Characteristics of patients referred by police to a psychiatric hospital

Predictors of the use of restraint in inpatient psychiatric care among patients admitted via the emergency department

BACKGROUND

Coercive measures are associated with negative consequences for both patients and hospital staff. The aim of the study was to identify predictors for the use of restraints in the emergency department and in subsequent inpatient care.

METHOD

Retrospective routine clinical data of all patients admitted to the psychiatric departments of Vivantes Klinikum Am Urban in Berlin via the emergency department in 2019 was examined case-wise (n = 2584) as well as patient-wise (n = 2118).

RESULTS

Of all cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. Of the 2584 cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. These 195 cases experienced a total of 358 restraints and were distributed across 159 individuals. Multivariate regression analyses on patient-level show that age (p < .001), judicial placement (p < .001), and police referral in the presence of others (p < .001) had a statistically significant effect on the use of restraint.

DISCUSSION

The results indicate that certain patient characteristics increase the risk of restraints. A majority of the findings of this study underline previous research findings. However, ICD-10 diagnosis and gender do not prove to be significant variables, contrary to expectations based on previous.

Using the interRAI brief mental health screener to identify persons with mental disorders having repeat contact with police

Repeat contacts between persons with serious mental disorder (PSMD) and police officers are costly to both police services and hospitals in terms of service utilization and can be viewed as a direct indicator of unmet needs and gaps in service provision. The intent of the current study was to examine the demographic and clinical characteristics of PSMD who had repeat contact with police officers in London, Ontario from 2016 to 2019 using data collected using the interRAI Brief Mental Health Screener (BMHS). Negative binomial regression was used on a sample of 4143 cases to develop a model predictive of repeat police contacts. The most parsimonious model predicting police contact based on items on the BMHS included age, command hallucinations, lack of insight, verbal abuse, known to possess weapons and family, friends and caregivers expressing concern over the possibility of self harm. Delusions were also independently significantly associated with repeat encounters. Unique to this study is the observation that possessing a weapon in the past 12 months was included in the predictive model. The results of the study add to the sparse research devoted to identifying the characteristics of PSMD who have repeat contact with police officers. Recommendations include integrating the findings into police training to ensure police officers flag those who have the potential for repeat encounters and refer them to appropriate community mental health service providers for proactive outreach services.

Substance use in psychiatric crisis: relationship to violence

BACKGROUND

Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting.

METHODS

We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24-36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression.

FINDINGS

There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2-7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7-13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4-7.9; p < 0.0001).

INTERPRETATION

In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.

Police involvement, characteristics and outcomes of place of safety referrals in the Scottish Highlands

AIMS AND METHOD

To characterise police involvement with those detained under place of safety legislation and determine factors associated with admission to hospital. Place of safety referrals over a 1-year period were identified retrospectively and evaluated.

RESULTS

Place of safety legislation is generally used with regard to concerns about suicide. Individuals are often removed from high-risk areas and referrals to police are frequently initiated by individuals themselves. A diagnosis of mental illness or personality disorder predicted hospital admission. Presence of senior nursing staff at assessment, but not the seniority of the doctor, was associated with discharge.

CLINICAL IMPLICATIONS

Closer multiagency working is required as police are currently being recruited to fill a void between mental health services and the population they serve. Junior doctors require more senior support in making complex, and often risky, emergency management decisions with this population.

The Emerging Role of Police in Facilitating Psychiatric Evaluation Since the 2013 Implementation of the First Chinese Mental Health Law

In 2013, China's first Mental Health Law (MHL) took effect, with the goal of better protecting patients' rights. Under the law the police, with appropriate training, rather than family members, employers or medical staff sent from a hospital, are the ones who bring persons in behavioral crises to medical facilities for psychiatric assessment for possible involuntary hospitalization. We examined the proportion and distinctive characteristics of persons brought to psychiatric emergency services (PES) by the police since the implementation of MHL. We used medical records to document demographic and clinical characteristics of all persons evaluated at the PES of the Guangzhou Psychiatric Hospital, the largest psychiatric hospital in China's fourth largest city, from April 2017 to August 2017. Bivariate and multivariate statistical analyses were performed to identify characteristics of patients brought to the PES by the police. Among 1515 PES visits, 166 (11.0%) were brought by the police as compared to virtually none in the years before the law took effect. Compared to non-police referrals, police referrals were associated with male gender, age greater than 30, more documented violent behavior, greater likelihood of having been restrained, and higher rates of hospital admission after assessment. Assessed risk of suicidality and diagnoses of substance use disorder were not significantly associated with police referral. A modest but increased and noteworthy proportion of patients evaluated at the PES after implementations of China's MHL were brought by the police, especially those with violent behavior requiring restraint and hospitalization resulting from mental illness.

Police response to individuals displaying suicidal or self-harming behaviours: An integrative review

Police are increasingly being called upon to respond to people experiencing suicidal crisis. Such incidents are a challenging aspect of modern policing. This paper reports on an integrative review study that aimed to investigate police responses to individuals displaying suicidal or self-harming behaviours. Six electronic databases were searched for peer-reviewed articles published between 2007 and 2017 relating to police responses to individuals in suicidal crisis. The review identified 12 studies that met the inclusion criteria. A content analysis was conducted to identify and describe the key characteristics emerging from the literature, which identified four themes: "characteristics of individuals"; "the use of violence and weapons"; "contact with police prior to suicide"; and, "police officer training". Findings from this study indicate that individuals involved in incidents of suicidal and self-harm crisis with police are often male, aged between 35 and 40 years, single and/or having relationship issues, with a history of mental health issues and in recent contact with police prior to the incident of suicidal crisis-either as a victim or a perpetrator. The results highlight that large proportions of individuals in suicidal crisis within a community located incident are likely to present with violent or aggressive behaviour and in many situations are armed with a weapon used to either threaten or injure police and/or bystanders or self-harm. Training and education can have a positive impact from the perspective of police responding to individuals in suicidal crisis. Limitations in the current evidence are identified and implications for future research are outlined.

