Compulsory treatment in psychiatry

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.

Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors

Background

Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent.

Methods

Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication.

Results

Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis.

Conclusion

Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.

Coercive Measures in Psychiatry: A Review of Ethical Arguments

Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues. Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords "coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy." We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories. Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development. Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.

What distinguish patients with compulsory treatment for severely undernourished anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a mental disorder potentially leading to severe malnutrition and life-threatening complications, with high mortality rates and dropouts from treatment. In the most severe cases, treatment refusal associated with acute nutritional disorders may require compulsory admission in specialised units. The aim of this study was to investigate clinical and nutritional parameters associated with the use of compulsory treatment for severely ill AN patients requiring intensive nutritional care.

METHODS

This retrospective, single-centre study performed in a unit of specialised nutritional care compared severely undernourished inpatients, compulsorily admitted for AN, with a population of sex- and age-matched voluntarily admitted patients. Socio-demographic and clinical variables were collected for univariate comparison and logistic regression.

RESULTS

Compulsory treatment in AN was mainly associated with lower socio-economic status (p < 0.01), history of lower weight (p < 0.05), more frequently prescribed psychotropic medication (p = 0.02), more previous admissions for AN, longer hospitalisations (p < 0.01) and binge eating/purging subtype (p = 0.02). Binge eating/purging subtype and the number of past admissions showed the strongest odds of compulsory treatment in multivariate analysis.

CONCLUSION

The knowledge of factors associated with compulsory treatment may help practitioners of all fields to better evaluate its pertinence and indications in AN.

COVID-19 and Mental Health: An Examination of 911 Calls for Service

The purpose of this study was to explore the rate and geographic distribution of 911 calls for service related to mental health issues during the Coronavirus Disease 2019 (COVID-19) pandemic in the City of Detroit, MI, USA. The results suggest that the total number of calls for mental health issues was at the lowest level when compared with the same time period for the previous 3 years. Furthermore, as both the daily reported COVID-19 cases and related deaths increased over time, there was a significant decline in both suicide threats and suicides in progress. Significant hot spots were found for the total calls as well as for threats of suicide. These hot spots did not coincide with the spatial distribution of reported cases of COVID-19 by ZIP code. While higher and lower areas of reported cases were found, these differences by ZIP code were not found to be significant. When compared with the previous 3 years of data, the hot spot area was much smaller in 2020, implying that the mental health-related calls for service were more evenly spread throughout the city.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

Purpose:

To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.

Methods:

We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).

Results:

Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).

Discussion:

There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.

Conclusion:

Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

A case report of guardian-consent forced paliperidone palmitate for behavioral disturbance due to traumatic brain injury

Psychosis after traumatic brain injury (TBI) occurs in up to 10% of cases. Although guideline consensus is lacking regarding drugs of choice for this condition, current literature points to the use of atypical antipsychotics. This case describes a 58-year-old male with major neurocognitive disorder due to TBI with behavioral disturbance that was successfully treated with paliperidone palmitate. In addition to the off-label use of paliperidone, this case also explores the use of forced medication as the initial injection was given per guardian consent. After completion of a literature review, this appears to be the first case report describing the use of a long-acting antipsychotic for the treatment of TBI-related psychosis. This case suggests that paliperidone palmitate may be efficacious for psychosis following TBI; however, further study is warranted.

Accountability: a missing construct in models of adherence behavior and in clinical practice

Piano lessons, weekly laboratory meetings, and visits to health care providers have in common an accountability that encourages people to follow a specified course of action. The accountability inherent in the social interaction between a patient and a health care provider affects patients' motivation to adhere to treatment. Nevertheless, accountability is a concept not found in adherence models, and is rarely employed in typical medical practice, where patients may be prescribed a treatment and not seen again until a return appointment 8-12 weeks later. The purpose of this paper is to describe the concept of accountability and to incorporate accountability into an existing adherence model framework. Based on the Self-Determination Theory, accountability can be considered in a spectrum from a paternalistic use of duress to comply with instructions (controlled accountability) to patients' autonomous internal desire to please a respected health care provider (autonomous accountability), the latter expected to best enhance long-term adherence behavior. Existing adherence models were reviewed with a panel of experts, and an accountability construct was incorporated into a modified version of Bandura's Social Cognitive Theory. Defining accountability and incorporating it into an adherence model will facilitate the development of measures of accountability as well as the testing and refinement of adherence interventions that make use of this critical determinant of human behavior.

