Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia

Ethical and Clinical Challenges in Involuntary Hospitalization for First-Break Psychosis

In our report, we discuss the case of a young adult female who presented to our institution's emergency department with new-onset third-degree heart block and psychotic-like symptoms. The patient had a psychiatric history remarkable for presumed bipolar disorder, anxiety, depression, and cannabis use disorder, with no inpatient admissions or suicide attempts and not taking any psychotropic medications. While in our care, the patient expressed grandiose delusions and hallucinations. All laboratory and diagnostic testing (including tick-borne diseases) were within the normal limits. The patient did not meet strict criteria for involuntary hospitalization in New York State, but the care team faced a dilemma about the patient's safety and fitness for discharge. Here, we discuss this commonly encountered scenario and the bioethics and clinical decision-making to ensure the presenting patient's health, safety, and rights.

Liberty or life: mental health care in Australia

This article reviews the development of mental health and psychiatric services in Australia for the international reader. The development of relevant legislation, health-care systems, and the effectiveness of treatment for people with schizophrenia is reviewed. Gaps in service delivery and future directions are considered.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion. Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization. Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization. Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval. Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Probability and loss: two sides of the risk assessment coin

Risk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.

Public attitudes towards involuntary admission and treatment by mental health services in Norway

PURPOSE

The role of compulsory treatment of serious mental disorders has been the topic of ongoing public debate involving among others mental health professionals, service providers, service user advocates, relatives of service users, media commentators and politicians. However, relatively little is known about general public attitudes towards involuntary admission and compulsory treatment of people with various mental disorders. This article examines the attitudes in a representative sample of Norway's population towards the use of involuntary admission and treatment, and under which circumstances does the general public consider compulsory treatment to be justified in the Norwegian mental health care services.

METHOD

Data were collected from a representative sample of the population in Norway aged 18 and older. The sample was stratified for gender, geographical region and age distribution (n=2001). The survey was performed in the months of May 2009 (n=1000) and May 2011 (n=1001), using Computer Assisted Telephone Interviews (CATI) by an independent polling company. All respondents were provided a general definition of coercive intervention before the interview was conducted.

ANALYSIS

Univariate descriptions and bivariate analyses were performed by means of cross-tabulation, analysis of variance (one-way ANOVA) and comparing of group of means. Cohen's d was used as the measure for effect size.

RESULTS

Between 87% and 97% of those surveyed expressed strong or partial agreement with the use of involuntary admissions or compulsory treatment related to specified cases and situations. The majority of interviewees (56%) expressed the opinion that overall, current levels are acceptable. A further, 34% were of the opinion that current levels are too low, while only 9.9% of respondents supported a reduction in the level of involuntary treatment. Lower levels of education were associated with a more positive attitude towards involuntary admission and treatment. There was stronger support for admission to prevent suicide than the possibility of violence by the mentally ill.

CONCLUSION

The Norwegian adult population largely supports current legislation and practices regarding involuntary admission and compulsory treatment in the mental health services.

Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia

BACKGROUND

Little is known about the reasons why people with schizophrenia have contact with police, especially prior to the first episode of illness.

AIM

To investigate the prevalence and correlates of police contact in first-episode schizophrenia.

METHODS

The prevalence and type of police contact was established among all 110 patients presenting to psychiatric services in one catchment area during a first episode of schizophrenia and among 65 non-mentally ill controls, by participant and collateral interview and from records. Socio-demographic and clinical characteristics were also recorded and the two groups compared.

RESULTS

The first episode of schizophrenia patients had more contact with police than controls, despite the higher prevalence of conduct disorder symptoms among the controls. The patients were not, however, more likely to be incarcerated or arrested. Among the patients, over half of the police call-outs occurred during the period of untreated psychosis. Positive psychotic symptoms were independently associated with police contact, after allowing for socio-demographics.

CONCLUSIONS

As over a third of people in a first episode of schizophrenia had been in contact with the police - more than twice the proportion among non-psychotic controls - and contact was associated with untreated positive psychotic symptoms, better early detection and treatment of psychosis seems indicated. In the meantime, police services may be playing an important role in reducing the duration of untreated psychosis. Copyright © 2015 John Wiley & Sons, Ltd.

