From a Contributing Editor, Colleague and Friend of the Editor
All of us psychiatrists have exercised our responsibility for the involuntary admission of patients. Some patients (and many families) have expressed gratitude for this temporary but fundamental abrogation of civil freedoms – the freedom of movement – but for many patients it may be a source of fear and of loss of control and autonomy (even though the illnesses that they are experiencing also undermine control and autonomy). It may also reflect an upstream failure of less intrusive and earlier interventions to treat mental illness.
In an era of being patient-centred and recovery-focused, is a reduction in rates of involuntary hospitalization desirable? If you’re a human rights lawyer, the answer may be “well, yes, obviously”. If you’re a clinician, the answer may be “that depends on whether the patient ends up better or worse”. Nevertheless, there are a number of clinical initiatives in place whose goal would be to reduce the frequency of involuntary hospitalization (which does not preclude an increase in the rate of voluntary hospitalization).
So along comes a careful systematic review and meta-analysis of randomized trials to examine four categories of intervention that have, as their explicit primary or secondary outcome, a reduction in the rates of involuntary admission to psychiatric inpatient units. The interventions will seem familiar to any reader who has been involved in the care of people with severe and persistent mental illness. But the results are surprising.
– David Goldbloom, OC, MD, FRCP(C)
Compulsory Hospitalizations and Options
“Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-Analysis”
Mark H. de Jong, Astrid M. Kamperman, Margreet Oorschot, Stefan Priebe, Wichor Bramer, Roland van de Sande, Arthur R. Van Gool, Cornelis L. Mulder
JAMA Psychiatry, published online 1 June 2016
For various reasons, compulsory admissions of psychiatric patients should be prevented as far as possible. Being compulsorily admitted has a strong effect on patients and their relatives and can be traumatic. A European multicenter study showed that 30% to 50% of patients who have been compulsorily admitted undergo coercive interventions, such as enforced medication, seclusion, and restraint. Although the exact definition of compulsory admission might differ from country to country depending on the judicial context, a compulsory admission is always an admission against the will of the patient (according to local judicial procedures). Compulsory admission also conflicts with principles of autonomy, shared decision making, and recovery-focused care. Fear of coercion may keep patients away from treatment. However, the consequences of compulsory admissions are not exclusively negative: they have also been associated with improvements in psychosocial functioning and better motivation for treatment. In cases of severe danger to self or others caused by a psychiatric condition, compulsory admission is commonly seen as justified and required.
Rates of compulsory admissions across the European Union range from only 6 per 100 000 in Portugal to just above 200 per 100 000 in Finland, but it is important to realize that differences in laws, regulations, and mental health care services make a direct comparison between the countries difficult. Although recent numbers for most countries are not available, rates in several European countries are tending to rise, albeit for reasons that are largely unknown. In England—where, as in many other countries, many patients have been moved from large institutions into the community—the reduction in the number of mental illness beds has been accompanied by a rise in compulsory admissions.
In Western societies, tolerance of deviant behavior by psychiatric patients in the community seems to be decreasing, parallel to an increasing emphasis on autonomy and rights of patients and to strictly defined and regulated coercive measures. Recently, the United Nations Convention on the Rights of Persons With Disabilities stated that “the existence of a disability shall in no case justify a deprivation of liberty,” and it has been argued that involuntary treatment, regardless of whether patients have a mental or physical illness, would be allowed only if a person’s decision-making capability for a specific treatment decision is impaired. Interventions that prevent patients from being compulsorily admitted are urgently needed.
So opens a paper by Dr. Mark H. de Jong et al.
The authors sifted through thousands of studies to identify 13 randomized clinical trials involving almost 3,000 subjects, and looked at the impact of four types of intervention:
1. Advance statements (including advance directives and joint crisis plans): these range from unilateral statements by patients of their prior expressed wishes to collaborative development of plans for the next crisis between patients and providers.
2. Community treatment orders: this enhancement to mental health legislation is now pervasive throughout Western jurisdictions and generally is advocated as a less restrictive alternative to involuntary hospitalization; that being said, it cannot result in physical force to comply with treatment; non-compliance may trigger involuntary return to hospital for assessment.
3. Compliance enhancement: this includes treatment that is individually tailored to address the reasons for someone’s non-compliance, as well as a randomized trial of offering patients approximately $30 for every depot (long acting) antipsychotic injection they received.
4. Augmentation of standard care: this includes a 24-hour crisis team in addition to usual care.
What did they find?
Of the four intervention categories, only advance statements significantly reduced the risk of involuntary hospitalization by 23%.
What does this mean?
Perhaps it is easier to say what this doesn’t mean.
1. It doesn’t mean that patients get better with advance directives and joint crisis plans, because clinical outcomes (or satisfaction with care or therapeutic alliance) were not measured in this meta-analysis. Neither were perceptions of coercion.
2. It doesn’t even mean that patients were hospitalized less frequently; it is entirely possible that advance directives may lead to better engagement for voluntary admission.
These caveats aside, I think it does mean that we need to look more seriously at the place of advance directives and documented joint crisis plans for our severely ill patients who do require recurrent hospitalization. Indeed, this was the subject of the accompanying editorial:
“Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission”
Graham Thornicroft, Claire Henderson
JAMA Psychiatry, published online 1 June 2016
The article by de Jong et al in this issue of JAMA Psychiatry raises fundamental questions about the practice of psychiatry. In essence, the review finds that advance statements can reduce the occurrence of compulsory admissions by approximately one-quarter, while community treatment orders, medication compliance enhancement, and integrated treatment measures were ineffective in reducing compulsory admissions.
Dr. Thornicroft is a British psychiatrist who has done important scholarly work in the area of stigma reduction and mental health policy. He and his co-author wisely point out that “advance statements” is an umbrella term reflecting a spectrum, from absolute patient autonomy to clinician-determined treatment planning, with shared decision making and joint crisis plans where an external facilitator helps complete the plan somewhere in the middle of these extremes; there is no persuasive evidence yet that such crisis plans reduce involuntary hospitalizations in clinical trials, despite the current meta-analysis results reflecting the broader category of advance statements. As a result, it is difficult to isolate the critical factor within the advance statements category that accounts for the striking result.
We are living in a larger context of greater emphasis on patient preference and values, which includes what they would wish to happen if they were to get ill again. Eminent psychologist and bipolar disorder authority Kay Redfield Jamison, in her memoir of her own bipolar disorder, has her inpatient unit, treatment team and mode of treatment all laid out.
How often are we having the conversation with our patients about “What would you like to see happen if you get sick again?”
I suspect the answer is still clear: not enough. Involuntary admission remains, in my view, an important tool and one that exists in virtually every democracy. But if patients can get help and get better without it, how is that not a good thing?
Kay Redfield Jamison’s autobiographical book is worth reading. An Unquiet Mind: A Memoir of Moods and Madness can be found at bookstores, including Caversham Booksellers.
Reading of the Week. Every week we pick articles and papers from the world of Psychiatry.