The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.
BackgroundCompulsory admissions have a strong effect on psychiatric patients and represent a deprivation of personal liberty. Although the rate of such admissions is tending to rise in several Western countries, there is little qualitative research on the mental health-care process preceding compulsory admission. The objective of the study was to identify crucial factors in the mental health-care process preceding compulsory admission of adult psychiatric patients.MethodsThis retrospective, qualitative multiple-case study was based on the patient records of patients with severe mental illness, mainly schizophrenia and other psychotic disorders. Twenty two patient records were analyzed. Patients’ demographic and clinical characteristics were heterogeneous. All were treated by Flexible Assertive Community Treatment teams (FACT teams) at two mental health institutions in the greater Rotterdam area in the Netherlands and had a compulsory admission in a predefined inclusion period. The data were analyzed according to the Prevention and Recovery System for Monitoring and Analysis (PRISMA) method, assessing acts, events, conditions, and circumstances, failing protective barriers and protective recovery factors.ResultsThe most important patient factors in the process preceding compulsory admission were psychosis, aggression, lack of insight, care avoidance, and unauthorized reduction or cessation of medication. Neither were health-care professionals as assertive as they could be in managing early signs of relapse and care avoidance of these particular patients.ConclusionThe health-care process preceding compulsory admission is complex, being influenced by acts, events, conditions and circumstances, failing barriers, and protective factors. The most crucial factors are patients’ lack of insight and cessation of medication, and health-care professionals’ lack of assertiveness.Electronic supplementary materialThe online version of this article (10.1186/s12888-017-1512-y) contains supplementary material, which is available to authorized users.
Background The characteristics of patients who have repeated compulsory psychiatric admissions are largely unknown. Aims To investigate the frequency and risk factors for repeated emergency compulsory psychiatric admission (ECPA); and to identify targets for interventions to reduce repeated ECPA. Method Data were collected from a database of electronic patient files (EPFs) held by three psychiatric emergency services (PES) in the Netherlands. Analyses were based on the data for adult patients (aged 18–75 years) with a first PES contact in 2010–2015. Using descriptive statistics and regression analysis, we studied the associations between baseline patient factors and repeated ECPA and time to readmission, within a 2-year follow-up period. Results We included 6059 patients: 15.6% had two or more ECPAs. In total, 66% of second ECPAs had occurred within 6 months of the first. About 30% of all ECPAs were repeated ECPAs. Two baseline factors were associated with a higher frequency of a second ECPA: history of receiving any mental healthcare treatment, whether in-patient or out-patient or both, and a lower level of self-care. Three were associated with a lower frequency: ethnicity (other than Dutch), older age and suicidality. Lower Global Assessment of Functioning (GAF) scores and housing problems were associated with a shorter time to compulsory readmission and persistent psychiatric problems with a longer time to compulsory readmission. Conclusions We found that 15.6% of patients had two or more ECPAs. Two-thirds of the second ECPAs had occurred within 6 months of the first. Like earlier studies, the risk factors we identified suggest that interventions to reduce the risk of repeated compulsory psychiatric admission should seek to improve self-care, general daily functioning and homelessness.
To the Editor JAMA Psychiatry recently published an important systematic review and meta-analysis by de Jong et al. 1 We want to congratulate the authors on this highly needed work and fully agree that lowering compulsory admissions constitutes a crucial issue to ensure optimal psychiatric treatment. However, we would like to point out 2 problems with their approach.First, to obtain results at the highest evidence level, they opted to include randomized clinical trials only. De Jong et al 1 "found only 13 [randomized clinical trials]" and stated that "this number is both small and disappointing." Although we agree that-considering the importance of the topic-there should be considerably more studies available, they excluded a large part of the literature because of their inclusion criteria. Also, randomized clinical trials might be limited in their ability to assess the overall effect of a change in mental health care policies on involuntary admissions. Based on the intricacy of the questions at hand, quasiexperimental and naturalistic studies seem to be more useful study designs for evaluating complex interventions, such as involuntary commitment, while maintaining ecological validity. 2 Therefore, we recommend that future systematic reviews and metaanalyses use a broader scope, enabling a more thorough overview of the field.Second, the authors analyzed important candidate interventions to reduce forced hospital admissions. However, analyzing isolated inter ventions alone, while ignoring the specific mental health care setting, w ill mask the possible benefic ial effec ts. Only an overall reduction in coercive measures within a particular mental health care system will lead to a reduction in compulsory psychiatric admissions. As an example, opendoor policies on psychiatric wards lead to a reduction of compulsory measures, including seclusion, restraint, and forced medication. 3 However, open-door policies n o t o n l y h ave a n i m m e d i ate e f fe c t o n t h e w a rd's atmosphere, but also lead to better acceptance of the psychiatric facilities, mental health care professionals, and treatment. 4 These advantages are not reduced by increased danger for the patients or others, as a recent study showed no significant differences regarding suicide and absconding. 5 Hence, a less-restrictive therapeutic environment will enhance the patients' collaboration and might ultimately reduce the need for involuntary admissions. Future research should also focus on embedding the interventions in an overall mental health care setting. We are convinced that interventions currently not showing significant benefits might do so if part of an open and empowering clinical environment.
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