We should replace conventional mental health law with capacity-based law

As general medicine moves away from 'paternalism' and places an increasing emphasis on patient choice and autonomy, George Szmukler and Brendan D. Kelly debate whether conventional mental health legislation should be replaced with a model that focuses on the person's decision-making capabilities.

Exploring and explaining involuntary care: The relationship between psychiatric admission status, gender and other demographic and clinical variables

Involuntary admission and treatment are features of psychiatric care in many countries, but the relationship between involuntary status and gender (among other factors) is not clear. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in a deprived area of Dublin's north inner-city over a 7-year period (2008 to 2014 inclusive). Over this period, there were 1099 admissions, yielding an annual admission rate of 504.8 admissions per 100,000 population per year. When adjusted for deprivation, this rate (387.7) was lower than the national rate (413.9). Consistent with other inner-city areas in Dublin, 14.1% of admissions were involuntary, yielding an involuntary admission rate of 71.2 per 100,000 population per year (deprivation-adjusted rate: 54.8), which is higher than the national rate (39.4). After controlling for age, occupation, marital status and diagnosis, the only independent predictors of admission status were place of origin (p<0.001) and male gender (p=0.001). These findings are consistent with studies showing associations between male gender and involuntary status in the United States, New Zealand, Netherlands, Norway, Belgium, France, and Luxembourg. In contrast, female gender is associated with involuntary status in Switzerland, Brazil, and China. These cross-national differences are likely related to differing legal traditions and different criteria for involuntary admission, possibly related to varying emphases placed on "dangerousness" as a mandatory criterion for involuntary hospitalization. This merits further, cross-national study.

Prevalence of Mental Illness among Homeless People in Hong Kong

Metholodogy

This study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.

Findings

The point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.

Conclusion

The low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.

Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: A Systematic Review and Meta-Analysis

Background

Violence in acute psychiatric wards affects the safety of other patients and the effectiveness of treatment. However, there is a wide variation in reported rates of violence in acute psychiatric wards.

Objectives

To use meta-analysis to estimate the pooled rate of violence in published studies, and examine the characteristics of the participants, and aspects of the studies themselves that might explain the variation in the reported rates of violence (moderators).

Method

Systematic meta-analysis of studies published between January 1995 and December 2014, which reported rates of violence in acute psychiatric wards of general or psychiatric hospitals in high-income countries.

Results

Of the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least one act of violence was 17% (95% confidence interval (CI) 14–20%). Studies with higher proportions of male patients, involuntary patients, patients with schizophrenia and patients with alcohol use disorder reported higher rates of inpatient violence.

Conclusion

The findings of this study suggest that almost 1 in 5 patients admitted to acute psychiatric units may commit an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors that are associated with violence among individual patients (male gender, diagnosis of schizophrenia, substance use and lifetime history of violence).

How much do we know about schizophrenia and how well do we know it? Evidence from the Schizophrenia Library

BACKGROUND

True findings about schizophrenia remain elusive; many findings are not replicated and conflicting results are common. Well-conducted systematic reviews have the ability to make robust, generalizable conclusions, with good meta-analyses potentially providing the closest estimate of the true effect size. In this paper, we undertake a systematic approach to synthesising the available evidence from well-conducted systematic reviews on schizophrenia.

METHOD

Reviews were identified by searching Medline, EMBASE, CINAHL, Current Contents and PsycINFO. The decision to include or exclude reviews, data extraction and quality assessments were conducted in duplicate. Evidence was graded as high quality if reviews contained large samples and robust results; and as moderate quality if reviews contained imprecision, inconsistency, smaller samples or study designs that may be prone to bias.

RESULTS

High- and moderate-quality evidence shows that numerous psychosocial and biomedical treatments are effective. Patients have relatively poor cognitive functioning, and subtle, but diverse, structural brain alterations, altered electrophysiological functioning and sleep patterns, minor physical anomalies, neurological soft signs, and sensory alterations. There are markers of infection, inflammation or altered immunological parameters; and there is increased mortality from a range of causes. Risk for schizophrenia is increased with cannabis use, pregnancy and birth complications, prenatal exposure to Toxoplasma gondii, childhood central nervous system viral infections, childhood adversities, urbanicity and immigration (first and second generation), particularly in certain ethnic groups. Developmental motor delays and lower intelligence quotient in childhood and adolescence are apparent.

