Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: a population-based linked administrative database study

Factors associated with involuntary mental healthcare in New South Wales, Australia

BACKGROUND

There is uncertainty about factors associated with involuntary in-patient psychiatric care. Understanding these factors would help in reducing coercion in psychiatry.

AIMS

To explore variables associated with involuntary care in the largest database of involuntary admissions published.

METHOD

We identified 166 102 public mental health hospital admissions over 5 years in New South Wales, Australia. Demographic, clinical and episode-of-care variables were examined in an exploratory, multivariable logistic regression.

RESULTS

A total of 54% of eligible admissions included involuntary care. The strongest associations with involuntary care were referral from the legal system (odds ratio 4.98, 95% CI 4.61-5.38), and psychosis (odds ratio 4.48, 95% CI 4.31-4.64) or organic mental disorder (odds ratio 4.40, 95% CI 3.85-5.03). There were moderately strong associations between involuntary treatment and substance use disorder (odds ratio 2.68, 95% CI 2.56-2.81) or affective disorder (odds ratio 2.06, 95% CI 1.99-2.14); comorbid cannabis and amphetamine use disorders (odds ratio 1.65, 95% CI 1.57-1.74); unmarried status (odds ratio 1.62, 95% CI 1.49-1.76) and being born in Asia (odds ratio 1.42, 95% CI 1.35-1.50), Africa or the Middle East (odds ratio 1.32, 95% CI 1.24-1.40). Involuntary care was less likely for people aged >75 years (odds ratio 0.68, 95% CI 0.62-0.74), with comorbid personality disorder (odds ratio 0.90, 95% CI 0.87-0.94) or with private health insurance (odds ratio 0.89, 95% CI 0.86-0.93).

CONCLUSIONS

This research strengthens the evidence linking diagnostic, socioeconomic and cultural factors to involuntary treatment. Targeted interventions are needed to reduce involuntary admissions in disadvantaged groups.

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action

BACKGROUND

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

AIMS

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

METHOD

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

RESULTS

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

CONCLUSIONS

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

The Judiciarization of People Living with Mental Illness: A Grounded Theory on the Perceptions of Persons Involuntary Admitted in Psychiatric Institution

The involvement of people living with mental illness in the judicial process, whether in civil or criminal justice system, is a growing phenomenon that can be defined as judiciarization. Such over-representation of people with mental illness in the justice system is related to several issues, including stigma, experienced coercion, loss of autonomy and social isolation. To explore this understudied phenomenon in nursing research, we conducted a study to better understand how judiciarization affects people living with mental illness. The specific objectives were: 1) to understand how insertion into a judicial process affects people living with mental illness; 2) to explore the perception of these people and their lived experience within the judicial trajectory. For the methodology, grounded theory was used as a research model. The theoretical framework of the total institution, proposed by Erwin Goffman, was used conceptually. Participants were recruited from a university-affiliated hospital. Hospitalized persons who had been involved in the justice system were interviewed (n = 10). Three conceptualizing categories were identified through the analyzed data: 1) Diversity of Judicial Trajectories; 2) Involuntary Psychiatric Admission Process; 3) Judiciarization Lived as a Complex Experience. The results of this research can be used to better inform nurses, clinicians, and policy makers about the impacts of the judiciarization of mental illness, and how clinical practices can be better adapted to populations with very complex health needs.

