The impact of public policy and publicity on admissions to state mental health hospitals

This paper examines the impact of broadened Washington state civil commitment standards on utilization of the state's mental hospitals. Included in the analysis is an assessment of the impact of a public event (a well-publicized murder case) which was in all likelihood a precursor to the law's revision. We also examine the different ways Washington's two state hospitals managed the dramatic increase in civilly committed patients that occurred after the revision took effect. The findings indicate that the murder case, in which the defendant had been denied voluntary admission to a state hospital prior to the killing, resulted in an increase in involuntary admissions in the county where it occurred a full year before the standards were revised. The law itself had the effect of increasing commitments throughout the state, reducing the levels of voluntary admissions, and increasing the likelihood of involuntary admission for individuals previously admitted voluntarily, thus transforming a principally voluntary system into one which was primarily involuntary. Finally, it was found that the increased demand for services mandated by the broadened commitment standards was managed differently in the two state hospitals: one imposed a cap on admissions; the other phased out voluntary admissions at a rate roughly equal to the increase in commitments. These findings illustrate both the substantive impact of broadened civil commitment law and the importance, when assessing the impact of laws, of examining public events and administrative interventions which may have significant causal links with legal interventions.     

Place and Punishment: The Spatial Context of Mass Incarceration

Objectives

Research on race and urban poverty views incarceration as a new and important aspect of social disadvantage in inner-city neighborhoods. However, in quantitative studies of the spatial distribution of imprisonment across neighborhoods, the pattern outside urban areas has not been examined. This paper offers a unique analysis of disaggregated prison admissions and investigates the spatial concentrations and levels of admissions for the entire state of Massachusetts.

Methods

Spatial regressions estimate census tract-level prison admission rates in relation to racial demographics, social and economic disadvantage, arrest rates, and violent crime; an analysis of outlier neighborhoods examines the surprisingly high admission rates in small cities.

Findings

Regression analysis yields three findings. First, incarceration is highly spatially concentrated: census tracts covering 15% of the state’s population account for half of all prison admissions. Second, across urban and non-urban areas, incarceration is strongly related to concentrated disadvantage and the share of the black population, even after controlling for arrest and crime rates. Third, the analysis shows admission rates in small urban satellite cities and suburbs comprise the highest rates in the sample and far exceed model predictions.

Conclusion

Mass incarceration emerged not just to manage distinctively urban social problems but was characteristic of a broader mode of governance evident in communities often far-removed from deep inner-city poverty. These notably high levels and concentrations in small cities should be accounted for when developing theories of concentrated disadvantage or policies designed to ameliorate the impacts of mass incarceration on communities.

     

Mental health legislation and human rights in England, Wales and the Republic of Ireland

In 2005, the World Health Organization (WHO) published its Resource Book on Mental Health, Human Rights and Legislation (Geneva: WHO) presenting a detailed statement of human rights issues which need to be addressed in national legislation relating to mental health. The purpose of this paper is to determine the extent to which revised mental health legislation in England, Wales (2007) and Ireland (2001) accords with these standards (excluding standards relating solely to children or mentally-ill offenders).Legislation in England and Wales meets 90 (54.2%) of the 166 WHO standards examined, while legislation in Ireland meets 80 standards (48.2%). Areas of high compliance include definitions of mental disorder, relatively robust procedures for involuntary admission and treatment (although provision of information remains suboptimal) and clarity regarding offences and penalties Areas of medium compliance relate to competence, capacity and consent (with a particular deficit in capacity legislation in Ireland), oversight and review (which exclude long-term voluntary patients and require more robust complaints procedures), and rules governing special treatments, seclusion and restraint. Areas of low compliance relate to promoting rights (impacting on other areas within legislation, such as information management), voluntary patients (especially non-protesting, incapacitated patients), protection of vulnerable groups and emergency treatment. The greatest single deficit in both jurisdictions relates to economic and social rights.There are four key areas in need of rectification and clarification in relation to mental health legislation in England, Wales and Ireland; these relate to (1) measures to protect and promote the rights of voluntary patients; (2) issues relating to competence, capacity and consent (especially in Ireland); (3) the role of “common law” in relation to mental health law (especially in England and Wales); and (4) the extent to which each jurisdiction wishes to protect the economic and social rights of the mentally ill through mental health legislation rather than general legislation.It is hoped that this preliminary analysis of mental health legislation will prompt deeper national audits of mental health and general law as it relates to the mentally ill, performed by multi-disciplinary committees, as recommended by the WHO.     