CONCLUSIONS

We conclude that while our knowledge of schizophrenia is very substantial, our understanding of it remains limited.

Alcohol abuse as the strongest risk factor for violent offending in patients with paranoid schizophrenia

Aim

To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia.

Method

The cross-sectional study including male in-patients with paranoid schizophrenia with (N = 104) and without (N = 102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between the groups. Binary logistic regression model was used to determine the predictors of violent offending.

Results

Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending.

Conclusion

This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.

Civil commitment law, mental health services, and US homicide rates

PURPOSE

The study considers whether involuntary civil comment (ICC) statute provisions are associated with homicide rates. Do statutes based solely upon dangerousness criteria versus broader ICC-criteria-i.e. "need for treatment," "protection of health and safety," and family protection-have differential associations related to their goal of reducing the frequency of homicide?

METHOD

State-level data were obtained from online data bases and key-informant surveys. Ordinary-least-squares and Poisson regression were used to evaluate the association between statute characteristics, mental health system characteristics, and 2004 Homicide Rates after controlling for firearm-control-law restrictiveness and social-economic-demographic-geographic-and-political indicators historically related to homicide rate variation.

RESULTS

Poisson and OLS models, respectively, were significant: likelihood ratio χ(2) = 108.47, df = 10; p < 0.000 and Adj. R (2) = 0.72; df = 10, 25; F = 10.21; p < 0.000. Poisson results indicate that social-economic-demographic-geographic-and-political-indicators had the strongest association with state homicide rates (p < 0.000). Lower rates were associated with: broader ICC-criteria (p ≤ 0.01), fewer inpatient-bed access problems (p ≤ 0.03), and better mental health system ratings (p ≤ 0.04). OLS results indicate that social-economic-demographic-geographic-and-political indicators accounted for 25% of homicide rate variation. Broader ICC-criteria were associated with 1.42 less homicides per 100,000. Less access to psychiatric inpatient-beds and more poorly rated mental health systems were associated with increases in the homicide rates of 1.08 and 0.26 per 100,000, respectively.

CONCLUSIONS

While social-economic-demographic-geographic-and-political indicators show the strongest association with homicide rate variation, the results show the importance and potentially preventive utility of broader ICC criteria, increased psychiatric inpatient-bed access, and better performing mental health systems as factors contributing to homicide rate variation.

Rising to the human rights challenge in compulsory treatment--new approaches to mental health law in Australia

OBJECTIVE

To analyse, and explain to Australasian psychiatrists, recent proposed changes to the terms of coercive treatment for mental illness in Tasmania and Victoria and to place the proposals in the context of a broader human rights framework that is likely to impact the future shape of mental health legislation more generally.

METHODS

The Australian law reform proposals are reviewed against the requirements of numerous human rights instruments, including the recently ratified United Nations Convention on the Rights of Persons with Disabilities. Ethical and legal arguments are made to support the proposed changes and to introduce others, taking into account academic commentary on mental health law and recent empirical work on the ability to usefully categorise patients by their likelihood of harm to self and others.

RESULTS

The Victorian and Tasmanian draft mental health bills propose a new basis for compulsory psychiatric treatment in Australasia. If they become law, coercive psychiatric treatment could only be applied to patients who lack decision-making capacity. The Tasmanian draft bill also sets a new benchmark for timely independent review of compulsory treatment. However both jurisdictions propose to retain an 'additional harm' test which must be satisfied before patients may be treated without consent. This differs from non-psychiatric cases, where if patients are unable to consent to medical treatment for themselves, they will be entitled to receive coercive treatment if it is in their best interests.

