Social and Clinical Determinants of Compulsory and Voluntary Admissions within the Framework of an Italian Community Mental Health System

Social and clinical determinants of 30 compulsory admissions (CAs) to a psychiatric ward during a six-month period were compared to 134 voluntary admissions (VAs), and outcomes of hospitalisation were assessed in relation to its types. Psychosocial and clinical characteristics at admission and discharge were measured using 5 scales. Unemployment, hospitalisations >7 days and continuing hospitalisation in Community Mental Health Centres were positively associated with CA. At admission, CAs showed lower functioning, while outcome at discharge was similar. Social determinants had a main role in determining CAs. Clinical and psychosocial outcomes might have been improved by a mental health system community-based.

Involuntarily and voluntarily admitted patients’ experiences of psychiatric admission and treatment—a comparison before and after changed legislation in Sweden

Objective

– The Swedish Compulsory Mental Care Act (LPT) of 1992 emphasises the participation of patients and relatives in the treatment of the patients. The purpose of this study was to compare patients' experiences under the LPT with patients' experiences under the previous law.

Method.

– Samples of 44 committed patients and 40 voluntarily admitted patients in 1991 and 49 committed and 49 voluntarily admitted patients in 1997/98 were interviewed at admission and at discharge, or after 3 weeks of care.

Results.

– There were similar proportions of committed and voluntarily admitted patients, respectively, in 1991 and 1997/98 who reported participation in treatment planning and participation of relatives and who reported deprivation of liberty, but more committed patients in 1997/98 reported coercive measures.

Conclusion.

– There were few differences of the patient's experiences between the study occasions. The fundamental aims of the legislation have not been fulfilled.

Are We Ready for the CARE Act?: Family Caregiving Education for Health Care Providers

The CARE Act, law in 40 states and territories in the United States, requires hospitals to identify and include family caregivers during admission and in preparation for discharge. Although the number of family caregivers has been steadily increasing, health care providers are ill-prepared to address their needs, and caregiving remains a neglected topic in health care providers' education. A market analysis was performed to explore the availability of and interest in interprofessional courses and programs focused on preparing health professionals to support family caregivers. Although nurses and chief nursing officers agreed on the importance of supporting caregivers, they were less likely to endorse formal educational preparation for this complex role. The current study elucidates a gap between what caregivers report they need and the preparation of health care professionals to advance family-centered approaches to care. [Journal of Gerontological Nursing, 45(3), 7-11.].

The Vexed Question of the Voluntary Patient

The current statutory framework in Ireland provides certain key safeguards for people who are admitted involuntarily for mental health treatment and care; the same legislation makes scant reference to the person who seeks treatment and care on a voluntary basis. This has led to concerns in relation to deprivation of liberty and to non-consensual medical treatment for these patients. This article seeks to examine the development of the law in relation to voluntary patients in Ireland and to assess in light of recent developments where Ireland now stands in terms of protecting the right of the voluntary patient to liberty.

Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries

Background

Physician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging.

Objectives

To demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects.

Design

Prospective cohort study.

Setting and participants

Adult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission.

Results

Among 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10).

Conclusion

Among patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.

Tensions between policy and practice: A qualitative analysis of decisions regarding compulsory admission to psychiatric hospital

The use of detention for psychiatric treatment is widespread and sometimes necessary. International human rights law requires a legal framework to safeguard the rights to liberty and personal integrity by preventing arbitrary detention. However, research suggests that extra-legal factors may influence decisions to detain. This article presents observational and interview data to describe how decisions to detain are made in practice in one jurisdiction (England and Wales) where a tension between policy and practice has been described. The analysis shows that practitioners mould the law into 'practical criteria' that appear to form a set of operational criteria for identifying cases to which the principle of soft paternalism may be applied. Most practitioners also appear willing, albeit often reluctantly, to depart from their usual reliance on the principle of soft paternalism and authorise detention of people with the capacity to refuse treatment, in order to prevent serious harm. We propose a potential resolution for the tension between policy and practice: two separate legal frameworks to authorise detention, one with a suitable test of capacity, used to enact soft paternalism, and the other to provide legal justification for detention for psychiatric treatment of the small number of people who retain decision-making capacity but nonetheless choose to place others at risk by refusing treatment. This separation of detention powers into two systems, according to the principle that justifies the use of detention would be intellectually coherent, consistent with human rights instruments and, being consistent with the apparent moral sentiments of practitioners, less prone to idiosyncratic interpretations in practice.