The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Police referrals at the psychiatric emergency service in Taiwan

INTRODUCTION

The police are the frontline workers in crisis situations involving patients with severe mental illness and act as a primary referral source for psychiatric emergency services (PES) in the community. The aims of this study were to investigate the distribution and characteristics of police referral among psychiatric patients in Taiwan.

METHODS

The study cohort consisted of patients who visited the PES of Taipei City Psychiatric Center from January 2009 to December 2010. The associations between the factors of demographics, clinical characteristics, and psychiatric service utilization and police referral were evaluated.

RESULTS

Among the 7656 psychiatric emergency visits, 3029 (39.6%) were referred by the police. These patients referred by police were more likely to be male and aged between 30 to 49 years. Clinical factors related to police referrals including a higher triage assessment level, chief problems included violence, disturbance, substance use, less anxiety, and a diagnosis of unspecified psychosis. The triage assessment level and chief problems assessed by nurses were major predictors. These patients tended to be referred from the catchment area and during the nighttime shift, were discharged during the daytime shift, and stayed longer in the PES. Disposition arrangements such as discharge against medical advice and involuntary admission were also associated with police referrals.

DISCUSSION

Patients referred by the police to the PES were those with more severe psychiatric problems and illnesses assessed by psychiatric nurses and psychiatrists. They tended to have more complex service utilization at the PES.

The locked psychiatric ward: hotel or detention camp for people with dual diagnosis

BACKGROUND

The concepts of autonomy and liberty are established goals in mental health care; however, involuntary commitment is used towards people with mental health and substance abuse problems (dual diagnosis).

AIMS

To explore how patients and staff act in the context of involuntary commitment, how interactions are described and how they might be interpreted.

METHOD

Ethnographic methodology in a locked psychiatric ward in Norway.

RESULTS

Two parallel images emerged: (a) The ward as a hotel. Several patients wanted a locked ward for rest and safety, even when admission was classified as involuntary. The staff was concerned about using the ward for real treatment of motivated people, rather than merely as a comfortable hotel for the unmotivated. (b) The ward as a detention camp. Other patients found involuntary commitment and restrictions in the ward as a kind of punishment, offending them as individuals. Contrary, the staff understood people with dual diagnoses more like a generalized group in need of their control and care.

CONCLUSION

Patients and staff have different perceptions of involuntary commitment. Based on the patients' points of view, mental health care ought to be characterized by inclusion and recognition, treating patients as equal citizens comparable to guests in a hotel.

Cannabis use and involuntary admission may mediate long-term adherence in first-episode psychosis patients: a prospective longitudinal study

BACKGROUND

This study aimed to examine factors associated with treatment adherence in first-episode psychosis (FEP) patients followed up over 8 years, especially involuntary first admission and stopping cannabis use.

METHODS

This prospective, longitudinal study of FEP patients collected data on symptoms, adherence, functioning, and substance use. Adherence to treatment was the main outcome variable and was categorized as 'good' or 'bad'. Cannabis use during follow-up was stratified as continued use, stopped use, and never used. Bivariate and logistic regression models identified factors significantly associated with adherence and changes in adherence over the 8-year follow-up period.

RESULTS

Of the 98 FEP patients analyzed at baseline, 57.1% had involuntary first admission, 74.4% bad adherence, and 52% cannabis use. Good adherence at baseline was associated with Global Assessment of Functioning score (p = 0.019), Hamilton Depression Rating Scale score (p = 0.017) and voluntary admission (p < 0.001). Adherence patterns over 8 years included: 43.4% patients always bad, 26.1% always good, 25% improved from bad to good. Among the improved adherence group, 95.7% had involuntary first admission and 38.9% stopped cannabis use. In the subgroup of patients with bad adherence at baseline, involuntary first admission and quitting cannabis use during follow up were associated with improved adherence.

CONCLUSIONS

The long-term association between treatment adherence and type of first admission and cannabis use in FEP patients suggest targets for intervention to improve clinical outcomes.

Police referrals to a psychiatric hospital: experiences of nurses caring for police-referred admissions

Police are a major source of referral to psychiatric hospitals in industrialized countries with mental health legislation. However, little attention has been paid to nurses' experience of caring for police-referred patients to psychiatric hospitals. This study utilized a Heideggerian phenomenological framework to explore the experiences of nine nurses caring for patients referred by the police, through semistructured interviews. Two major themes emerged from the hermeneutic analyses of interviews conducted with nurse participants: (i) 'expecting "the worst" '; and (ii) 'balancing therapeutic care and forced treatment'. Expecting 'the worst' related to the perceptions nurse participants had about patients referred by the police. This included two sub-themes: (i) 'we are here to care for whoever they bring in'; and (ii) 'but who deserves care?' The second theme balancing therapeutic care and forced treatment included the sub-themes: (i) 'taking control, taking care'; and (ii) 'managing power'. The study raises ethical and skill challenges for nursing including struggling with the notion of who deserves care, and balancing the imperatives of legislation with the need to work within a therapeutic framework.