CONCLUSIONS

The proposed changes under the Tasmanian and Victorian draft mental health bills will ensure that, in line with local and international human rights obligations, only patients who lack decision-making capacity may be coercively treated for mental illness. However the continuing 'additional harm' criteria may breach human rights obligations by imposing a discriminatory threshold for care on patients who are unable to consent to treatment for themselves. This could be avoided by replacing the 'additional harm' test with a 'best interests' test.

The validity and utility of risk assessment for inpatient suicide

OBJECTIVE

It is widely assumed that identifying clinical risk factors can allow us to determine which patients are at high risk of suicide while in hospital, and that identifying those patients can help prevent inpatient suicide. We aimed to examine the validity and utility of categorizing psychiatric patients to be at either high or low risk of committing suicide while in hospital.

METHOD

The assumption that high-risk categorizations are valid was examined by comparing factors included in high-risk models derived from individual studies of inpatient suicide with the results of a meta-analysis of factors associated with inpatient suicide. A valid high-risk model was then applied to a hypothetical clinical setting in order to test the assumption that high-risk categorizations are useful.

RESULTS

The existing models for assessing whether inpatients are at high risk of suicide all include one or more factors that were not found to be associated with inpatient suicide by meta-analysis and were probably chance associations. Depressed mood and a prior history of self-harm are the only well-established independent risk factors for inpatient suicide. Using these risk factors to classify patients as being at high or low risk would prevent few, if any, suicides, and would come at a considerable cost in terms of more restrictive care of many patients and the reduced level of care available to the remaining patients.

CONCLUSIONS

Risk categorization of individual patients has no role to play in preventing the suicide of psychiatric inpatients.

Violence in first-episode psychosis: a systematic review and meta-analysis

BACKGROUND

Violence towards others is a recognised complication of first-episode psychosis.

AIMS

To estimate the rate of violence and the associations with violence in first-episode psychosis.

METHOD

A systematic review and meta-analysis of 9 studies.

RESULTS

Pooled estimates of the proportion of patients with first-episode psychosis committing any violence, serious violence and severe violence were 34.5%, 16.6% and 0.6%, respectively. Violence of any severity was associated with involuntary treatment (OR=3.84), a forensic history (OR=3.28), hostile affect (OR=3.52), symptoms of mania (OR=2.86), illicit substance use (OR=2.33), lower levels of education (OR=1.99), younger age (OR=1.85), male sex (OR =1.61) and the duration of untreated psychosis (OR=1.56). Serious violence was associated with a forensic history (OR=4.42), the duration of untreated psychosis (OR=2.76) and total symptom scores (OR=2.05). Violence in the period after initiation of treatment for first-episode psychosis was associated with involuntary treatment (OR=5.71).

CONCLUSIONS

A substantial proportion of patients in first-episode psychosis commit an act of violence before presenting for treatment, including a number who commit an act of more serious violence causing injury to another person. However, severe violence resulting in serious or permanent injury to the victim is uncommon in this population.

Obligatory dangerousness criteria in the involuntary commitment and treatment provisions of Australian mental health legislation

OBJECTIVE

Involuntary commitment and treatment (IC&T) of people affected by mental illness may have reference to considerations of dangerousness and/or need for care. While attempts have been made to classify mental health legislation according to whether IC&T has obligatory dangerousness criteria, there is no standardised procedure for making classification decisions. The aim of this study was to develop and trial a classification procedure and apply it to Australia's mental health legislation.

METHOD

We developed benchmarks for 'need for care' and 'dangerousness' and applied these benchmarks to classify the mental health legislation of Australia's 8 states and territories. Our focus was on civil commitment legislation rather than criminal commitment legislation.

RESULTS

One state changed its legislation during the course of the study resulting in two classificatory exercises. In our initial classification, we were able to classify IC&T provisions in legislation from 6 of the 8 jurisdictions as being based on either 'need for care' or 'dangerousness'. Two jurisdictions used a terminology that was outside the established benchmarks. In our second classification, we were also able to successfully classify IC&T provisions in 6 of the 8 jurisdictions. Of the 6 Acts that could be classified, all based IC&T on 'need for care' and none contained mandatory 'dangerousness' criteria.