Perceived coercion and need for hospitalization related to psychiatric admission

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.     

Changing patterns in emergency involuntary admissions in the Netherlands in the period 2000-2004

BACKGROUND: In England, rates of involuntary admissions increased in subgroups of patients. It is unknown whether this is true in other European countries. AIMS: To establish whether the increase in emergency commitments was uniform across subgroups of patients and dangerousness criteria used to justify commitment in The Netherlands. METHOD: National data on all commitments in the period 2000-2004. RESULTS: Commitments increased from 40.2 to 46.5 (16%) per 100,000 inhabitants. Controlling for population changes in age and sex, relatively large increases were found in patients over 50 years (25-40% increase), in patients with dementia (59%), 'other organic mental disorders' (40%) and substance abuse (36%). 'Arousing aggression', increased most strongly as a dangerousness criterion for commitment (30%). CONCLUSION: Changing patterns of commitments in The Netherlands and England might indicate a wider European shift in diagnoses and reasons for admission of committed patients.     

Outcomes in a low secure unit: pre-admission and post-discharge comparisons

Empirical research seldom reports on clinical outcomes within low secure services. By comparing outcome measures prior to admission and following discharge this study aimed to investigate the care pathways of patients admitted to a low secure unit (LSU). The study was conducted in an LSU and consisted of 70 patients (54 male, 16 female). Data were collected retrospectively and analysed in relation to placement security (upon admission and discharge) and admissions to hospital. Results revealed that admissions to hospital and time spent in hospital decreased post-discharge in comparison with pre-admission. Forensic patients were found to have fewer admissions than civil patients prior to LSU admission. Some differences were also observed within gender and Mental Health Act (MHA) section status for placement security. The findings demonstrated that following treatment in a LSU, care pathways may be less restrictive than prior to admission. Further, more robust research on the outcomes of LSUs is required.     

Effects of a new commitment law on involuntary admissions and service utilization patterns

Recently Nebraska changed its commitment law to include many procedural safeguards and require behaviorally manifested dangerousness as a criterion of commitment. An interrupted time-series design was used to determine what effects the new law had on admission characteristics and service utilization patterns of all those committed to Nebraska's three state hospitals. An immediate drop in involuntary admissions was found, but this decline was temporary. Several changes in the demographic characteristics of those committed were also found. Finally, the law apparently caused an increase in the number of those having to be readmitted. These results raise questions about the implementation of the law, the perception of dangerousness, and the need for more effective liaison between state hospitals and community-based treatment facilities.     

Intrathoracic and subconjunctival petechiae in sudden infant death syndrome (SIDS)

The frequency and density of intrathoracic and subconjunctival petechiae was studied in 250 cases of SIDS and 69 controls. The control group included 37 infants with natural and 32 infants with traumatic causes of death. Intrathoracic petechiae were found significantly more frequently in the SIDS group (91.2% SIDS; 42% controls; p < 0.001) and were present at a higher density (p < 0.001). Subepicardial and thymic petechiae were detected at high density in older SIDS infants. Subconjunctival petechiae were low in density and found only in 2.4% of the SIDS group but they were detected in 8.1% of the natural death group and 21.9% (p < 0.05) of the lethal trauma group. Subconjunctival petechiae were found at highest density in strangulation. Intrathoracic petechiae are commonly found in SIDS but are not specific for SIDS. Subconjunctival petechiae are typical but not specific for strangulation. In SIDS, subconjunctival petechiae are rare and appear at low density.     

Local justice in the allocation of college admissions: A statistical study of beliefs versus practice

This study examines admission decisions at a highly selective private university. A statistical analysis of 300 admission decisions is used to compare admissions officers' beliefs about how the admissions process works with their actual pattern of decisions. As a group, the officers underestimate the effect of applicant race, gender, alumni status, and athletic ability on their academic and personality ratings and final admission decisions. Individual officers place different weights on the decision-making criteria, with the model explaining less variation in the ratings of officers with more years of experience. The comparison of beliefs with practice has implications for evaluating the distributive and procedural fairness of the college admissions process.     