Crisis plans in mental health: A scoping review

Crisis situations are frequent among people with mental health disorders. Several interventions have been developed to act in prevention, including crisis plans recognized as particularly effective in reducing coercive measures. In the literature, several models of crisis plans are proposed with similar aims and contents. Based on the methodology proposed by the Joanna Briggs Institute, a scoping review was conducted to map the state of knowledge on crisis plans in adult mental health settings. The literature search conducted on six databases (CINAHL, PubMed, Medline, EMBASE, PsychINFO and Cochrane) yielded 2435 articles. Of these, 122 full-text articles were assessed for eligibility, and 78 met the inclusion criteria. Studies were critically appraised using the Joanna Briggs Institute appraisal tools, and data were extracted by two independent reviewers. Content analysis identified a typology of crisis plans: (1) the legal crisis plan and (2) the formal crisis plan. Five modalities were identified for its completion: the sections, the moment, the completion steps, the people involved and the training of key actors. Most identified outcomes are consistent with the main purpose of the intervention, which is crisis prevention. However, the most identified outcomes focused on the service user's recovery and indicated that crisis plans could provide an opportunity to operationalize recovery in mental healthcare, thus suggesting an evolution in the aim of the intervention. Future research should further focus on the modalities of crisis plans to guide the implementation in clinical practice.

Psychiatric inpatient services in Ontario, 2019-2021: a cross-sectional comparison of admissions, diagnoses and acuity during the COVID-19 prerestriction, restriction and postrestriction periods

BACKGROUND

The COVID-19 pandemic was associated with increased mental health problems in the general population, yet psychiatric hospital admissions decreased. Early evidence suggested that psychiatric admissions normalized within weeks; we sought to examine the longer-lasting impacts on the psychiatric inpatient population beyond this initial period.

METHODS

We compared Ontario Mental Health Reporting System admission data for patients admitted to 8 psychiatric hospitals in Ontario, Canada, between 3 time periods - before restrictions were imposed (June 22, 2019, to Mar. 16, 2020), during restrictions (Mar. 17 to June 21, 2020) and after restrictions were lifted (June 22, 2020, to Mar. 16, 2021) for changes in involuntary status, diagnoses and clinical presentation using descriptive analysis. For clinical presentation, we extracted scores on 4 Resident Assessment Instrument-Mental Health symptom scales (Depressive Severity Index, Cognitive Performance Scale, Positive Symptoms Scale-Long Version and Social Withdrawal Scale), and 2 behaviour scales (Aggressive Behavior Scale and Violence Sum).

RESULTS

A cross-sectional sample of 9848 patients was included in the analysis. The mean number of daily admissions decreased 19% from 16.4 (standard deviation [SD] 8.0) before the restriction period to 13.3 (SD 6.1) during the restriction period, and was still 6% below prerestriction levels after restrictions were lifted 15.4 (SD 6.8), with standard error difference of 1.03 (95% confidence interval -0.22 to 2.29). From the pre- to the postrestriction periods, the proportion of involuntary patients increased by 6 percentage points, and the proportions of patients diagnosed with a psychotic disorder or personality disorder increased by 4 percentage points and 1 percentage point, respectively.

INTERPRETATION

Psychiatric admissions did not fully return to prerestriction levels in absolute rates and patient acuity after COVID-19 restrictions were lifted. Psychiatric services must prepare to appraise and respond to any increased acuity through interventions for patients, workforce planning and mental health support for staff.

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry

INTRODUCTION

Managing violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate the assessment of risk involve training machine learning (ML) models on data from electronic health records (EHRs) to predict these behaviours. However, no studies to date have examined which patient groups may be over-represented in false positive predictions, despite evidence of social and clinical biases that may lead to higher perceptions of risk in patients defined by intersecting features (eg, race, gender). Because risk assessment can impact psychiatric care (eg, via coercive measures, such as restraints), it is unclear which patients might be underserved or harmed by the application of ML.

METHODS AND ANALYSIS

We pilot a computational ethnography to study how the integration of ML into risk assessment might impact acute psychiatric care, with a focus on how EHR data is compiled and used to predict a risk of violence or aggression. Our objectives include: (1) evaluating an ML model trained on psychiatric EHRs to predict violent or aggressive incidents for intersectional bias; and (2) completing participant observation and qualitative interviews in an emergency psychiatric setting to explore how social, clinical and structural biases are encoded in the training data. Our overall aim is to study the impact of ML applications in acute psychiatry on marginalised and underserved patient groups.

