Compulsory Psychiatric Admissions in an Italian Urban Setting: Are They Actually Compliant to the Need for Treatment Criteria or Arranged for Dangerous Not Clinical Condition?

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.

Mental health law: a comparison of compulsory hospital admission in Italy and the UK

In Europe, the mental health law legal framework has had several changes throughout the years to achieve and develop new reforms, better mental health care, and protect the human rights of patients. The UK national data shows rising detention rates and the disproportionate use of the legal framework among people from black and minority ethnic groups. At the national level, compulsory admissions are lower in Italy; it also shows that it has increased in the last few years in both countries. The lack of ethnic national data, especially in Italy, limited the ability to understand compulsory admission, discrimination, and stigma in mental health. The present study aims to compare the legal framework of mental health law and compulsory hospital admission in Italy and the UK. A review of each country's latest amendments to mental health law and the number of compulsory hospital admissions was conducted to understand the impact of changes in mental health care.

Digital Phenotyping: Data-Driven Psychiatry to Redefine Mental Health

The term "digital phenotype" refers to the digital footprint left by patient-environment interactions. It has potential for both research and clinical applications but challenges our conception of health care by opposing 2 distinct approaches to medicine: one centered on illness with the aim of classifying and curing disease, and the other centered on patients, their personal distress, and their lived experiences. In the context of mental health and psychiatry, the potential benefits of digital phenotyping include creating new avenues for treatment and enabling patients to take control of their own well-being. However, this comes at the cost of sacrificing the fundamental human element of psychotherapy, which is crucial to addressing patients' distress. In this viewpoint paper, we discuss the advances rendered possible by digital phenotyping and highlight the risk that this technology may pose by partially excluding health care professionals from the diagnosis and therapeutic process, thereby foregoing an essential dimension of care. We conclude by setting out concrete recommendations on how to improve current digital phenotyping technology so that it can be harnessed to redefine mental health by empowering patients without alienating them.

Who is coercively admitted to psychiatric wards? Epidemiological analysis of inpatient records of involuntary psychiatric admissions to a University General Hospital in Greece for the years 2008-2017

BACKGROUND

Involuntary psychiatric admissions are a widely used practice despite ethical concerns about coercion. There are particular concerns that vulnerable groups, such as single, unemployed or racial minorities, may be more subjected to such practices.

AIM

We aimed to investigate the social patterns of involuntary psychiatric admissions from 2008 to 2017 at University General Hospital in Ioannina, Greece.

METHOD

We retrospectively assessed inpatient records from 2008 to 2017 of patients admitted to the Department of Psychiatry of the Ioannina University General Hospital, Northwestern Greece. Alternative patients of alternative years were selected for inclusion; this yielded 332 patients involuntarily admitted, corresponding to 28.5% of total involuntary psychiatric admissions.

RESULTS

Over the 10-year period, the overall numbers of annual involuntary psychiatric admissions remained relatively stable, as did the length of hospital stay (mean = 23.8 days). The most common disorder upon admission was schizophrenia spectrum disorders, accounting for approximately two-thirds of all admissions, followed by mood disorders (about 20%). There was evidence that people who lacked social support or experienced financial hardship were more greatly represented among those admitted: 70.2% of admitted patients were single and 64.8% were unemployed. Most patients had been admitted to the psychiatric ward in the past (64.2%).

CONCLUSION

Our study indicates potentially worrisome evidence that patients who are in vulnerable positions are at elevated likelihood of being involuntarily admitted to psychiatric wards. Future research is needed to evaluate the socio-demographic patterning of involuntary admissions in other European countries.

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.

Involuntary psychiatric hospitalization in Italy: critical issues in the application of the provisions of law

Involuntary psychiatric hospitalisation in Italy raises some critical forensic issues. We analysed the sociodemographic, psychopathological, and behavioural characteristics of involuntarily hospitalised psychiatric patients, and the effectiveness of the juridical procedure of guarantee. Case files (n = 2796) related to involuntary psychiatric hospitalisation (IPH) at the Office of the Tutelary Judge of the Ordinary Court of Rome (Italy) between January 2013 and May 2016 were analysed. For each case file sociodemographic, clinical and procedural information were collected. The sample included 53.7% men, patients had a mean age of 41.8 ± 13.9. Most of the IPH proposal certificates reported more than one reason, among which the most frequent were symptoms referring to a psychotic dimension (54.8%), agitation (38.0%), and symptoms of bipolar and related disorders (26.3%) Female patients showed a higher prevalence of symptoms of the bipolar spectrum (F = 29.7%, M = 23.3%; p < 0.05), while male patients showed a higher prevalence of aggressive behaviour (F = 7.7%, M = 12.6%; p < 0.01). Over 85% of the IPH proposal certificates did not explicitly mention issues related to adherence to care, which is the second criterium requested for IH (treatment refusal) and up to 7.3% of the proposals were not properly motivated. However, only 0.8% cases were not validated by the Tutelary Judge. Possible issues in the IPH procedures emerged since a significant number of certifications showed poor concordance with law- criteria for involuntary psychiatric hospitalisation. Despite this evidence, the low rate of unvalidated procedures by the Tutelary Judge, suggests a possible limitation of this form of guarantee.

Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles

The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.

Compulsory admissions and preferences in decision-making in patients with psychotic and bipolar disorders

PURPOSE

Participation in medical decisions and taking into account patients' values and preferences are especially important for psychiatric patients who may be treated against their will. The increasing rates of coercive measures and the underlying clinical, ethical, and legal issues highlight the need to examine their use in psychiatry. Although limited congruence in decision-making preferences may be on the basis of these coercive practices, this issue has not been adequately addressed. We explore the relationship between compulsory admissions and congruence in decision-making preferences in mental health settings.

METHODS

Cross-sectional study among 107 outpatients with DSM diagnoses of schizophrenia of bipolar disorder using the Control Preference Scale to assess congruence in decision-making experienced and preferred style. History of compulsory admissions was obtained through review of available records. Descriptive statistics and multivariate analyses were used.

RESULTS

70% of patients reported experiencing their preferred style of decision-making and 44% patients had history of compulsory admissions. These patients were more autonomous and preferred to take a more active role. The degree of congruence was lower in patients with previous compulsory admissions. The best predictors of compulsory admissions were not having a regular doctor and the unmatched participation preferences.

CONCLUSIONS

Patients who experienced a different level of participation in decision-making than desired more frequently had compulsory admissions. We propose to assess participation preferences each time a relevant treatment decision is about to be made and tailor care accordingly. We identified several factors leading to compulsory admissions that can be modified to prevent further coercive measures.

Compulsory Admission to Psychiatric Wards-Who Is Admitted, and Who Appeals Against Admission?

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with "involuntary admission" and "appeal against compulsory admission order." Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.