CONCLUSIONS

The classification system developed for this study provided a transparent and probably reliable means of classifying 75% of Australia's mental health legislation. The inherent ambiguity of the terminology used in two jurisdictions means that further development of classification may not be possible until the meaning of the terms used has been addressed in case law. With respect to the 6 jurisdictions for which classification was possible, the findings suggest that Australia's mental health legislation relies on 'need for care' and not on 'dangerousness' as the guiding principle for IC&T.

Clinical decisions in psychiatry should not be based on risk assessment

OBJECTIVE

Risk assessments that place patients in high or low risk categories have been widely adopted by mental health services in an attempt to reduce the harms associated with psychiatric disorders. This paper examines the effects of categorization based on the results of a risk assessment.

METHODS

The violence prediction instrument derived from the MacArthur Study of Mental Disorder and Violence was used to illustrate the nature and effects of risk assessment and the consequent categorization of patients.

RESULTS

The majority of patients categorized as being at high risk will not commit any harmful acts.

CONCLUSIONS

Patients who are classified as high risk share the cost of efforts to reduce harm in the form of additional treatment and restrictions, although the majority will not go on to commit a harmful act. Clinical decisions made on the basis of risk assessment also divert resources away from patients classified as low risk, even though a significant proportion do go on to a commit harmful act. We argue that psychiatric professionals should discuss the risks of treatment and of non-treatment with patients (or with their substitute decision-makers) and should maintain a duty to warn about the consequences of not having treatment. However, assessment of risk of harm should not form the basis for clinical decision making. We should aim to provide optimal care according to the treatment needs of each patient, regardless of the perceived risk of adverse events.

Compulsory treatment in psychiatry

PURPOSE OF REVIEW

Compulsory treatment is a common, yet controversial, practice in psychiatry. This paper reviews recent studies on the use of compulsory measures in hospital, the community and special populations.

RECENT FINDINGS

Researchers continue to examine the rates and patterns of involuntary hospitalization. However, they have extended their investigations to care in the community, acknowledging it as the primary locus of treatment for most patients. Research shows that the implementation of community mental health legislation presents complex clinical and practical issues that require further investigation. Recognition that compulsory treatment is an objective event which is subjectively experienced by patients, families and clinicians has led to research investigating stakeholder views. The therapeutic relationship has been found to be an important modifier of the experience of compulsory treatment. Recent studies have also focused on specific coercive practices, such as forced medication and seclusion, and the use of these in patient subgroups, including those with eating disorders and adolescents. The debate about whether compulsory treatment is ethical continues in the literature.

SUMMARY

Compulsory treatment in psychiatry remains an ethically and clinically contentious issue. As ethical concerns are generally countered by the argument that compulsory measures can lead to beneficial clinical outcomes, further empirical investigation in this area is required.

Did the introduction of 'dangerousness' and 'risk of harm' criteria in mental health laws increase the incidence of suicide in the United States of America?

INTRODUCTION

Mental health laws limiting involuntary admission to psychiatric hospitals to those assessed to be dangerous or at risk of harm to themselves or others (obligatory dangerousness criteria, ODC) have been introduced in almost every jurisdiction in the United States of America. Some mentally ill patients, who might have been admitted for treatment under previous laws, but who were not admitted because they were not considered 'dangerous', could subsequently have committed suicide. In order to investigate whether or not suicide rates increased after the introduction of ODC, we examined suicide statistics from 48 states and the District of Columbia.

METHODS

We aligned suicide statistics according to the year in which ODC were introduced in each jurisdiction. We then examined suicide rates in the 15 years before and after the introduction of ODC and trends in national and state suicide rates between 1960 and 1990. Meta-analysis was used to examine differences in suicide rates in the year immediately before and in the year immediately after the introduction of ODC.

RESULTS

Between 1968 and 1977, the decade in which ODC were introduced in the majority of jurisdictions, national suicide rates increased from under 11 per 100,000 per annum to over 12.5 per 100,000 per annum. The increase in many jurisdictions occurred in the years immediately before the introduction of ODC. The introduction of ODC was associated with a non-significant increase in suicide rates in the 49 jurisdictions. There was a significant increase in suicide rates after the introduction of ODC in the 19 jurisdictions that introduced ODC prior to 1976.