ETHICS AND DISSEMINATION

The project was approved by the research ethics board at The Centre for Addiction and Mental Health (053/2021). Study findings will be presented in peer-reviewed journals, conferences and shared with service users and providers.

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018

INTRODUCTION

Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018.

METHOD

We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender.

RESULTS

Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%).

CONCLUSION

Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

Compulsory psychiatric admissions in the canton of Basel-Stadt between September 2013 and April 2022: Analysis of the cantonal database of the Health Department of Basel-Stadt

BACKGROUND

According to federal and cantonal law, persons with an acute mental illness can be admitted to a psychiatric hospital or another suitable institution against their will, when other therapeutic options are not available or have been exhausted. In the canton of Basel-Stadt, this is the responsibility of public health officers employed by the division of Social Medicine of the cantonal Health Department.

AIMS

This study aims to elucidate which factors influence the decision-making of public health officers regarding compulsory admissions over the period from September 2013 to April 2022 in the canton of Basel-Stadt.

METHOD

Leveraging comprehensive clinical data from the health department of the canton Basel-Stadt (N = 5,'550), we estimated a mixed effects logistic regression model to identify factors contributing to the decision of public-health officers to compulsorily admit patients, while controlling for potential clustering effects among public health officers.

RESULTS

The risk for compulsory admissions was most strongly predicted by the presence of potential self-harm. In comparison, while being a strong predictor, potential harm to others played a considerably lesser role. Furthermore, psychiatric syndrome, previous compulsory admissions, and the specific context of evaluation were significant predictors. Finally, we found no meaningful personal bias among public health officers.

CONCLUSION

The results suggest that public health officers' decision-making regarding compulsory admissions focuses on preventing self-harm and, to a lesser degree, harm to others. This indicates that such measures are only used as a measure of last resort, which is in line with current evidence regarding the detrimental effects of compulsory measures on treatment outcomes in psychiatry. Our findings suggest that all relevant stakeholders, including the police, share this perspective. Decision-making regarding compulsory admissions was mostly free of personal biases, suggesting adherence to shared professional standards by public health officers.

‘It Just Feels Like an Invasion’: Black First-Episode Psychosis Patients’ Experiences With Coercive Intervention and Its Influence on Help-Seeking Behaviours

Studies from the United States and United Kingdom show that Black patients are disproportionately diagnosed with psychosis and receive excess coercive medical intervention. There has been little discussion of this topic in Canada, and of how coercive interventions may have influenced Black patient attitudes towards mental health services. To address these issues, semi-structured interviews were administered to five Black men with first-episode psychosis (FEP) to (a) explore their experiences with coercive interventions and (b) describe how these experiences may have influenced help-seeking behaviours. Interpretative phenomenological analysis (IPA) was used to analyze the data. Four core themes and four additional themes emerged from the interviews. Patients described loneliness, not being heard, police contact and forced medication as influencing their attitudes towards mental health care. Further research is needed to develop reparative strategies to encourage reflection about and awareness of coercive intervention among Black FEP patients.

Factors associated with perceived coercion in adults receiving psychiatric care: a scoping review protocol

INTRODUCTION

Coercion is inevitably linked to psychiatric and mental healthcare. Though many forms of coercion exist, perceived coercion appears to be a less studied form despite its marked prevalence and negative consequences. In the literature, several factors have been studied for their association with perceived coercion, but few literature reviews have focused on this precise subject. Gaining knowledge of the association between these factors and the degree of perceived coercion is essential to guide future research and develop informed interventions. The purpose of this review will be to identify, in the literature, factors associated with perceived coercion by adults receiving psychiatric care.

METHODS AND ANALYSIS

A scoping review will be conducted by following the Joanna Briggs Institute methodology. A search with descriptors and keywords will be performed in the following databases: CINAHL, MEDLINE, PUBMED, EMBASE and PsycINFO. Then, a search for grey literature will be conducted, psychiatric and mental health journals will be searched, and reference lists will be examined to identify further pertinent literature. All literature on factors (human, health related, organisational, etc) and their association to perceived coercion by adults (18 and older) in inpatient, outpatient and community-based psychiatry will be included. A quality assessment of the literature included will be performed. The extracted data will be analysed with a method of content analysis. An exploratory search was conducted in September 2021 and will be updated in September 2022 once the evidence selection process is planned to begin.