Intellectual and developmental disabilities and Ontario’s forensic inpatient system: a population-based cohort study

Individuals with intellectual and developmental disabilities (IDD) in forensic inpatient beds are both complex and understudied. Previous studies have been limited and largely based on smaller clinical samples. We used data from a population-based cohort of Ontario adults with IDD (H-CARDD cohort, n?=?66,000) to describe their prevalence in forensic inpatient beds during 2005–2015 and compare their demographic and clinical profiles with non-IDD forensic patients. Results show that forensic patients with IDD and without IDD have similar profiles, with the exception that patients with IDD are more likely to have a psychiatric disorder and to be younger, rural, and have high or very high morbidity. Strong support was found for disproportionate admission: individuals with IDD are 12.2% of forensic inpatients but only 0.8% of the general population (d?=?1.57). Support for disproportionate utilization was less dramatic and mixed. Little difference was found in terms of the per cent of longer-stay (treatment) admissions or multiple forensic admissions; however, patients with IDD did have longer number of bed days over 10 years (averaging 220.6 days more, d?=?0.28). A better understanding of the barriers to discharge for individuals with IDD will support implementation of appropriate pathways out of the hospital.     

Compulsory mental health care in Norway: The treatment criterion

The Norwegian government has chosen to retain a treatment criterion in the Mental Health Care Act despite the opposition of several user organizations. From a critical user perspective, the only reason for using coercion to require mental health treatment is that the individuals are in a state where they are an immediate danger to themselves and/or their surroundings. This articles aims, first, to provide an overview of research studies concerning the benefits or harmfulness of involuntary treatment after coerced admission and, second, to evaluate studies that try to compare involuntary with voluntary treatment. A systematic overview of studies of compulsory mental health care with regard to treatment criteria, coercion in mental health, and involuntary admission published over the last decade was examined in detail, along with a secondary manual search of references cited in identified publications. Few studies have been conducted on the effect of compulsory mental health care, and the results have been contradictory. More randomized studies are needed to document the kinds of effects that the use of compulsory treatment has on treatment results. Another issue that needs further examination is whether the use of coercion should be transferred to legal bodies with an adjudicatory process.     

A profile of mentally disordered offenders admitted to inpatient psychiatric services in the United States

This research note presents data about mentally disordered offenders (MDOs) treated in inpatient psychiatric services. Data are derived from 1980 admission surveys by the Survey and Reports Branch, National Institute of Mental Health (NIMH). These data report for the first time inpatient services provided to MDOs by non-Federal general and private hospitals. A total of 31,773 MDOs were admitted, with 85% going to state and county mental hospitals. The largest group, including admissions for evaluation, was ISTs (58%), followed by mentally disordered prisoners (32%), NGRIs (8%), and MDSOs (3%). Women and whites tended to be overrepresented among MDOs as compared to prison and jail inmates. Clear diagnostic differences by legal status were found, with schizophrenia predominant among NGRIs (81%) and alcohol and drug abuse disorders more frequent among ISTs. Overall, state and county hospitals in both 1967 and 1980 were the primary locus of care for mentally disordered offenders.     

Ethical issues in child and adolescent forensic psychiatry: a review

Ethical challenges in child and adolescent forensic psychiatry arise, on the one hand, from the dilemmas commonly faced in forensic psychiatry with adult patients, such as the dual role of the forensic psychiatrist, questions of criminal responsibility, autonomy and competence and involuntary treatment, and, on the other, from the immaturity and dependent position of the minor. Child and adolescent forensic psychiatry deals with minors involved in crime, not only as offenders, but also as victims. In this review, we attempt to describe ethical challenges in child and adolescent psychiatry using as a frame of reference the principles of biomedical ethics according to Beauchamp and Childress.     

Experiences of coercion during investigation and treatment

According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n=39), or with previous experience of assessment and involuntary care (n=35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p<.05) and they were more positive towards the final decision (60% vs. 24%, p<.05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.     

Psychiatric Medication Intake in Suicide Victims: Gender Disparities and Implications for Suicide Prevention

Frequency and gender differences of psychiatric medication intake in a sample of suicide victims from the Athens Greater Area were investigated with a particular focus on the implications for suicide prevention. Data were collected from the toxicological analyses of the suicide cases of the period November 2007–October 2009. Information was available for 262 individuals, 196 men (74.8%) and 66 women (25.2%); 109 of these (41.6%) were receiving psychiatric medication(s). Women were statistically more frequently under treatment: antidepressants (32.8% vs. 11.3%, p < 0.001), antiepileptics (9.1% vs. 0.5%, p = 0.001), antipsychotics (24.2% vs. 9.2%, p = 0.003), and benzodiazepines (16.7% vs. 6.6%, p = 0.024). Campaigns aiming to bring men with psychological difficulties in contact with mental health services and to lessen the stigma of mental illness, together with better training of nonpsychiatrists into “suspecting” “male” depression, could be particularly helpful for decreasing male suicides. More thoughtful choice of psychiatric medication could possibly already prevent a number of female suicides.     