The Treatment Perspectives of Mentally Ill Offenders in Medium- and High-Secure Forensic Settings in Flanders

There is an increasing interest in mentally ill offenders' (MIOs) treatment experiences in forensic settings. This study focuses on the treatment perspectives of MIOs in treatment as well as in prison settings in Flanders. Seventeen MIOs were interviewed about the treatment they received. Data were analyzed using thematic analysis to derive key themes while acknowledging the individuality of the participants' experiences. Treatment perspectives of MIOs in both settings revolved around similar themes, including "good" staff and privacy. However, their views differed on two themes: MIOs in treatment settings reported on feelings of lacking control and experiencing too much pressure, whereas MIOs in prison settings reported the opposite. The positive experiences in prison settings may complicate the transition from prison to a forensic treatment setting. The study further underscores the major challenge to create more opportunities for MIOs to meet their needs of self-determination in secure forensic treatment settings.

THE PERSONAL REPRESENTATIVE--THE "ACHILLES HEEL" OF THE ROMANIAN MENTAL HEALTH LAW SYSTEM

The psychiatric law system was created with the sole purpose of protecting patients with mental illnesses, a vulnerable segment of the population. The laws regarding voluntary and non-voluntary admission of mental patients have been reformed in many European countries. After 1989, Romania starts to gradually benefit from a law system that meets the requirements of modern society. From this general context the Mental Health Law takes form, with the main purpose of ratifying the relationship between patient and psychiatrist. This system provides a new, more modern approach but also proves to have certain flaws. One of the most obvious is the aspect regarding the personal representative, which generates both ethical and professional conduit problems, difficult to manage from the standpoint of modern medicine. Minimizing the effects of such an error is possible by simply considering the small number of solutions suggested by the author in the end of this article.

A retrospective cohort study describing six months of admissions under Section 136 of the Mental Health Act; the problem of alcohol misuse

BACKGROUND

Section 136 of the Mental Health Act 1983 empowers police to remove a person they believe to be suffering from a mental disorder from a place to which the public have access, if they deem them a risk to themselves or others. In the UK, the number of Section 136 orders is increasing.

OBJECTIVE

This retrospective cohort study identified the demographic profiles, circumstances of detention and assessment outcomes of all individuals detained under Section 136 between February 2012 and July 2012 at a London Mental Health Trust. The study explored the relationship between alcohol and/or drug use, the process and outcomes.

DESIGN AND METHOD

This study retrospectively obtained data from electronic notes for a six-month period. Demographic details were recorded. Other variables included previous admissions, reasons for assessment, evidence of intoxication, time taken for assessment and discharge outcomes. The effects of alcohol and/or drug intoxication on the process were recorded.

RESULTS

A total of 245 individuals were assessed during the time period. Threatening to self-harm (n = 100, 44.8%) was the most common reason for assessment. Of the 245 patients assessed, 108 (44.1%) were found to be intoxicated with drugs and/or alcohol. Intoxication resulted in longer assessment times and a decreased likelihood of admission to hospital (p < .000).

Psychiatric Boarding in Washington State and the Inadequacy of Mental Health Resources

Psychiatric boarding is a term derived from emergency medicine that describes the holding of patients deemed in need of hospitalization in emergency departments for extended periods because psychiatric beds are not available. Such boarding has occurred for many years in the shadows of mental health care as both inpatient beds and community services have decreased. This article focuses on a 2014 Washington State Supreme Court decision that examined the interpretation of certain sections of the Washington state civil commitment statute that had been used to justify the extended boarding of detained psychiatric patients in general hospital emergency departments. The impact of this decision on the state of Washington should be significant and could spark a national debate about the negative impacts of psychiatric boarding on patients and on the nation's general hospital emergency services.

Custody, care and country of origin: demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Involuntary detention is a feature of psychiatric care in many countries. We previously reported an involuntary admission rate of 67.7 per 100,000 population per year in inner-city Dublin (January 2008-December 2010), which was higher than Ireland's national rate (38.5). We also found that the proportion of admissions that was involuntary was higher among individuals born outside Ireland (33.9%) compared to those from Ireland (12.0%), apparently owing to increased diagnoses of schizophrenia in the former group. In the present study (January 2011-June 2013) we again found that the proportion of admissions that was involuntary was higher among individuals from outside Ireland (32.5%) compared to individuals from Ireland (9.9%) (p<0.001), but this is primarily attributable to a lower rate of voluntary admission among individuals born outside Ireland (206.1 voluntary admissions per 100,000 population per year; deprivation-adjusted rate: 158.5) compared to individuals from Ireland (775.1; deprivation-adjusted rate: 596.2). Overall, admission rates in our deprived, inner-city catchment area remain higher than national rates and this may be attributable to differential effects of Ireland's recent economic problems on different areas within Ireland. The relatively low rate of voluntary admission among individuals born outside Ireland may be attributable to different patterns of help-seeking which mental health services in Ireland need to take into account in future service-planning. Other jurisdictions could also usefully focus attention not just on rates on involuntary admission among individuals born elsewhere, but also rates of voluntary admission which may provide useful insights for service-planning and delivery.

