Factors associated with disallowance of compulsory mental healthcare referrals

Abstract

ObjectiveNorwegian studies report that a substantial amount of referrals for compulsory mental health care are disallowed at specialist assessment, at a rate that varies with referring agent. Knowledge on factors associated with disallowance could improve the practice of compulsory mental health care. This study aims to examine such factors, placing particular emphasis on the impact of referring agents.MethodThis study utilized data from the prospective, longitudinal cohort study ‘Suicidality in Psychiatric Emergency Admissions’ conducted at a Norwegian psychiatric emergency unit which served approximately 400 000 inhabitants. Data on referral, admission and patient characteristics were retrieved on compulsory admissions conducted between 1 May 2005 and 30 April 2008. Bivariate and logistic regression analyses and structural multilevel modelling were performed.ResultsAmong 2813 compulsory admissions, 764 were disallowed. Low competence in the referring agent, high GAF S score, observed alcohol or drug intoxication, reported suicide risk, and the presence of neurotic, stress‐related and somatoform disorders, personality disorders and other non‐specified diagnoses were associated with above average disallowance frequency. Non‐Norwegian ethnicity and schizophrenia spectrum disorders were associated with below average disallowance rates.ConclusionAmong several factors associated with disallowance, low symptom load was the strongest, whilst referring agent competence modestly affected disallowance rate.

Involuntary admission in Norwegian adult psychiatric hospitals: a systematic review

“…Eleven studies [ 26 , 27 , 44 – 52 ] examined the topic of the referral and/or the admission of involuntary patients to psychiatric hospitals. The studies were primarily based on the examination of medical records [ 44 – 48 , 52 ] or on interviews with referring GPs [ 26 , 49 – 51 ] or admitting specialists [ 27 ]. In this category, two of the 11 studies were qualitative [ 26 , 27 ].…”

“…The most frequent expectations for the involuntary admissions are the starting of treatment with neuroleptics and taking care of the patient [ 51 ]. While one study found that referring GPs and admitting specialists were mostly in agreement [ 45 ], other studies had found that 27% [ 52 ], 45% [ 46 ], and 54% [ 44 ] were disallowed, i.e. either admitted voluntarily or not admitted at all.…”

“…One study showed that those who were not received involuntarily had shorter stays [ 44 ]. Factors that have been found to predict disallowance were: less symptoms, neurotic and personality disorders, suicide risk, intoxication, and low referring agent competence [ 52 ]. One study [ 27 ] found that admitting specialists expressed a paternalistic attitude.…”

Characteristics of Psychiatric Emergency Situations and the Decision-Making Process Leading to Involuntary Admission

“…The proportion of residents among psychiatric participants was much smaller and the few psychiatric residents had much more clinical experience (in years) compared to non-psychiatric participants. Clinical routine experience with IA has been discussed to elevate process quality, and the need for more specific training in the field of IA has been mentioned (30, 32, 37). Our findings suggest that training for residents working in internal medicine is likely to have a big impact on the process quality of IA in the canton of Zurich.…”

“…As the gatekeeper to IA, the physician has a crucial role in implementing legal regulations (27) and weighing risks and benefits of involuntary care for the individual patient (28, 29). Studies indicate that the referring physician's experience or competence with psychiatric emergency situations may be associated with disallowance rate and time to discharge (30–32). It has been shown that referring general practitioners find it difficult to apply the legal criteria and assess the necessity for involuntary care (33, 34).…”