated with standard neuroleptics; the second was when patients were treated with depot neuroleptics. There were 231 hospitalizations during the first period, which involved 48 patients, i.e. 4.8 hospitalizations per patient. The mean total duration of these hospitalizations was 5.2 years, i.e. it was on average 5 years before the patient was treated with a depot neuroleptic, with 0.93 hospitalizations per year. The duration of the second period was the same as the first. Only 44 patients remained in the study during this period; their mean number of hospitalizations was 7.2 per patient. The mean number of hospitalizations per year per patient was 1.25. The results suggest that the number of hospitalizations is only a partially satisfactory way of evaluating the efficacy of neuroleptic treatments, and questions the relative efficacy of depot neuroleptics compared with standard neuroleptic treatment.