Priv.-Doz., Mental Health Services Research Unit
Priv.-Doz., Forensic Department, Central Institute of Mental Health, Mannheim, Germany
Correspondence: Dr Hans Joachim Salize, Mental Health Services Research Unit, Central Institute of Mental Health, J5, D-68159 Mannheim, Germany
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To give an overview of compulsory admission data from official sources across the European Union (EU).
Method Data on the legal frameworks for involuntary placement or treatment of people with mental illness and their outcomes were provided and assessed by experts from all EU member states.
Results Total frequencies of admission and compulsory admission rates vary remarkably across the EU. Variation hints at the influence of differences in legal frameworks or procedures. Time series suggest an overall tendency towards more or less stable quotas in most member states.
Conclusions Further research is greatly needed in this field. Common international health reporting standards are essential to the compilation of basic data.
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INTRODUCTION |
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In the search for predictive factors for compulsory admission rates, some socio-demographic characteristics have been identified as increasing the risk of being placed involuntarily (Gove & Fain, 1977; Mahler & Co, 1984; Dunn & Fahy, 1990; Davies et al, 1996; Sanguineti et al, 1996; Singh et al, 1998; Crisanti & Love, 2001), although some of the findings are contradictory (Szmulker et al, 1981; Nicholson, 1988; Tremblay et al, 1994). All in all, the scarcity of data and the variety of controversial research results may be attributed to a complex set of poorly understood legal, political, economical, social, medical, methodological and other factors interacting in the process. Rapid European integration requires valid overviews and a sound database for increased research concerning this most controversial and important issue.
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METHOD |
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Information on the legislation and practice of involuntary placement and treatment in the EU states was gathered by means of a detailed questionnaire. This questionnaire included 80 items addressing four main areas: legislation, practice, patients' rights and epidemiology. It covered aspects such as criteria for compulsory admission, procedures of decision-making, time frames, regulations for compulsory treatment or other coercive measures, quality assurance aspects, complaint procedures and epidemiological data. A draft of the questionnaire was evaluated and revised by a core group of experts before distribution, and tested in a pilot study in Germany. The final version of the questionnaire was filled in by selected experts (psychiatrists) from all EU member states. An expert meeting to discuss the preliminary results was held in Germany in November 2001. Experts were asked to collect epidemiological data from official sources (national health reports, statistical bureaus, etc.), thus relying on the definitions of terms such as episode, preliminary detention and compulsory admission.
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RESULTS |
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Availability of data
Experts from five countries reported the absence of an official institution
or agency responsible for gathering or providing nationwide data on compulsory
admission numbers or rates at the time of the study (Austria, Germany, Greece,
Italy and Spain). Some countries do record such data, although it may not be
available to the public, as in Belgium. In some other countries, nationwide
registers were implemented only recently (e.g. Portugal). Most of the data in
our study were taken from these agencies or institutions, in some cases
supplemented by information from other sources. In detail, data were obtained
from Belgium (national and regional departments), Denmark (Danish Psychiatric
Case Register, Århus University and the National Board of Health),
Finland (National Research and Development Centre for Welfare and Health
(STAKES)), France (Ministère Chargé de la Santé),
Ireland, (Health Board), The Netherlands (Geeste-lijke Gezondheidszorg
Nederland, Utrecht), Luxembourg (Department of Health), Portugal (Commission
for the Supervision of the Mental Health Law), Sweden (National Board of
Health and Welfare) and the United Kingdom (Department of Health). In the case
of Austria, data were requested from the Ministry of Health. The German
Department of Justice provided the number of applications for involuntary
placements, owing to the unavailability of information on legally confirmed
compulsory admissions. From Italy, selected regional data for the province of
Lombardy were forwarded. For Greece and Spain, epidemiological data were
completely unavailable.
Frequency of compulsory admission
Table 1 shows the most
recently available national data on frequency and percentages of involuntary
placements of people with mental disorder across the EU. Total numbers differ
considerably, but there are also remarkable differences in commitment rates
(annual number of compulsory admissions per 100 000 population) and quotas
(percentage of all psychiatric admissions), which are more appropriate for
comparing indicators between countries.
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In addition, time series for involuntary placements during the past decade were assessed. The availability of these data were better than expected. Only Greece, Italy and Spain were unable to provide nationwide data from the 1990s. Contributions from Belgium and Portugal cover only short periods from the late 1990s, and all other states provided continuous annual frequencies. Not surprisingly, France, Germany and the UK, being the most populous countries, reported the most frequent involuntary placements. These series are displayed using separate scales (Figs 1 and 2).
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Total annual frequencies are presented here to demonstrate national trends over time and might be appropriate for analysing changes in policies within a particular country. For comparisons between countries, weighted data as percentages of involuntary placements on all psychiatric admissions (quotas) must be used (Table 2). Despite reduced reliability or validity in some cases, time series suggest that in most member states involuntary placement quotas have remained more or less stable during the past decade, or even have decreased in some countries. This finding is in contrast to the increasing numbers of involuntary placements as shown in Figs 1 and 2, and does not confirm an overall trend of increasing compulsory admissions.