ETHICS AND DISSEMINATION

No ethics approval is required for this review. The results of this scoping review will be submitted to a scientific journal for publication, presented in conferences and shared with clinicians working in psychiatric and mental healthcare.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals

AIMS

To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control.

DESIGN

Population-based retrospective cohort study conducted between September 30, 2018 and September 26, 2020.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden.

MEASUREMENTS

ED visits for drug overdoses of accidental and undetermined intent.

FINDINGS

Average rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7-153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7-24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re-opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44-1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08-1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02-1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period.

CONCLUSIONS

Recently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re-opening period of the COVID-19 pandemic compared with housed people.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

Real world evidence in involuntary psychiatric hospitalizations: 64,685 cases

OBJECTIVE

We explored hospitalization patterns and the clinical and individual characteristics of a large cohort of patients who underwent involuntary psychiatric hospitalization in Brazil (n=64,685).

METHODS

Data were collected from the District Attorney's Office of the State of São Paulo (Ministério Público do Estado de São Paulo) on all involuntary psychiatric hospitalizations in the city of São Paulo between January 2003 and February 2020. The annual involuntary psychiatric hospitalization rate was calculated and descriptive statistics of the characteristics were produced.

RESULTS

Involuntary psychiatric hospitalizations increased from 5.8 to 25.5 per 100,000 population, with an eight-folder increase in the first 10-year period (2003-2013). The majority of admissions were to public institutions (86.6%), involved a psychotic disorder in the primary diagnosis (26.1%), involved more than one diagnosis (83.7%), and lasted less than 7 days (52.4%). The majority of the patients were aged 18 to 39 years and were single, and readmission was relatively common (13%). Although the reason for admission was missing in many reports (44%), the risk of harm to self or others was the most common (68.5%).

CONCLUSION

This is one of the largest cohorts of involuntary psychiatric hospitalization records ever explored. These findings build upon existing international evidence about involuntary psychiatric hospitalizations and show recent trends in admission rates in the largest city in Brazil.

Ethnoracial Differences in Coercive Referral and Intervention Among Patients With First-Episode Psychosis

OBJECTIVE

Using a retrospective sample, the authors sought to determine whether Black patients with first-episode psychosis (FEP) in Canada were at a higher risk for coercive referral and coercive intervention than non-Black patients with FEP.

METHODS

Retrospective data from patients referred to an FEP program in 2008-2018 were collected via chart review (N=208). The authors used chi-square and logistic regression analyses to explore the relationships among race-ethnicity, diagnosis of psychosis, and coercive referral and intervention.

RESULTS

Results showed that Black persons of Caribbean or African descent with FEP were significantly more likely to be coercively referred (χ²=9.24, df=2, p=0.010) and coercively treated (χ²=9.21, df=2, p=0.010) than were non-Black individuals with FEP. Age and violent or threatening behavior were predictors of coercive referral. Ethnoracial status, age, and violent or threatening behavior were predictors of coercive intervention.

CONCLUSIONS

This study contributes to the dearth of research on Black Canadians and offers insight into factors that may place patients with FEP at risk for coercive treatment. More research is needed to explore the role that ethnoracial status may play in hospital admissions and to uncover the role of racial prejudices in the assessment of danger.

The integration of mental health care act in primary care: an audit of the use of mental health care act forms for patients´ admission and the effect of continuing medical education on health professionals´ performance of usage, based on Letsholathebe II Memorial Hospital´s experience, in Maun, Botswana

Introduction

despite the adoption of mental disorders act in 1972, the use of required mental health care act (MHCA) forms during admission of patients with mental illnesses remained below the legal expectation in the Maun District Hospital. This study audited Letsholathebe II Memorial Hospital (LIIMH) professionals´ usage of MHCA forms.