CONCLUSIONS

The introduction of ODC might have contributed to increased suicide rates prior to 1976. However, a simpler explanation for the finding is that national suicide rates were rising for other reasons in the same period. We did not find an increase in suicide rates in the jurisdictions where ODC mental health laws were introduced after 1976. Hence, the findings of this study do not support the conclusion that ODC laws have a measurable impact on suicide rates.

The relationship between the rate of homicide by those with schizophrenia and the overall homicide rate: a systematic review and meta-analysis

BACKGROUND

It is widely believed that the rate of homicide by the mentally ill is fixed, differs little between regions and is unrelated to the total homicide rate.

METHODS

We conducted a systematic review and meta-analysis of population-based studies conducted in developed countries of homicide committed by persons diagnosed with schizophrenia.

FINDINGS

We found that rates of homicide by people diagnosed with schizophrenia were strongly correlated with total homicide rates (R=0.868, two tailed, P<0.001). Using meta-analysis, a pooled proportion of 6.48% of all homicide offenders had a diagnosis of schizophrenia (95% confidence intervals [CI]=5.56%-7.54%). Rates of other homicides did not contribute to the heterogeneity in the proportion of homicides committed by those with schizophrenia (slope=-0.055, P=0.662).

CONCLUSIONS

Homicide rates by people with schizophrenia are associated with rates of all homicides. It is therefore likely that both types of homicide have some common etiological factors. Accordingly, measures to reduce the likelihood of a person committing homicide during a psychotic illness should not only attempt to optimise treatment, but include attention to those factors associated with an increased risk of all homicides, such as improving the social circumstances of disadvantaged patients, treating substance abuse and reducing access to weapons.

The relationship between the duration of untreated psychosis and outcome in low-and-middle income countries: a systematic review and meta analysis

BACKGROUND

The duration of untreated psychosis (DUP) is defined as the period between the onset of symptoms of psychosis and the start of antipsychotic treatment. Delay in the initiation of treatment, resulting in a long DUP, is associated with a poor prognosis in high-income (HI) countries. It is not known if longer DUP is associated with poor outcomes in Low and Middle Income (LAMI) countries, where schizophrenia might have a more benign course.

METHODS

A systematic review and meta-analysis of studies from LAMI countries that reported an association between DUP and response to treatment, measures of disability and mortality. The association between DUP, symptoms and cognitive function at presentation were also examined.

FINDINGS

Meta analysis of five studies that reported the association between DUP and the reduction in total symptoms scores after treatment found a significant negative correlation between DUP and improvement in symptoms after treatment (r=-0.290, 95% CI=-0.483 to -0.069, z=-2.559, p<0.011). Prolonged DUP was also associated with increased levels of disability. One study reported that longer DUP was associated with a higher mortality in the following decade.

CONCLUSIONS

Delay in the initial initiation of treatment for psychosis is associated with a poorer response to treatment and increased levels of disability in LAMI countries.

Relationship between gross domestic product and duration of untreated psychosis in low- and middle-income countries

BACKGROUND

The duration of untreated psychosis (DUP), the period between the first onset of psychotic symptoms and treatment, has an important influence on the outcome of schizophrenia.

AIMS

To compare the published studies of DUP in low- and middle-income (LAMI) countries with the DUP of high-income countries, and examine a possible association between DUP and per capita income.

METHOD

We used six search strategies to locate studies of the DUP from LAMI countries published between January 1975 and January 2008. We then examined the relationship between DUP and measures of economic activity, which was assessed using the LAMI classification of countries and gross domestic product (GDP) purchasing power parity.

RESULTS

The average mean DUP in studies from LAMI countries was 125.0 weeks compared with 63.4 weeks in studies from high-income countries (P=0.012). Within the studies from LAMI countries, mean DUP fell by 6 weeks for every $1000 of GDP purchasing power parity.

CONCLUSIONS

There appears to be an inverse relationship between income and DUP in LAMI countries. The cost of treatment is an impediment to care and subsidised antipsychotic medication would improve the access to treatment and the outcome of psychotic illness in LAMI countries.