Psychology › Clinical Psychology

Healthcare Decision-Making and Restraints

Works Count: 34660

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Description

This cluster of papers focuses on the assessment of decisional capacity in psychiatric patients, including topics such as informed consent, coercive measures, mental health law, involuntary hospitalization, competency assessment, seclusion and restraint, patient autonomy, capacity evaluation, and ethical considerations.

Keywords

Informed Consent; Psychiatric Treatment; Coercive Measures; Mental Health Law; Involuntary Hospitalization; Competency Assessment; Seclusion and Restraint; Patient Autonomy; Capacity Evaluation; Ethical Considerations

Understanding the impact of stigma on people with mental illness.

2002-02-01

Patrick W. Corrigan , Amy C. Watson

Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged … Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. As a result of both, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people. Although research has gone far to understand the impact of the disease, it has only recently begun to explain stigma in mental illness. Much work yet needs to be done to fully understand the breadth and scope of prejudice against people with mental illness. Fortunately, psychologists and sociologists have been studying phenomena related to stigma in other minority groups for several decades. In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area. The impact of stigma is twofold, as outlined in Table Table1.1. Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination. Social psychologists view stereotypes as especially efficient, knowledge structures that are learned by most members of a group (1-3). Stereotypes are considered social because they represent collectively agreed upon notions of groups of persons. They are efficient because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group (4). Table 1 Comparing and contrasting the definitions of public stigma and self-stigma The fact that most people have knowledge of a set of stereotypes does not imply that they agree with them (5). For example, many persons can recall stereotypes about different racial groups but do not agree that the stereotypes are valid. People who are prejudiced, on the other hand, endorse these negative stereotypes (That's right; all persons with mental illness are violent!) and generate negative emotional reactions as a result (They all scare me!) (1,3,6). In contrast to stereotypes, which are beliefs, prejudicial attitudes involve an evaluative (generally negative) component (7,8). Prejudice also yields emotional responses (e.g., anger or fear) to stigmatized groups. Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioral reaction (9). Prejudice that yields anger can lead to hostile behavior (e.g., physically harming a minority group) (10). In terms of mental illness, angry prejudice may lead to withholding help or replacing health care with services provided by the criminal justice system (11). Fear leads to avoidance; e.g., employers do not want persons with mental illness nearby so they do not hire them (12). Alternatively, prejudice turned inward leads to self-discrimination. Research suggests self-stigma and fear of rejection by others lead many persons to not pursuing life opportunities for themselves (13,14). The remainder of this paper further develops examples of public and self-stigma. In the process, we summarize research on ways of changing the impact of public and self-stigma.

The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions

1997-11-01

Thomas Grisso , Paul S. Appelbaum , Carolyn Hill-Fotouhi

The feasibility, reliability, and validity of a new instrument, the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), which was developed for use by clinicians, was tested. The instrument assesses patients' competence to … The feasibility, reliability, and validity of a new instrument, the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), which was developed for use by clinicians, was tested. The instrument assesses patients' competence to make treatment decisions by examining their capacities in four areas--understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice.The MacCAT-T and instruments to measure symptom severity were administered to 40 patients recently hospitalized with schizophrenia or schizoaffective disorder and 40 matched subjects in the community without mental illness.A high degree of ease of use and interrater reliability was found for the MacCAT-T. Overall, the hospitalized patients performed significantly more poorly than the community subjects on understanding and reasoning, although many patients performed as well as community subjects. Poor performance was related to higher levels of some psychiatric symptoms, such as conceptual disorganization, hallucinations, and disorientation.The MacCAT-T offers a flexible yet structured method with which caregivers can assess, rate, and report patients' abilities relevant for evaluating competence to consent to treatment.

Trauma‐informed care in inpatient mental health settings: A review of the literature

2013-01-30

Coral Muskett

Abstract Trauma‐informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma‐informed care, like recovery, leaves mental health nurses struggling to … Abstract Trauma‐informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma‐informed care, like recovery, leaves mental health nurses struggling to translate these values into day‐to‐day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma‐informed care movement in A ustralia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma‐informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000–2011 in identifying those practices and clinical activities that have been implemented to effect trauma‐informed care in inpatient mental health settings.