'She can't come here!' Ethics and the case of birth centre admission policy in the UK

Using ethnographic data lifted from an investigation into midwifery talk and practice in the South of England, this paper sets out to interrogate the ethics underpinning current admission policy for Free Standing (midwifery led) Birth Centres in the UK. The aim of this interrogation is to contest the grounds upon which birth centres admissions are managed, particularly the over-reliance on abstract calculations of risk--far removed from the material lived experience of the mother wishing to access these birth centre services.

[The imminent peril in the law of July the fifth 2011, two years later: the impact on health?]

In 1938, the French government decided to enact a first legislation to enforce admission of the mentally ill to hospitals. Later in 1990, the law took into consideration the evolution of practices with an increase of free admissions and the right to maintain the mentally ill in cities. Three types of psychiatric hospitalization were defined: free, on third party request and for involuntary confinement. A review had theoretically to be conducted every 5 years. In practice this was not the case, probably due to the balance between individual freedom, patient care and public safety always hard to find. However, considering the imperative European harmonization and the fact the Constitutional Council declared a double unconstitutionality of the law, the Act of July 5th was enacted in a hurry during the summer 2011. The Act defines the "rights and the protection of people subject to psychiatric care and methods of coverage". In this document, we will briefly review the context of this law. We will also explore the clinical implications of the very innovative measure: the "péril imminent". We will use the admissions at the Sainte-Anne hospital in Paris in 2010 to 2012. Three major key points were introduced in the law: a judge controls an agreeable release after 15 days and 6 months of continuous hospitalization. The law let the new possibility to provide ambulatory cares under constraints, and these to make an involuntary confinement without a third party request, using the "imminent peril". This law implies the involvement of the judge and the lawyer. This one has to defend a client who needs care, he controls the formal validity of decisions concerning the patient. To provide treatment without consent in "imminent peril" to someone, conditions are requested: these mental disorders make his consent impossible and his mental state requires immediate care with immediate care of constant medical monitoring justifying a full hospitalization or regular medical monitoring for support under another form of full hospitalization (Article L.3212. 1 of the Code of Public Health). Moreover, a demand for care by a third party has also to be impossible to obtain and an imminent peril to the person's health has to exist, supported by a medical certificate from a doctor who does not belong to the patient's psychiatric hospital. The imminent peril would be an immediate danger to the health or life of the patient. What has been the impact of this law adopted in emergency at Sainte-Anne hospital? This psychiatric hospital is in charge of the population in southern Paris, where reside about 655,000 people. This work observes the evolution of the type of hospitalization and care before and after the adoption of the law. We can observe an overall increase in entries under constraints. There is a decrease in admissions for involuntary confinement for the benefit of imminent peril. This imminent peril corresponds to only a small proportion of hospitalizations without consent but are rising between 2011 and 2012, perhaps in part due to a better understanding of the law. But this progression is to monitor to ensure compliance with the restrictive conditions laid down by this law. Also note that the imminent peril may be used at the refusal of the family or entourage to make the demand for care. The number of hospitalizations at the request of a third party with two certificates is down, which is probably due to a change in status of the CPOA, emergency structure within Sainte-Anne, which is no longer seen as extraterritorial. The imminent peril has advantages: it allows access to the care of people isolated and desocialized, of people whose identity is unknown, of pathological travellers. It avoids hospitalization at the request of the representative of the State for social reasons and not for risks to the safety of persons, even when this type of hospitalization is more stigmatizing and often more difficult to remove. It protects the entourage sometimes, when the family is ambivalent or hostile to care, or has been designated as a persecutor. The imminent peril also has disadvantages. One of them is the risk of its misuse to allow rapid hospitalization without taking the time to seek a third party. The imminent danger made when there is an entourage but which refuses to request care can undermine the development work on information about the disease, the need for care and treatment and the importance of the involvement of the entourage in the care plan. The alliance with the patient may be compromised. In some cases, a decision of care by the request of the representative of the State is more appropriate than the "imminent peril". The "imminent peril" may be preferred because of the administrative burden of prefectural measures when patient presents clinical improvement and we would go up to the ambulatory care in a care program. Yet, the use of a symbolic third, carrying authority, can avoid the too direct confrontation with the patient. Do not use it can complicate the management of the patient. Finally, with desocialized patients, imminent peril can facilitate access to care, but not continuity of care. Indeed, for the care program it is necessary to have an address for the patient. Once the crisis is not to develop a plan of care. Finally in some situations of desocialized patients, the imminent peril can promote access to care but not the continuity of care as to the care program it is necessary to have an address for the patient. Once the crisis is past, it is impossible to implement a program of care. The Law of 5 July 2011 marks a change in the practice of psychiatrists. Take into account the fundamental rights of the patient and to harmonize legislation at EU level was necessary. Some measures are designed to promote access to care as the "imminent peril", we now need to be vigilant to ensure that it is not diverted to promote an increase in care under constraints and that psychiatrists remain in an obligation of means and not of result.