EPA guidance on improving the image of psychiatry

This paper explores causes, explanations and consequences of the negative image of psychiatry and develops recommendations for improvement. It is primarily based on a WPA guidance paper on how to combat the stigmatization of psychiatry and psychiatrists and a Medline search on related publications since 2010. Furthermore, focussing on potential causes and explanations, the authors performed a selective literature search regarding additional image-related issues such as mental health literacy and diagnostic and treatment issues. Underestimation of psychiatry results from both unjustified prejudices of the general public, mass media and healthcare professionals and psychiatry's own unfavourable coping with external and internal concerns. Issues related to unjustified devaluation of psychiatry include overestimation of coercion, associative stigma, lack of public knowledge, need to simplify complex mental issues, problem of the continuum between normality and psychopathology, competition with medical and non-medical disciplines and psychopharmacological treatment. Issues related to psychiatry's own contribution to being underestimated include lack of a clear professional identity, lack of biomarkers supporting clinical diagnoses, limited consensus about best treatment options, lack of collaboration with other medical disciplines and low recruitment rates among medical students. Recommendations are proposed for creating and representing a positive self-concept with different components. The negative image of psychiatry is not only due to unfavourable communication with the media, but is basically a problem of self-conceptualization. Much can be improved. However, psychiatry will remain a profession with an exceptional position among the medical disciplines, which should be seen as its specific strength.

Involuntary admission: the case of anorexia nervosa

Involuntary treatment of psychiatric disorders has always been controversial; this is especially true for eating disorders. Patients with anorexia nervosa of life threatening severity frequently refuse psychiatric hospitalization. Ambivalence toward treatment is characteristic of eating disorders and patients are often admitted to inpatient programs under pressure from family and doctors. In this article, we report research on the positive or negative impact of involuntary admission in the treatment of eating disorders, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders. A literature review was done. From a total of 134 publications which were retrieved from the literature search, 50 studies were directly relevant to the scope of this review and fulfilled all inclusion criteria. There are trends and arguments for both sides; for and against involuntary treatment in anorexia nervosa. The scientific literature so far is inconclusive, although in the short term, involuntary hospitalization has benefits. This review has also shown that involuntary hospitalization can have adverse long-term consequences for the patient-therapist allegiance. We conclude that in some cases, involuntary treatment can save lives of young patients with anorexia nervosa; however, in other cases, it can break the psychotherapeutic relationship and make the patient abandon treatment. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.

As time goes by: reasons and characteristics of prolonged episodes of mechanical restraint in forensic psychiatry

Evidence suggests the prevalence and duration of mechanical restraint are particularly high among forensic psychiatric inpatients. However, only sparse knowledge exists regarding the reasons for, and characteristics of, prolonged use of mechanical restraint in forensic psychiatry. This study therefore aimed to investigate prolonged episodes of mechanical restraint on forensic psychiatric inpatients. Documentary data from medical records were thematically analyzed. Results show that the reasons for prolonged episodes of mechanical restraint on forensic psychiatric inpatients can be characterized by multiple factors: "confounding" (behaviors associated with psychiatric conditions, substance abuse, medical noncompliance, etc.), "risk" (behaviors posing a risk for violence), and "alliance parameters" (qualities of the staff-patient alliance and the patients' openness to alliance with staff), altogether woven into a mechanical restraint spiral that in itself becomes a reason for prolonged mechanical restraint. The study also shows lack of consistent clinical assessment during periods of restraint. Further investigation is indicated to develop an assessment tool with the capability to reduce time spent in mechanical restraint.

Withdrawal from mental and psychosocial care during pregnancy

Psychopathology, psychosocial problems and substance use (PPS) commonly occur in pregnant women, and can have a negative impact on the course of pregnancy and the healthy development of the child. As PPS often remains undetected and untreated during pregnancy, we developed and implemented a four-step screen-and-treat protocol in routine obstetric care, with: (i) screening including triage and subsequent confirmation, (ii) indication assessment, (iii) transfer towards care and (iv) utilization of care. Adherence to the protocol and risk factors associated with dropout were examined for 236 Dutch pregnant women in a deprived urban area. Seventy-nine percent of women accepted the screening, 21% dropped out during triage, 15% during confirmation, 3% during transfer and 8% thereafter. Provided reasons for dropout were lack of time and lack of perceived benefit. In particular, smokers, multiparous women, and women of non-Western ethnicity dropout on the way towards mental and psychosocial care. For a successful implementation of the protocol in the future, with improved adherence of pregnant women to the protocol, education of women on PPS risks, motivational skills and compulsory treatment are worth investigation.

Patient experiences of autonomy and coercion while receiving legal leverage in forensic assertive community treatment

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.

Use of coercive measures in mental health practice and its impact on outcome: a critical review

Although coercive measures have always been part of the psychiatric armamentarium, the ethical dilemma between the use of a "therapeutic" coercion and the loss of patients' dignity is one of the major controversial issues in mental health research and practice. The aims of the present review are to explore the existing literature on predictors of use of coercive measures and to explore the relationship between coercive measures and patient outcome. A literature search was conducted using MEDLINE, PsychyINFO, Scopus, Web of Knowledge and the Cochrane Database. In all selected papers, references were cross-checked to identify other possible eligible papers. The use of coercive measures was predicted by patients' clinical and socio-demographic features, staff characteristics and ward-related factors. Coercive measures have only a limited impact on patients' clinical and social outcome. At the current level of knowledge, coercion is still a controversial issue in mental health practice. Only few studies with a solid methodology have been carried out. Large multicenter and rigorous studies, with long-term follow-ups, are highly needed.

