Involuntary Psychiatric Admissions and Development of Psychiatric Services as an Alternative to Full-Time Hospitalization in France

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

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

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

The impact of implementing a psychiatric emergency hotline on the reduction of acute hospitalizations in a Swiss tertiary hospital

BACKGROUND

Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission.

METHODS

This pre-post intervention quality improvement study compared changes in the management of psychiatric patients' admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments' costs. Fisher's Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student's t-test for continuous variables and Fishers's Exact test for proportions.

RESULTS

Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p < 0.001). In addition, for the patients hospitalized after the introduction of the emergency hotline there was a trend-level reduction of the average length of stay (9.32 days vs 17.35 days).

CONCLUSION

Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

Use of the French national health insurance information system for research in the field of mental health: Systematic review and perspectives

PURPOSE

This systematic review registered in PROSPERO (CRD42021225296) aimed to describe the use of the French national health insurance information system, which covers the entire French population (67 million inhabitants), for research in the field of mental health.

METHODS

Three electronic databases and a journal hand-search identified 15 265 articles from January 1, 2003 (year of creation of the database) to October 31, 2020. Studies of any design were eligible for inclusion provided that they (i) made use of at least one component of the French health insurance database and (ii) focused on a topic in near and far connection with the field of mental health in France. Database used, design and methods, study period, population, key findings, and type of use for medical research were described.

RESULTS

A total of 152 studies were included in the review analysis. There was an increase in the number of published articles over time throughout the studied period. Studies focusing on adults (n = 139) largely outnumbered those focusing on children and adolescents (n = 11). Pharmacoepidemiological studies were by far the most frequent (n = 123), followed by methodological studies (n = 23), epidemiological studies (n = 17), and health economics studies (n = 3). The most studied psychotropic drugs were antidepressants (n = 27), anxiolytics (n = 27), and opioids (n = 25) while fewer studies focused on methylphenidate (n = 6) and on mood stabilizers (n = 5). Few studies specifically focused on psychiatric disorders, mainly depression (n = 4), suicide (n = 4), and psychotic disorders (n = 3).

CONCLUSION

This systematic review highlighted a relatively poor exploitation of the Système national des données de santé database in the field of psychiatric research with regard to the great possibilities it offers, with a clear lag in certain fields such as epidemiological or health economics studies and in specific populations, in particular children and adolescents.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

Trashing Property: Characteristics of Psychiatric Patients Who Engage in Domestic Property Damaging

This descriptive record-based study included 75 patients who had engaged in domestic property damaging (DPD) and needed assessment by an urban emergency psychiatric service team in The Netherlands. The DPD patients were compared to 1145 other patients referred because of aggression, suicidality or other reasons. DPD patients were more often diagnosed with a psychotic disorder or a manic episode, had more often a migration background, were less often diagnosed with depression, and had lower GAF scores. There were no differences with respect to personality disorders or substance use. DPD patients were two to six times more likely to be (mostly involuntarily) admitted to a psychiatric department (64%), than the other patient groups (aggression 45%, suicidality 21%, other referral reasons 37%). The findings indicate that DPD patients represent an exclusive group who possibly have more intercultural and communication disadvantages due to less cultural acceptance or lack of knowledge about mental healthcare in the Netherlands.

Do Home-Based Psychiatric Services for Patients in Medico-Social Institutions Reduce Hospitalizations? Pre-Post Evaluation of a French Psychiatric Mobile Team

World Health Organization recommends the implementation of alternatives to full-time hospitalizations. Psychiatric home-care has known a worldwide development in the last 20 years. The psychiatric mobile team for social and medico-social institutions in Saint-Etienne, France, (Equipe mobile d'intervention en établissements Sociaux et Médico-sociaux, ESMS) aims to support professionals from medico-social housing institutions (MSHI) in order to maintain people in housing. The objective of the study was to evaluate the efficiency of home-based interventions to reduce hospitalizations and improve collaboration between psychiatric hospital facilities and MSHI. We used a pre-post study design. A same cohort of patients living in a MSHI one year before intervention and one year after implementation of the ESMS was studied. Hospitalizations were compared between the two periods. A survey was conducted for qualitative evaluation among professionals in MHSI. Sixty-three patients were included. Most patients suffered from psychotic disorders (71%). We found a significant decrease in the mean number of admissions per year from 2,06 to 1,48 (Wilcoxon signed rank test; df64; p = 0,01). Mobile-team interventions included answering phone calls, home visits, coordination meetings, or clinical interviews with patients in inpatient and outpatient services, with an average of 9,3 interventions per patient (SD = 11,4). ESMS was evaluated as "essential" for 73% of 11 professionals from MSHI who answered the questionnaire in May 2017. Assertive Community Treatment and Crisis Resolution Teams are the most studied home-care models in psychiatry. Our results tend to show the efficiency of mobile-team interventions in MSHI, to enhance partnerships.

Psychiatric care without consent in France: Does the type of administrative measure chosen differ according to patients' clinical profile?

The French Mental Health Law of 5 July 2011 stipulates that psychiatric patients can be hospitalized in five different ways. Three types of admission for involuntary treatment are defined under "admission at the request of a third party". The first is "psychiatric care at the request of a third party", followed by two "exceptional" admission measures in the case of an emergency ("emergency psychiatric care at the request of a third party") and imminent danger ("psychiatric care in the case of imminent danger"). The aim of this retrospective study was to determine whether the demographic and clinical characteristics of patients involuntarily admitted to psychiatric care in a French regional teaching hospital differed according to the administrative measure enabling this type of placement. We reviewed a sample of admission medical certificates issued between 1 July 2014 and 30 June 30, 2015 at the Tours University Hospital (France) for psychiatric care without consent. We recorded the following patient characteristics. Collected data included the type of care measure, age, gender, and the presence or absence of various clinical syndromes, such as suicidal thoughts and behavioral, depressive, manic or psychotic disorders. Multivariable analysis showed that a psychotic syndrome was a risk factor for hospitalization under "exceptional" measures and a behavioral syndrome for hospitalization under "psychiatric care at the request of a third party". Several clinical profiles emerged, but suicidal thoughts did not appear to be associated with the type of measures taken. In our sample, the choice of measure applied does not appear to rely on the only clinical observation at admission, contrary to what was planned in the Law.