[Surveillance of antibiotic consumption : clarification of the "definition of data on the nature and extent of antibiotic consumption in hospitals according to § 23 paragraph 4 sentence 2 of the IfSG"]

According to § 23 paragraph 4 of the German Infection Prevention Act (IfSG; July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring system of antibiotic consumption. This is aimed at contributing to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The general requirements (restricted to hospitals) on the method and extent of data collection are provided by the national public health institution after discussion with representatives of various professional societies (Robert Koch-Institut, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 59, 2013). The article aims to clarify these specifications and to provide background details. In agreement with national and European surveillance systems, the Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) classification system recommended by the WHO should be used as reference standard. Antibiotic consumption should be expressed as the number of DDDs per 100 patient days and per 100 admissions. The categories of antimicrobials and hospital organizational units to be monitored and the time intervals in which analyses should be conducted are determined. Furthermore, various approaches of data assessment are described.

[A descriptive study of the procedures of psychiatric admissions at Razi hospital]

BACKGROUND

The law 92-83, has established the rights of the mentally ill to respect for individual freedom and to appropriate care. However some gaps in its implementation led to the revision by Act 2004-40.

AIM

To study the evolution of the number of admissions with and without consent (hospitalizations at the request of a third party and compulsory hospitalizations), between 2000 and 2009.

METHODS

Retrospective study of the archives of the mental health unit of Razi hospital. The study population included inpatients under the mode of voluntary and involuntary admission either compulsory hospitalizations or at the request of a third party.

RESULTS

An increase in the number of hospitalizations without the consent from 2000 to 2009 was noted. The number of compulsory hospitalizations and the one of hospitalizations at the request of a third party rose respectively from 1,048 to 1,443 and from 22 to 1,323. So the number of free hospitalizations has decreased while the number of involuntary hospitalizations has increased, leading to a constant number of total hospitalizations. The sex ratio for compulsory hospitalizations has increased from 2.04 to 5.83 while it markedly decreased for hospitalizations at the request of a third party (from 10 to 1.7).Men, unlike women, were more likely to be hospitalized compulsorily than at the request of a third party.

CONCLUSION

There is a larger use of hospital admissions under constraints than free ones; is it due to a concern for the respect of law or an abuse in the deprivation of freedom for some patients?

Caught in the middle. Under tough scrutiny from the CMS over which patients should be admitted for care, hospitals are frustrated--and patients are fighting back

As hospitals face growing pressure to reclassify inpatients to "observation" status, patients are the ones being hit with unexpected bills to pay what Medicare won't. One solution to the dilemma is a bill that would restructure the rules on when skilled-nursing care is paid for. "We have very broad-based support," says U.S. Rep. Joe Courtney (D-Conn.), left, one of the House sponsors.

[Involuntary admission of addict during early pregnancy]

A 30-year-old cocaine-dependent woman was 16 weeks pregnant. Because of possible endangerment of the fetus, an involuntary provisional admission was authorized. Of particular interest is the application of the Dutch Act on Formal Admissions to Psychiatric Hospitals for the primary diagnosis 'addiction' and the fact that the fetus was regarded as a legal 'other'. In severe cases of addiction combined with pregnancy an earlier intervention is needed and arrangement of accelerated legal custody of the newborn before birth should be considered. For the protection of the unborn, we advocate a stricter application of the United Nations Convention on the Rights of the Child. Information for addicted women with preconception counselling can help prevent a compulsory admission.