Implementing the Mental Health Act 2001 in Ireland: views of Irish general practitioners

OBJECTIVES

The Mental Health Act 2001 introduced important reforms of Irish mental health law and services. This paper aims to provide an evidence-based exploration of general practitioners' views on the implementation of the Mental Health Act 2001.

METHODS

We posted questionnaires to 1200 general practitioners in Ireland seeking their views on their experiences with the Mental Health Act 2001.

RESULTS

Eight hundred and twenty general practitioners (68.3%) responded. Among those who provided comments, a majority (75.2%) provided negative comments. The most commonly occurring themes related to difficulties with transport of patients to inpatient facilities, form filling, time requirements and administrative matters. Other negative comments related to general practitioner recommendations for involuntary admission, training, mental health tribunals, applications for involuntary admission and the position of children. Minorities provided neutral (18.0%) or positive comments (6.8%), chiefly related to user-friendliness, transparency and improved communication.

CONCLUSIONS

General practitioners highlight a need for greater training and clear guidelines in relation to the Mental Health Act 2001. Their forthright responses demonstrate deep engagement with the new legislation and eagerness to see the Mental Health Act 2001 realise its full potential to improve the involuntary admission process and protect human rights, in the best interests of patients.

Attitudes among medical and law students toward decision-making in regard to involuntary psychiatric hospitalization

BACKGROUND

The management of individuals with mental illnesses sometimes requires involuntary hospitalization. The Israel Mental Health Act requires that cases of involuntary psychiatric hospitalization (IPH) be periodically reviewed by the district psychiatric committee. The discussion in the committee often leads to debate regarding the need for an IPH potentially depriving the patient of his freedom. Little is known about the way in which the psychiatrists and attorneys on these committees arrive at their decisions. The present study was designed to examine the views of future doctors and attorneys concerning cases of possible IPH to determine whether their decisions would be influenced by their respective professional educational backgrounds.

METHODS

After compiling demographic data, we asked 170 students from each of the two disciplines what their decision would be in two hypothetical cases that dealt with the question of a prolongation of a psychiatric hospitalization. Questionnaires examining social distance and possible stigmatizing views concerning psychiatric patients were also distributed and collected.

RESULTS

The response rates for the medical and law students were, respectively, 90% and 85%. We found no differences between the medical and law students regarding their views on prolongation of a psychiatric hospitalization. This was consistent regardless of whether the hospitalization was against the patient's will or according to his wish and against the treating physicians' advice. We also found that the medical and law students had similar general views regarding psychiatric patients, but that the latter evidenced greater social distance than the former.

CONCLUSIONS

Academic background and socialization were not found to influence the decisions of students regarding IPH. Educational programs and exposure to psychiatric patients during law studies are proposed to lessen psychiatric stigma and promote better understanding between members of the two disciplines.

Reflecting on forced medication

There are multiple concerns regarding the practice of forced medication of clients with mental illness. Clients often report that side effects outweigh the benefits of psychotropic medication, while mental health clinicians often think the client may become dangerous without medication. Who should have the right to decide whether a client takes medication? Nursing plays an integral role in the decision making by considering alternative therapies and current research, addressing the diversity among our clients, and ensuring comprehensive assessments. This article presents circumstances that may lead to forced medication and explores beliefs of clients, mental health clinicians, and mental health advocacy groups.Building upon Johns' (2008) model for structured reflections of clinical experiences, this article reflects upon the experience of forced medication in psychiatric nursing practice. First, the process and consequences of forced medication are explored. Next, the factors influencing the thoughts and responses of psychiatric clinicians, clients, and advocacy groups is discussed. Finally, possible alternative actions are presented.

Mental health care and the politics of inclusion: a social systems account of psychiatric deinstitutionalization

This paper provides an interpretation, based on the social systems theory of German sociologist Niklas Luhmann, of the recent paradigmatic shift of mental health care from an asylum-based model to a community-oriented network of services. The observed shift is described as the development of psychiatry as a function system of modern society and whose operative goal has moved from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population. From this theoretical viewpoint, the wider deployment of the modern social order as a functionally differentiated system may be considered to be a consistent driving force for this process; it has made asylum psychiatry overly incompatible with prevailing social values (particularly with the normative and regulative principle of inclusion of all individuals in the different functional spheres of society and with the common patterns of participation in modern function systems) and has, in turn, required the availability of psychiatric care for a growing number of individuals. After presenting this account, some major challenges for the future of mental health care provision, such as the overburdening of services or the overt exclusion of a significant group of potential users, are identified and briefly discussed.