Methods

this was a quasi-experimental study that audited files of patients admitted with mental illnesses, before, three and six months after a continuing medical education (CME). Cochran Q, McNemar symmetry Chi-square were used for comparison of performance.

Results

of the 239 eligible files, we accessed 235 (98.3%). About two in ten (n=36/235, 15.3%) MHCA forms were not used in combination with required forms. The quasi-majority of MHCA forms set used, aligned with involuntary admission (n=134/137, 97.8%). Required admission MHCA forms significantly increased from nil before continuing medical education (CME-0), to 64.6% (n=51/79) at CME-3 and 77% (n=59/77) at CME-6 (p<0.001). However, there was no statistical difference between the last two periods (64.6% vs 77%, p=0.164). Voluntary admission remained below 13% (n=10/79). Only six types of MHCA forms were used during this study.

Conclusion

there was no adequate use of required MHCA forms at LIIMH before CME. Thereafter, the proportion of adequate use increased from period CME-0 to the periods CME-3 and CME-6. However, there was no difference in proportion between the last two periods. We recommend an effective and regular CME twice a year for health professionals on selected MHCA forms.

Sociodemographic, Circumstantial, and Psychopathological Predictors of Involuntary Admission of Patients with Acute Psychosis

Studies have consistently determined that patients with acute psychosis are more likely to be involuntarily admitted, although few studies examine specific risk factors of involuntary admission (IA) among this patient group. Data from all patients presenting in the psychiatric emergency department (PED) over a period of one year were extracted. Acute psychosis was identified using specific diagnostic criteria. Predictors of IA were determined using logistic regression analysis. Out of 2533 emergency consultations, 597 patients presented with symptoms of acute psychosis, of whom 118 were involuntarily admitted (19.8%). Involuntarily admitted patients were more likely to arrive via police escort (odds ratio (OR) 10.94) or ambulance (OR 2.95), live in a psychiatric residency/nursing home (OR 2.76), report non-adherence to medication (OR 2.39), and were less likely to suffer from (comorbid) substance abuse (OR 0.53). Use of mechanical restraint was significantly associated with IA (OR 13.31). Among psychopathological aspects, aggressiveness was related to the highest risk of IA (OR 6.18), followed by suicidal intent (OR 5.54), disorientation (OR 4.66), tangential thinking (OR 3.95), and suspiciousness (OR 2.80). Patients stating fears were less likely to be involuntarily admitted (OR 0.25). By understanding the surrounding influencing factors, patient care can be improved with the aim of reducing the use of coercion.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study

BACKGROUND

There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission.

METHODS

This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors.

RESULTS

Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED.

CONCLUSIONS

We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

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

Methods

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

Results

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

Conclusions

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

Sociodemographic and clinical variables associated with discharge under compulsory treatment orders

OBJECTIVE

To document the sociodemographic and clinical variables associated with discharge under compulsory treatment orders in patients with schizophrenia or related disorders.

METHOD

Information on various sociodemographic and clinical variables were extracted from the clinical files of 349 patients discharged from an adult (age 18-65) inpatient psychiatric unit with diagnoses of schizophrenia or related disorders. Univariate and multiple logistic regression analyses with legal compulsion (compulsory versus voluntary) as outcomes were applied.

RESULTS

Two hundred of the 349 discharged patients were placed under compulsory treatment orders. In the univariate logistic regression analysis, unemployment, diagnosis of schizophrenia, forensic history, dosage of antipsychotics, prescription and frequency of injectable antipsychotics, polypharmacy and a hospital stay of more than 28 days were associated with compulsory status. Being married or in partnership and living with partner was associated with voluntary status. Multiple regression models respectively confirmed most of these relationships observed in the univariate analyses.

CONCLUSION

Clarification of the apparent drivers for compulsory treatment may help thoughtful reductions in the use of compulsion.