[A proposal of a patient psychiatric treatment and hospitalisation consent form]

The Polish medical law has accepted the rule of equivalence in the doctor-patient relationship. In this way it gave up on the medical paternalism". To a large extent, the newly passed or renewed Rules and Regulations were responsible for this. All Polish hospitals, the psychiatric ones amongst them, must abide the rules on patients' agreement to being hospitalised, examined and treated in accordance with the regulations on: the profession of the doctor and the dentist (passed on the 5th December 1996); on the patient's laws and the Speaker of Patient's Laws (passed on the 6th November 2008) and the Minister of Health Regulation on the type and range of medical records kept in the health care centres and the means of dealing with those records (from the 21st December 2006). Many hospitals have use their own adapted records, which are in accordance with those rules and regulations. There is no universal forms concerning the patient's consent to being admitted and treated in a psychiatric hospital. The problem that is taken on by the psychiatrists about the difference and specificity of psychiatric treatment and the situation of the patient being admitted onto a psychiatric ward, proves the general consent forms to be inadequate. The article shows the current and running regulations on the patient's consent to hospital admission, an agreement to receiving health care and receiving medical information and insight into medical records. The character, scope, types of patient's agreement and their forms have been discussed here. Appropriate form types and outlines are presented.

[Numbers and patterns in compulsory admissions in 3 Dutch cities; problems in urban areas and regional differences in the implementation of the law on special admissions to psychiatric hospitals]

BACKGROUND

In the Netherlands little research has been done on the regional variability in the implementation of the law on Special Admissions to Psychiatric Hospitals (Dutch acronym Bopz).

AIM

To investigate regional variability in the numbers, combinations and characteristics of emergency compulsory admissions and other types of legally authorised admissions.

METHOD

Data from the Bopz information system covering a 12-month period were analysed. Missing data were supplied by the courts in Maastricht, Groningen and Rotterdam.

RESULTS

There was regional variability in the way in which compulsory measures were implemented, particularly as far as emergency compulsory admissions were concerned. The relative number of Bopz measures increased in relation to the degree of urbanisation. Rotterdam had the highest percentage of emergency compulsory admissions. Patients in Maastricht and Rotterdam were more often involved in legally authorised admissions only. In Rotterdam an unlinked combination of emergency compulsory admissions and legally authorised admissions was more common. In Maastricht a larger number of patients were admitted because they were a danger to themselves, whereas in Groningen and Rotterdam admissions were also used as a means of safeguarding the public.

CONCLUSION

The number of admissions and the diversity of Bopz measures are highest in urban areas. Regional variations in the way in which compulsory measures are applied persist, but there is room for improvement in the monitoring of the effects of these differences and the types of services that are available.

Exploring medical identity theft

The crime of medical identity theft is a growing concern in healthcare institutions. A mixed-method study design including a two-stage electronic survey, telephone survey follow-up, and on-site observations was used to evaluate current practices in admitting and registration departments to reduce the occurrence of medical identity theft. Survey participants were chief compliance officers in acute healthcare organizations and members of the Health Care Compliance Association. Study results indicate variance in whether or how patient identity is confirmed in healthcare settings. The findings of this study suggest that information systems need to be designed for more efficient identity management. Admitting and registration staff must be trained, and compliance with medical identity theft policies and procedures must be monitored. Finally, biometric identity management solutions should be considered for stronger patient identification verification.

[Independent psychiatrists rarely dispute an application for compulsory admission]

BACKGROUND

In recent years in the Netherlands there has been a marked increase in the number of compulsory admissions, particularly those that require court authorisation. Little is known about the decision-making process that precedes the issuing of a court authorisation for compulsory admission.

AIM

To obtain more insight into the factors that an independent psychiatrist has to consider when assessing whether he or she should sign a medical certificate that will advise on compulsory admission.

METHOD

Data on clinical and demographic patient characteristics were gathered for 862 commitment applications. Motives for rejection of the application or doubt about the necessity of commitment were collected. results In the case of 9% of the applications, the psychiatrist hesitated about the need for compulsory admission but nevertheless signed the necessary medical certificate. In the case of 3% of the applications, the psychiatrist turned down the application for compulsory admission. The psychiatrist found to reject or query an application less often if a patient presented a direct physical threat to himself or others. The principal reason for rejecting an application for compulsory admission was the possibility that an alternative type of treatment was available.