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Correlation with procedural features
Certain procedural regulations from the variety of assessed characteristics
of national laws (qualitative data) were selected to analyse possible
correlations with compulsory admission rates or quotas
(Table 2). Among these
characteristics, the legally defined set of conditions required for compulsory
detention or treatment is a major feature. Although the laws of all EU member
states stipulate a confirmed mental disorder as a major condition for
detention, additional criteria are heterogeneous. Threatened or actual danger
to oneself or to others is the most common additional criterion across the EU,
but is not a prerequisite in Italy, Spain or Sweden. Among countries
stipulating the need for treatment (the second most common criterion),
Denmark, Finland, Greece, Ireland, Portugal and the UK consider the danger
criterion to be sufficient on its own. Some countries emphasise a lack of
insight by the patient, additionally. No significant correlation could be
identified with compulsory admission quotas or rates when comparing countries
applying the danger or need for treatment
criterion.
In ten member states, the final decision on involuntary placement is made by a non-medical authority, either a representative of the legal system (judge, prosecutor, mayor) or another agency independent of the medical system. In the remaining member states the decision is left to psychiatrists or other health care professionals (Table 3). Compulsory admission quotas and compulsory admission rates did not differ significantly between these countries.
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The mandatory notification of relatives or other persons in case of a compulsory admission is a basic civil right. According to the laws of six member states, notification or inclusion of a legal representative of the patient (e.g. advocate, counsellor or social worker) into the procedure is mandatory. Member states with obligatory inclusion of a legal representative showed significantly lower compulsory admission quotas (P=0.03, Mann-Whitney U-test) and a trend towards lower compulsory admission rates (P=0.14, Mann-Whitney U-test).
Mental disorders and socio-demographic characteristics of detained patients
A third of the EU member states were able to provide diagnostic profiles of
involuntarily placed persons. Despite a non-standardised usage of diagnostic
categories, the specified mental disorders might provide a rough indicator of
which patient groups are given priority for involuntary placement in the
various countries. The largest group being admitted involuntarily are people
with severe and chronic mental disorders such as schizophrenia or other
psychoses, accounting for 30-50% of all involuntary placements in states that
provided diagnostic data (Table
4). The proportions of groups with other diagnoses, such as
dementia, affective disorders or substance misuse, differ remarkably. The
occurrence in the table of conditions other than these most severe mental
disorders is remarkably frequent. Unfortunately, details for these remaining
patient groups (type of disorder, severity) were not available.
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Information about the socio-demographic characteristics of involuntarily admitted patients is as scarce as the psychopathological background information. Even the most basic gender data were available from only nine countries, five of which showed a tendency to place male patients more often involuntarily than females (Belgium, France, Ireland, Luxembourg and The Netherlands; Table 4). An overrepresentation of male patients might serve as a rough indicator that danger is the prime consideration in involuntary placement, since men with mental illness reportedly are more likely than women to show dangerous behaviour. However, for a valid comparison, the proportion of compulsorily admitted males should have been tested against the proportion of total admissions of males to psychiatric in-patient care in each country. Unfortunately, these data were not available.
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DISCUSSION |
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Trends in compulsory admission rates
Whereas variations in the frequencies of annual compulsory admissions of
people with mental illness are not surprising in view of the different
population sizes of EU countries, compulsory admission rates (annual
admissions per 100 000 population) vary remarkably, too. Rates ranging from a
mere 6 annual compulsory admissions per 100 000 population in Portugal to 218
in Finland (see Table 1)
strongly hint at differences in definitions, legal backgrounds, or procedures.
Comparison of the time series of compulsory admission quotas during the past
decade reveals a slightly more homogeneous pattern, suggesting an overall
tendency towards more or less stable quotas in most countries (see
Table 2). This finding
contradicts conclusions indicating an overall international trend towards
increasing numbers of compulsory admissions. Similar assumptions might arise
from this study too if compulsory admissions are considered in isolation, as
total numbers were found to be increasing in Germany, France, England,
Austria, Sweden and Finland (see Figs
1 and
2). However, the increasing
number of compulsory admissions seems to be balanced by the effects of
internationally changing patterns of mental health care delivery, which
shortens the mean length of in-patient stay at the expense of more frequent
readmissions.
The finding of significantly lower compulsory admission quotas in member states stipulating the inclusion of an independent counsel into the procedure suggests further analyses. At the moment it can only be postulated that better legal support for patients might contribute to lower compulsory admission rates or quotas, since we are not able to control for the real number of patients who are compulsorily detained without any legal representation.
Diagnostic and socio-demographic profiles of involuntarily placed patients
The limited data on diagnostic patterns or socio-demographic
characteristics of compulsorily admitted patients submitted by some EU member
states also suggest further analyses. Overall, schizophrenia and related
disorders seem be the predominant diagnosis in countries that were able to
provide diagnostic overviews, without giving a clear hint as to a correlation
with any legal or procedural approach. However, analysis of the gender of
compulsorily admitted patients indicates that countries preferring the
danger criterion appear to place more male patients
involuntarily than female. This pattern might reflect general findings that
mentally ill men are more violent, and thus are selected more frequently for
compulsory admission when the danger criterion is applied.
Whether this result indicates any real influence of the criteria on the gender
of compulsorily admitted populations has to be confirmed in further analyses,
through controlling the proportion of compulsorily admitted men by the overall
gender proportion of psychiatric in-patients in the respective EU member
states.
Consequences for health reporting
All in all, results of this study show the strong necessity for further
research in this field. Internationally standardised and annually updated
involuntary placement rates on a national level (detailing a number of basic
items, such as regular or emergency admission as well as socio-demographic and
diagnostic characteristics) are fundamental to the evaluation of national as
well as Europe-wide policies. The improvement of common international
standards of mental health reporting seems to be essential, at least within
the EU, to guarantee valid overviews for the future and provide a basis for
more detailed research in the field.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication February 3, 2003. Revision received June 9, 2003. Accepted for publication June 19, 2003.