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Tying Down the Elderly

1989-01-01

Lois K. Evans , Neville E. Strumpf

The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various … The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.

Abuse liability of benzodiazepines.

1987-12-01

James H. Woods , Jonathan L. Katz , Gail Winger

Seclusion and restraint for people with serious mental illnesses

2000-01-24

Eila ES Sailas , Mark Fenton

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<scp>S</scp>afewards: a new model of conflict and containment on psychiatric wards

2014-02-19

Len Bowers

Accessible summary Rates of violence, self‐harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The … Accessible summary Rates of violence, self‐harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc. The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur. Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow. The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff. Abstract Conflict (aggression, self‐harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This S afewards M odel depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict‐originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.

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Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

2015-07-09

Len Bowers , Karen James , Alan Quirk +3 more

Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce … Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both. To test the efficacy of these interventions. A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment. Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals. For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%). Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. IRSCTN38001825.

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Understanding and Improving Patient Compliance

1984-02-01

Stephen A. Eraker

The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance, are described in relation to a new model of health decisions … The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance, are described in relation to a new model of health decisions and patient behavior. The health decision model combines decision analysis, behavioral decision theory, and health beliefs. This model provides a framework for modifying general health beliefs; treatment recommendations; experience with therapeutic regimens and health care providers; patient knowledge and social interaction patterns. Physicians, guided by certain ethical restraints, are in a unique position of responsibility and opportunity to actively encourage patient compliance with treatment.

The MacArthur Treatment Competence Study. I: Mental illness and competence to consent to treatment.

1995-01-01

Paul S. Appelbaum , Thomas Grisso

This is the first of three papers reporting the results of the MacArthur Treatment Competence Study, a project designed to develop reliable and valid information with which to address clinical … This is the first of three papers reporting the results of the MacArthur Treatment Competence Study, a project designed to develop reliable and valid information with which to address clinical and policy questions regarding the abilities of persons with mental illness to make decisions about psychiatric treatment. Four commonly applied legal standards for determin'ing decision-making competence are described: abilities to communicate a choice, understand relevant information, appreciate the nature of the situation and its likely consequences, and rationally manipulate information. Previous research related to the capacities of persons with mental illness in relation to these standards is reviewed and critiqued. The principles underlying the design of the MacArthur Treatment Competence Study are described.

Does This Patient Have Medical Decision-Making Capacity?

2011-07-26

Laura L. Sessums , Hanna Zembrzuska , Jeffrey L. Jackson

Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.To determine the prevalence of incapacity and … Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.To determine the prevalence of incapacity and assessment accuracy in adult medicine patients without severe mental illnesses.MEDLINE and EMBASE (from their inception through April 2011) and bibliographies of retrieved articles.We included high-quality prospective studies (n = 43) of instruments that evaluated medical decision-making capacity for treatment decisions.Two authors independently appraised study quality, extracted relevant data, and resolved disagreements by consensus.Incapacity was uncommon in healthy elderly control participants (2.8%; 95% confidence interval [CI], 1.7%-3.9%) compared with medicine inpatients (26%; 95% CI, 18%-35%). Clinicians accurately diagnosed incapacity (positive likelihood ratio [LR+] of 7.9; 95% CI, 2.7-13), although they recognized it in only 42% (95% CI, 30%-53%) of affected patients. Although not designed to assess incapacity, Mini-Mental State Examination (MMSE) scores less than 20 increased the likelihood of incapacity (LR, 6.3; 95% CI, 3.7-11), scores of 20 to 24 had no effect (LR, 0.87; 95% CI, 0.53-1.2), and scores greater than 24 significantly lowered the likelihood of incapacity (LR, 0.14; 95% CI, 0.06-0.34). Of 9 instruments compared with a gold standard, only 3 are easily performed and have useful test characteristics: the Aid to Capacity Evaluation (ACE) (LR+, 8.5; 95% CI, 3.9-19; negative LR [LR-], 0.21; 95% CI, 0.11-0.41), the Hopkins Competency Assessment Test (LR+, 54; 95% CI, 3.5-846; LR-, 0; 95% CI, 0.0-0.52), and the Understanding Treatment Disclosure (LR+, 6.0; 95% CI, 2.1-17; LR-, 0.16; 95% CI, 0.06-0.41). The ACE was validated in the largest study; it is freely available online and includes a training module.Incapacity is common and often not recognized. The MMSE is useful only at extreme scores. The ACE is the best available instrument to assist physicians in making assessments of medical decision-making capacity.