Involuntary outpatient treatment in patients with severe mental illness: A one-year follow-up study

Introduction

Involuntary outpatient treatment (IOT) aims to ensure adherence to therapy in patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.

Objectives

To evaluate the effectiveness of IOT in preventing relapse among patients with serious mental disease.

Method

A retrospective observational study was carried out on all of the patients (n = 140) receiving IOT in the city of Valencia, Spain. Hospital service uses (emergency care, admissions and mean stay times) during the 12 months before and after the introduction of IOT were compared.

Results

Patients with schizophrenia, delusional disorder or schizoaffective disorder showed a significant reduction in the number of admissions and days spent in the psychiatry ward during the year of IOT. The reduction in the number of visits to the emergency department was only significant for the patients with schizophrenia.

Discussion

We conclude that involuntary outpatient treatment may be effective for patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.     

Trends in involuntary psychiatric hospitalization in Israel 1991-2000

BACKGROUND: Though information about involuntary psychiatric hospitalizations (IPH) is crucial for the planning of Israel's National Mental Health Care Policy, very few studies have been carried out to date on this subject. AIMS: To identify trends in first IPH to all inpatient psychiatric settings in Israel. METHOD: The sample included all admissions of adults (18 years and older) over the ten-year period, 1991-2000, according to the registration of such admissions in the National Psychiatric Case Registry. RESULTS: A 2.4-fold increase was found in first IPH over the decade studied. The typical profile of the involuntarily admitted patient was that of a native-born Jewish male, aged 18-24 or 65 and older, single, with less than 8 years of education, and with a diagnosis of schizophrenia or delusional psychosis. CONCLUSIONS: These findings suggest the need for improving the interfaces between hospital and community services, and for preparing specific guidelines to extend the use of involuntary ambulatory treatment orders. Further study is needed to explore the respective roles of involuntary inpatient and outpatient treatment.     

Civil commitment in Turkey: reflections on a bill drafted by psychiatrists

Involuntary hospitalization of the mentally ill has been an issue that still remains outside the judicial system in Turkey. Despite the new Turkish Civil Code, which includes several articles relevant to involuntary psychiatric hospital admissions, there still appears to be a need for a comprehensive mental health law to address specific issues concerning civil commitment of the mentally ill. As a result of the lack of specific statutory regulation, an insufficient number of psychiatric hospital beds and limited appreciation of the safety risks involved in untreated mental illness, involuntary hospitalization remains an underutilized option by psychiatrists and the courts alike. In response to its concerned members, the Psychiatric Association of Turkey has appointed a task force to draft a proposed mental health law, entitled the "Psychiatric Patients' Bill of Rights." Although the draft suggests a model with emphasis on the right to psychiatric treatment, it also recommends close judicial oversight to prevent potential abuses of discretion by the system. However, this might present logistic problems in a country with already overburdened courts. Authors discuss the highlights of the draft within the context of Turkey's current cultural, social and judicial structure, and compare it to similar laws of other countries.     

人体皮肤索沟局部肥大细胞脱颗粒率的观察

本文观察人体皮肤索沟局部肥大细胞脱颗粒率变化。发现生前皮肤损伤局部脱颗粒率在皮肤受在处及距受压边缘０～１．０ｍｍ区域明显升高（＞４９％），与死后皮肤索沟有显著差异（Ｐ＜０．００１）。作者认为损伤局部肥大细胞脱颗粒率明显升高（＞４９％）可作为人体生前索沟的诊断依据。     

略论价值生成和发展的规律——兼论创建人类共同价值观体系的途径

价值是主客体之间需要与满足关系的产物。主体有人类整体、人类整体之下的群体以及人类个体三个层次 ,与之相应 ,客体也包括与人类整体相对的外部世界 (群体 +个体 +人以外的世界 )、与人类群体相对的外部世界以及与人类个体相对的外部世界。因而不仅物具有价值 ,人亦有价值。由于人自身是主客体的统一 ,因而人还有自我价值。构成价值的各个要素相互作用决定价值的生成、推动价值的变化 ,这是 (哲学 )价值规律的基本内容。影响价值变化的主要有主体需要、客体属性及实践三个要素。价值观念冲突的最终根源在于人类主体生存条件之差别和对立 ,直接根源则在于价值客体的差别和对立。因而要逐步消除人类价值观念的冲突就必须从根本上消除人类主体生存条件方面的差别做起