International Journal of Law and Psychiatry 57 (2018) 17–23

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International Journal of Law and Psychiatry

Variations in involuntary admission rates at three psychiatry centres in the Involuntary Admission Study (DIAS): Can the differences be explained?

Emmanuel Umama-Agada a, Muhammad Asghar a, Aoife Curley a, Jane Gilhooley b, Richard M. Duffy a, Brendan D. Kelly a,⁎ a Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Hospital, Dublin D24 NR0A, Ireland b St. Patrick's University Hospital, James Street, Dublin D08 K7YW, Ireland article info abstract

Article history: Involuntary psychiatric admission is an established practice for patients who are acutely or severely mentally ill Received 25 May 2017 but the factors contributing to involuntary (as opposed to voluntary) admission are not fully clear. Nor is it clear Received in revised form 12 December 2017 why rates of involuntary admission often vary between hospitals within the same jurisdiction. We studied all Accepted 12 December 2017 admissions, voluntary and involuntary, in three inpatient psychiatry units in Dublin, Ireland, which cover a Available online xxxx population of 552,019 people, over a one-year period (1 July 2014 until 30 June 2015, inclusive), as part of the Dublin Involuntary Admission Study (DIAS). During the study period, there was a total of 1136 admissions to Keywords: Mental disorders these three units, of which 17% were involuntary for all or part of their admission. The overall admission rate Commitment (205.8 admissions per 100,000 population per year) was lower than the national rate (387.9) but this varied sub- Legislation and jurisprudence stantially across the three units studied. On multi-variable analysis, involuntary admission status was associated Social control with male gender, being unmarried, and a diagnosis of schizophrenia, and was not significantly associated with age, occupation or which inpatient unit the person was admitted to. We conclude that variations in involuntary admission rates between different psychiatry admission units in Dublin are significantly explained by patient- level variables (such as gender, marital status and diagnosis) rather than centre-level variables, but that much of the variation in admission status between patients remains unexplained. Future, multi-level research could usefully focus on other patient-level factors of possible relevance (e.g. symptom severity), centre-level factors (e.g. local mental health service resourcing) and community-level factors (e.g. socio-economic circumstances in different areas) in order to further elucidate unexplained variance in admission status between patients. © 2018 Elsevier Ltd. All rights reserved.

1. Introduction national legislation and local service delivery structures (Salize & Dressing, 2004). Variations in detention rates across Europe appear to Involuntary psychiatric admission and treatment is an established be influenced by a broad range of factors including professionals' ethics practice in many countries, for patients who are acutely or severely and attitudes, sociodemographic variables, public preoccupation with mentally ill. Owing to mental illness, such patients may be unable to rec- apparent risk arising from mental illness, and differing legal frameworks ognise the need for inpatient care and are therefore admitted involun- (Zinkler & Priebe, 2002). tarily under mental health legislation. In most countries, the process of Against this background, a variety of factors have been associated involuntary admission involves a combination of clinical assessments with involuntary as opposed to voluntary admission status. The and specific legal procedures to ensure care is provided and rights are Amsterdam Studies of Acute Psychiatry (ASAP), for example, showed respected (Gostin, Bartlett, Fennell, McHale, & Mackay, 2010). that police referral (as opposed to medical referral) and a diagnosis of Rates of involuntary admission vary significantly across different psychosis (as opposed to other mental illness) were associated with in- countries and within countries owing, at least in part, to differences in voluntary rather than voluntary admission (Van der Post, Mulder, Schoevers, Dekker, & Beekman, 2012). This is consistent with much of the international literature (Curley et al., 2016), although ethnic background was not associated with admission status in the ASAP stud- ⁎ Corresponding author. ies, after controlling for socio-demographic characteristics, diagnosis, E-mail addresses: [email protected] (E. Umama-Agada), [email protected] (M. Asghar), [email protected] (A. Curley), referral pattern and psychiatric treatment history. [email protected] (J. Gilhooley), [email protected] (R.M. Duffy), In Ireland, legislation governing involuntary admission was radically [email protected] (B.D. Kelly). revised over the past two decades to bring practice more in line with