Proposed hostility and Pharisaic-virtue scales for the MMPI.

1954-12-01

Walter Wheeler Cook , Donald M. Medley

Patient injury and physical restraint devices: a systematic review

2003-02-01

David Evans , Jacquelin Wood , Leonnie Lambert

Objective. To investigate physical restraint‐related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury. Definitions. … Objective. To investigate physical restraint‐related injuries. Areas of interest were the prevalence of injury, types of injuries, risk of sustaining an injury and specific restraint devices associated with injury. Definitions. Injury in the context of this review was considered to be either direct injury, such as lacerations and strangulation, or indirect injury considered to be an adverse outcome such as increased mortality rates or duration of hospitalization. Method. A comprehensive search was undertaken that involved all major databases and the reference list of all relevant papers. To be included in the review studies had to involve people in acute or residential care settings and report data related to injury caused by restraint devices. A number of different types of research designs were included in the review. The findings of studies were pooled using odds ratio and narrative discussion. Results. The search identified 11 papers reporting the findings of 12 observational studies. These studies were supplemented with the findings of a number of other types of studies that reported restraint‐related data. The review highlights the potential danger of using physical restraint in acute and residential health care facilities. Observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined. Discussion. Many of the findings highlight the urgent need for further investigation into the use of physical restraint in health care facilities. Further research should investigate the magnitude of the problem and specific restraint devices associated with injury. However, given the limited nature of the evidence, this association should be investigated further using rigorous research methods.

The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems.

1999-09-01

Bernice A. Pescosolido , John Monahan , Bruce G. Link +2 more

OBJECTIVES: The authors examined Americans' opinions about financial and treatment competence of people with mental health problems, potential for harm to self or others, and the use of legal means … OBJECTIVES: The authors examined Americans' opinions about financial and treatment competence of people with mental health problems, potential for harm to self or others, and the use of legal means to force treatment. METHODS: The 1996 General Social Survey provided interview data with a nationally representative sample (n = 1444). Respondents were given a vignette based on diagnostic criteria for schizophrenia, major depression, alcohol dependence, or drug dependence, or a "control" case. RESULTS: The specific nature of the problem was the most important factor shaping public reaction. Respondents viewed those with "troubles," alcohol dependence, or depression as able to make treatment decisions. Most reported that persons with alcohol or drug problems or schizophrenia cannot manage money and are likely to be violent toward others. Respondents indicated a willingness to coerce individuals into treatment. Respondent and other case characteristics rarely affected opinions. CONCLUSIONS: Americans report greater concern with individuals who have drug or alcohol problems than with persons who have other mental health problems. Evaluations of dangerousness and coercion indicate a continuing need for public education.