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

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

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background&#160;: The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim&#160;: To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology&#160;: A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results&#160;: The analysis of the forty-six selected studies revealed four distinct themes&#160;: coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion&#160;: Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

The nature of police shootings in New Zealand: A comparison of mental health and non-mental health events

The use of firearms by police in mental health-related events has not been previously researched in New Zealand. This study analysed reports of investigations carried out by the Independent Police Conduct Authority between 1995 and 2019. We extracted data relating to mental health state, demographics, setting, police response, outcome of shooting, and whether the individual was known to police, mental health services, and with a history of mental distress or drug use. Of the 258 reports analysed, 47 (18%) involved mental health-related events compared to 211 (82%) classified as non-mental health events. Nineteen (40.4%) of the 47 mental health events resulted in shootings, compared to 31 (14.8%) of the 211 non-mental health events. Of the 50 cases that involved shootings 38% (n = 19) were identified as mental health events compared to 62% (n = 31) non-mental health events. Over half of the mental health events (n = 11, 57.9%) resulted in fatalities, compared to 35.5% (n = 11) of the non-mental health events. Cases predominantly involved young males. We could not ascertain the ethnicity of individuals from the IPCA reports. Across all shooting events, a high proportion of individuals possessed a weapon, predominantly either a firearm or a knife, and just under half were known to police and had known substance use. Of the 19 mental health events, 47.4% (n = 9) of individuals were known to mental health services and in 89.5% (n = 17) of cases whānau (family) were aware of the individual's current (at the time of the event) mental health distress and/or history. These findings suggest opportunities to prevent the escalation of events to the point where they involve shootings. Lack of ethnicity data limits the accountability of the IPCA and is an impediment to informed discussion of police response to people of different ethnicities, and Māori in particular, in New Zealand.

Governance of mental healthcare: Fragmented accountability

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

Observed Outcomes: An Approach to Calculate the Optimum Number of Psychiatric Beds

The number of psychiatric beds, in most developed countries, has decreased progressively since the late 1950s. Many clinicians believe that this reduction has gone too far. But how can we determine the number of psychiatric beds a mental health system needs? While the population health approach has advantages over the normative approach, it makes assumptions about optimal and minimum duration of hospitalization required for various psychiatric disorders. In this paper, we describe a naturalistic approach that estimates the required number of psychiatric beds by comparing the bed levels at which negative outcomes develop in different jurisdictions. We hypothesize that there will be a threshold below which negative outcomes will be seen across jurisdictions. We predict that hospital key performance indices will be more sensitive to bed reductions than the clinical and social outcomes of patients. The observed outcome approach can complement other approaches to determining bed numbers at the national and local levels, and should be a priority for future health services research.

Experiences with legally mandated treatment in patients with schizophrenia: A systematic review of qualitative studies

Background:

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Methods:

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

Results:

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Conclusions:

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

Reasons behind the rising rate of involuntary admissions under the Mental Health Act (1983): Service use and cost impact

There has been a significant rise in the use of the Mental Health Act (1983) in England over the last 10 years. This includes both health-based Place of Safety detentions and involuntary admissions to NHS mental health facilities. Although these trends should clearly inform the implementation of mental health care and legislation, there is currently little understanding of what caused these increased rates. We therefore sought to explore potential underlying reasons for the increase in involuntary admissions and Place of Safety detentions and to ascertain the associated service costs. We extracted publicly available data to ascertain the observed number of involuntary admissions (Section 2 or 3) and health-based Place of Safety detentions in England between 1999/2000 and 2015/2016. A simple regression analysis then enabled us to compare observed admission rates with predicted rates, between 2008/2009 and 2015/2016. This prediction model was based on observed figures before 2008. We then generated a costing model for these rates and compared admission costs to alternative interventions. Finally, we added relevant covariates to the prediction model, to explore potential relationships with observed rates. Since 2008/2009, there has been a marked increase in the number of involuntary admissions (38%) and Place of Safety detentions (617%). The analysis revealed that for involuntary admissions, the period of greatest increase occurred after 2012, two years after austerity measures were implemented. For Place of Safety detentions, substantial rises were seen from 2008/2009 to 2015/2016, coinciding with the economic recession. The rise in Place of Safety detentions may have been worsened by a reduction in mental health bed availability. During the study period, involuntary admissions are estimated to have cost the English NHS £6.8 billion; with a further £120 million spent on Place of Safety detentions. This is approximately £597 million greater than predicted, had involuntary admissions continued to change at pre-2008 rates. We conclude that the rise in involuntary admissions, and to a lesser extent Place of Safety detentions, were associated with three specific impactful events: the economic recession, legislative changes and the impact of austerity measures on health and social care services. In addition to the extensive arguments presented elsewhere, there is also an urgent economic case for addressing this trend.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Caregivers' Attitude and Perspective on Coercion and Restraint Practices on Psychiatric Inpatients from South India