https://doi.org/10.1016/j.ijlp.2017.12.007 0160-2527/© 2018 Elsevier Ltd. All rights reserved. 18 E. Umama-Agada et al. / International Journal of Law and Psychiatry 57 (2018) 17–23 international human rights standards, through the Mental Health Act 2. Methods 2001, which was fully implemented in November 2006 (Kelly, 2007). This legislation has had a significant and generally positive impact on 2.1. Setting mental health services in Ireland (Kelly, 2016) and is outlined in detail by Ng and Kelly (2012). We studied all admissions over a one-year period (1 July 2014 until In 2014, there were 17,797 admissions to Irish psychiatric units and 30 June 2015, inclusive) at three Dublin adult psychiatry inpatient units: hospitals, yielding a rate of 387.9 admissions per 100,000 population in St Aloysius Ward in the Mater Misericordiae University Hospital, Dublin that year (Daly & Walsh, 2015). Of these, 2066 admissions (11.6%) were (Dublin's north inner-city); the Acute Psychiatric Unit in Tallaght involuntary, yielding an involuntary admission rate of 45.0 per 100,000 Hospital, Dublin (south west Dublin city); and the Ashlin Centre in population per year. Beaumont Hospital, Dublin (north Dublin city). All three inpatient The rate of involuntary admission is not, however, uniform across units are co-located with large general hospitals (i.e. with medical and different parts of Ireland and even across different parts of Dublin surgical patients) in Dublin city. All three units are psychiatry inpatient city. Between 2007 and 2011, for example, the rate of involuntary ad- facilities or wards in which adults (aged 18 years or over) receive care mission in south west Dublin city was 33.8 per 100,000 population for acute mental illness. Occasionally children (i.e. people aged under per year, which was significantly lower than the national rate for 18 years) are admitted, when there are no appropriate child and adoles- that period (48.6 per 100,000 population per year) (McManus, cent inpatient facilities available. All three units treat voluntary patients McDonnell, & Whitty, 2015). By contrast, the involuntary admission and involuntary patients detained under Ireland's Mental Health Act rate in Dublin's north inner-city between 2008 and 2014 was 71.2 2001 (Ng & Kelly, 2012). per 100,000 population per year, which was significantly higher Ireland's public mental health service is arranged on a strict than the national rate for that period and the rate in in south west “catchment area” basis, so that all public (non-fee-paying) psychiatry Dublin city (Curley et al., 2016). admissions of individuals resident within the geographical catchment It is difficult to explain this difference in rates within the same areas of these three mental health services must occur in these jurisdiction. Factors known to be associated with involuntary ad- admission units, thus enhancing the completeness of these samples. mission in Ireland include male gender, diagnosis of schizophrenia Together, the three units included in this study cover a population of or related disorders (Cunningham, 2012), and reduced insight 552,019 people in Dublin. (Kelly et al., 2004). Socio-economic deprivation is also significant St Aloysius Ward in the Mater Misericordiae University Hospital in Ireland and elsewhere (Bindman, Tighe, Thornicroft, & Leese, is an acute adult psychiatry inpatient unit with 15 beds. The Mater 2002), but even when the involuntary admission rate for north Catchment Area Adult Psychiatry Service is provided by the Mater inner-city Dublin was adjusted to take account of the fact that Misericordiae University Hospital (a voluntary hospital, funded but this is the most socio-economically deprived catchment area in not run by the Irish government), the Health Service Executive (HSE; Ireland, the adjusted involuntary admission rate (54.8 per Ireland's governmental provider of free mental health care) and St 100,000 population per year) was still higher than the national Vincent's Hospital, Fairview (another voluntary hospital). This service rate and substantially higher than that in south west Dublin city covers an inner-city catchment area of 31,100 people. (Curley et al., 2016). The Acute Psychiatric Unit in Tallaght Hospital is an acute adult There is limited literature on reasons underpinning variations in psychiatry inpatient unit with 52 beds. It is the admission unit for the rates of involuntary admission between hospitals in the same juris- Dublin South West and West Mental Health Service, a HSE general diction, although international studies suggest that the magnitude adult psychiatry service serving a catchment area of 273,419 people. of variation in other countries is similar to that in Ireland (Braam This mental health service includes four multidisciplinary general adult et al., 2016; Health and Social Care Information Centre, 2015). In psychiatry teams, one old age psychiatry service and one rehabilitation/ Norway, regional differences have been linked to variations in diag- assertive outreach service. nosis, with severe mental illness associated with involuntary admis- The Ashlin Centre is the Acute Admissions Unit for the North Dublin sion status (Hatling, Krogen, & Ulleberg, 2002). In Zurich, variations Mental Health Service with 44 beds (six of which are dedicated to old in rates of use of coercive measures (involuntary admission, seclu- age psychiatry). It provides inpatient care for a total of approximately sion/restraint, and coerced medication) across hospitals were also 247,500 people in seven sectors: Swords (77,000 people), linked with severity of mental illness, but the researchers addition- (55,600), (21,000), (14,000), West ally found that patient-level factors did not seem to explain the dif- (27,400), Kilbarrack East (36,500), and Killester (16,000). ferences in full (Lay, Nordt, & Rössler, 2011). Earlier research suggested that centre effects might explain such variations 2.2. Data collection (Bindman et al., 2002; Hansson et al., 1999) but in Zurich size of hos- pital, length of inpatient stay, and workload of nursing staff had For all admissions to these three psychiatry inpatient units between weak effects on rates of detention, and bed occupancy rate had no ef- 1 July 2014 and 30 June 2015, inclusive, we recorded gender, date of fect. As a result, the variation in involuntary admission rates between birth, occupation, marital status, date of admission, and date of dis- hospitals within countries remains, in large part, unexplained. charge. We recorded clinical discharge diagnosis using the International Against this background, we aimed in the present study to compare Classification of Diseases, Volume 10 (World Health Organization, involuntary admission rates in three Dublin adult psychiatry admission 1992). units, including units previously studied individually in south west For patients whose status was involuntary for part or all of their Dublin city and Dublin's north inner-city, and one additional, previously admission, we recorded the date their status became involuntary and unstudied service in north Dublin city, in order to see if similar differ- the criteria upon which this was based, as outlined in section 3(1) of ences in involuntary admission rates persist in Dublin and, if so, why. the Mental Health Act 2001, as follows: (a) “because of the illness, More specifically, as part of the Dublin Involuntary Admission Study disability or dementia, there is a serious likelihood of the person (DIAS) (Gilhooley et al., 2017; Kelly, Duffy, & Curley, 2017), we aimed concerned causing immediate and serious harm to himself or herself to assess rates of voluntary and involuntary admission in these three ad- or to other persons” (the “risk criterion”); (b) “because of the severity mission units over a one-year period; to compare these with national of the illness, disability or dementia, the judgement of the person con- figures; and to use individual-level demographic and clinical data to cerned is so impaired that failure to admit the person to an approved try to explain any differences in involuntary admission rates across centre would be likely to lead to a serious deterioration in his or her con- these three units. dition or would prevent the administration of appropriate treatment Download English Version: https://daneshyari.com/en/article/6554513

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