CONCLUSION

In principle the independent psychiatrist nearly always signs a medical certificate if the clinician treating the patient had requested a court authorisation. Factors that might help to reduce the number of court authorisations are better and earlier use of intensive care services, improved management or the deployment of legal restraints to prevent danger.

Transitioning dementia residents from assisted living to memory care units: a pilot study

Our study examined the process of transitioning residents of assisted living facilities (ALFs) who have Alzheimer's disease or a related disorder to memory care units (MCUs). In-depth surveys with 10 ALF administrators in South Carolina were conducted. Grounded theory identified major themes; thematic analysis organized content. Most administrators used a preadmission screening process to assess cognitive status. About half reported that they discussed the possibility of future transfer to another level of care with the family at admission. Most administrators said that their facilities had transfer policies in place; of these, only two-thirds discussed their policies with families on admission. Transfer triggers included leaving the facility without anyone's knowledge, disturbing behaviors, and increased care needs. Challenges included family resistance and greater costs of MCUs. Assisted living facilities that were part of continuing care retirement communities used more multidisciplinary transfer decision-making than free-standing ALFs. Suggested improvements stressed educating families about dementia and MCUs.

[Evaluation of the appropriateness of public hospital use using AEP in the Abruzzo Region of Italy: results by hospital and ward, main predictors and potential implications]

In the context of a wide healthcare system reorganization, the Abruzzo Region of Italy used the Appropriateness Evaluation Protocol (AEP) to carry out a systematic evaluation of the appropriateness of the admissions performed during 2006 in all public hospitals. After specific training courses, a sample representative of all ordinary admissions was assessed twice: first by regional investigators (external assessment) then by the local personnel (internal assessment). Random-effect logistic regression was used to evaluate potential inappropriateness predictors. On a total of 13081 hospital days (2393 hospitalizations), 39.7% (95% Confidence interval: 38.9%-40.6%) were inappropriate at the regional assessment; 39.5% at the internal assessment, with high correlation between the two controls (K = 0.73). Another 10.4% of admissions, excluded by the evaluation, was assigned to DRGs at high risk of inappropriateness and should be considered. In single hospitals, the inappropriateness ranged between 17.9% and 57.9%, with large variation across wards. Additional significant predictors of inappropriateness were the day and hour of admission and hospital size, with lower inappropriateness in bigger ones. In 2006, there was a large degree of hospital misuse in public hospitals in the Abruzzo Region. The approach used in the survey may have contributed to the drastic reduction of the number of ordinary admissions observed in the Region between 2006 and 2007.

Aggression control therapy for violent forensic psychiatric patients: method and clinical practice

Aggression control therapy is based on Goldstein, Gibbs, and Glick's aggression replacement training and was developed for violent forensic psychiatric in- and outpatients (adolescents and adults) with a (oppositional-defiant) conduct disorder or an antisocial personality disorder. First, the conditions for promoting "treatment integrity" are examined. Then, target groups, framework, and procedure are described in detail, followed by the most important clinical findings during the period 2002 to 2006. Finally, new programme developments are mentioned, with aggression control therapy as a starting point.

[The judge follows the advice of the psychiatrist; an investigation into the jurisprudence concerning compulsory admission requests and decisions under the Dutch Act on Special Admissions to Psychiatric Hospitals (Bopz)]

BACKGROUND

People are under the impression that there are differences between regions and between psychiatrists and judges in the criteria that are applied with regard to compulsory admission under the Dutch Act on Special Admissions to Psychiatric Hospitals (Bopz).

AIM

To find out how the legal criteria are currently put into operation, what topics come up for discussion and what evidence the judge generally requires in order to have recourse to compulsory admission.

METHOD

All judgments pronounced between 2002 and June 11 2005 and published in the journal Bopz Jurisprudence (bj) were analysed juridically. results In two-thirds of the cases the judge followed the advice of the psychiatrist and decided on compulsory admission. The required admission was refused for formal judicial reasons or because circumstances during the court hearing differed from those prevailing at the time when the medical report was drawn up. There was very little discussion about psychiatric disturbances or about the seriousness of the danger involved, but no objective criteria on this subject exist.

CONCLUSIONS

The jurisprudence suggests that within the boundaries of the legally defined criteria there is still room for manoeuvre and negotiation with regard to compulsory admission applications under the Bopz Act. It is very important that the psychiatrist fully underpins his findings and draws up his application in accordance with the requirements of the Bopz Act and satisfies the judge's need for detailed information. The development and utilisation of instruments for assessing the degree of danger and the severity of the psychiatric disturbance within the framework of the Bopz could be a useful supplement to the law in its current form.