Background:

Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date.

Aims:

Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients.

Methodology:

This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers’ attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables.

Results:

The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients.

Conclusion:

Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

Involuntary hospitalization among young people with early psychosis: A population-based study using health administrative data

OBJECTIVE

Early psychosis is an important window for establishing long-term trajectories. Involuntary hospitalization during this period may impact subsequent service engagement in people with newly diagnosed psychotic disorder. However, population-based studies of involuntary hospitalization in early psychosis are lacking. We sought to estimate the proportion of people aged 16 to 35 years with early psychosis in Ontario who are hospitalized involuntarily at first admission, and to identify the associated risk factors and outcomes.

METHODS

Using linked population-based health administrative data, we identified incident cases of non-affective psychosis over a five-year period (2009-2013) and followed cases for two years to ascertain the first psychiatric hospitalization. We used modified Poisson regression to model sociodemographic, clinical, and service-related risk factors, and compared service-related outcomes for cases admitted on an involuntary versus voluntary basis.

RESULTS

Among 17,725 incident cases of non-affective psychosis, 38% were hospitalized within two years, and 81% of these admissions occurred on an involuntary basis (26% of cohort). Sociodemographic factors associated with an increased risk of involuntary admission included younger age (16-20), and first-generation migrant status. The strongest risk factors were poor illness insight, recent police involvement, and admission to a general (versus psychiatric) hospital. Outcomes associated with involuntary admission included increased likelihood of control intervention use and a shorter length of stay.

CONCLUSIONS

One in four young people with first-episode psychosis will have an involuntary admission early in the course of their illness. Our findings highlight areas for intervention to improve pathways to care for people with psychotic disorder.

Changing characteristics of forensic psychiatric patients in Ontario: a population-based study from 1987 to 2012

PURPOSE

To quantify the demand for forensic psychiatric services in Ontario over the past 25 years and investigate whether the sociodemographic, clinical and offense-based characteristics of forensic patients have changed over time.

METHODS

We investigated all forensic admissions from 1987 to 2012 resulting in a disposition of Not Criminally Responsible on account of Mental Disorder (N = 2533). We present annual proportions of patients with specified sociodemographic, clinical and offense characteristics, and investigate whether the duration of forensic system tenure varies as a function of admission year, psychiatric diagnosis, or index offense.

RESULTS

There has been a steady increase in forensic admissions over this time period, particularly individuals with comorbid substance use disorders and individuals of non-Caucasian ethno-racial background. The proportion of persons committing severe violence has remained low and has decreased over time. Having a comorbid personality, neurological, or substance use disorder significantly increased forensic system tenure, as did committing a violent offense. Individuals who came into the system in earlier years had slower rates of discharge compared to more recent admissions.

CONCLUSIONS

Defining the trends characterizing the growth of the forensic population has important policy implications, as forensic services are costly and involve a significant loss of liberty. The current results indicate that young, substance abusing individuals of diverse ethno-racial backgrounds and who commit relatively low-level violence comprise an increasing proportion of Ontario's forensic population, and suggest that treatment must be optimized to best serve the needs of these individuals.