Assessing the Competency of Patients With Alzheimer's Disease Under Different Legal Standards

1995-10-01

Daniel Marson

To assess empirically the competency of patients with Alzheimer's disease (AD) to consent to medical treatment under different legal standards (LSs).Comparison of normal older subjects and patients with AD on … To assess empirically the competency of patients with Alzheimer's disease (AD) to consent to medical treatment under different legal standards (LSs).Comparison of normal older subjects and patients with AD on measures of competency to consent to medical treatment.University medical center.Normal older control subjects (n = 15) and patients with probable AD (n = 29 [15 with mild and 14 with moderate AD]).Two specialized clinical vignettes were developed that test a subject's capacity to consent to medical treatment under five well-established LSs for this competency: LS1, evidencing treatment choice; LS2, making the reasonable choice; LS3, appreciating consequences of choice; LS4, providing rational reasons for choice; and LS5, understanding treatment situation and choices. Performance on the LSs was compared across control and AD groups using Student's t test, chi 2, and analysis of variance. Demented subjects were categorized as competent, marginally competent, or incompetent under each LS by using a cutoff score derived from normal control performance.No differences between groups emerged for LS1 and LS2. Control subjects performed significantly better than patients with mild AD on LS4 and LS5, and significantly better than patients with moderate AD on LS3, LS4, and LS5. Patients with mild AD performed significantly better than patients with moderate AD on LS4 and LS5. With respect to competency status, patients with AD showed a consistent and progressive pattern of compromise (marginal competence or incompetence) related to dementia severity and stringency of the LS.A reliable prototype instrument validly discriminated the competency performance and classified the competency status of control subjects and patients with mild and moderate AD under five LSs for competency to consent to medical treatment. While the groups performed equivalently on minimal standards requiring merely a treatment choice (LS1) or the reasonable treatment choice (LS2), patients with mild AD had difficulty with more difficult standards requiring rational reasons (LS4) and understanding treatment information (LS5), and patients with moderate AD had difficulty with appreciation of consequences (LS3), rational reasons (LS4), and understanding treatment (LS5). The results raised the concern that many patients with mild AD may not be competent to consent to treatment and supported the value of standardized clinical vignettes for assessment of competency in dementia.

Mental Capacity Act

2008-02-01

John Dow

This article will examine the changes in law brought about by the Mental Capacity Act and consider the practical implications for health and social care staff. This article will examine the changes in law brought about by the Mental Capacity Act and consider the practical implications for health and social care staff.

Assessment of Patients' Competence to Consent to Treatment

2007-10-31

Paul S. Appelbaum

A 75-year-old woman has type 2 diabetes mellitus, peripheral vascular disease, and a gangrenous ulcer of her left foot. A below-the-knee amputation is recommended, but she declines, saying that she … A 75-year-old woman has type 2 diabetes mellitus, peripheral vascular disease, and a gangrenous ulcer of her left foot. A below-the-knee amputation is recommended, but she declines, saying that she has lived long enough and wants to die with her body intact. Her internist is concerned about her increasing confusion over the past year and notes that she appears to be depressed. How should her physician determine whether her decision is competent?

Neurologic status, cough, secretions and extubation outcomes

2004-03-04

Adil Salam , Lisa Tilluckdharry , Yaw Amoateng‐Adjepong +1 more

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A study of antipsychotic drug use in nursing homes: epidemiologic evidence suggesting misuse.

1980-05-01

Wayne A. Ray , Charles F. Federspiel , William Schaffner

We reviewed 384,326 prescriptions for 5,902 Medicaid patients residing continuously for one year in 173 Tennessee nursing homes. Of these patients, 43 per cent received antipsychotic drugs; 9 per cent … We reviewed 384,326 prescriptions for 5,902 Medicaid patients residing continuously for one year in 173 Tennessee nursing homes. Of these patients, 43 per cent received antipsychotic drugs; 9 per cent were chronic recipients (received at least 365 daily doses per year). Of the 1,580 physicians who cared for these patients, 42 per cent prescribed antipsychotic medication. Physicians with large nursing home practices (10 or more patients) prescribed 81 per cent of the total antipsychotic medication, and were usually family practitioners (78 per cent) and in rural practice (47 per cent). As nursing home practice size increased, doctors prescribed more drug per patient (p less than .001). Wide variation in antipsychotic drug use occurred among nursing homes; the chronic recipient rate ranged from 0 to 46 per cent. More drug was given per patient in larger homes (r = .18, p less than .05). Typically, one physician (the "dominant" physician) provided care for the majority of a nursing home's patients. The proportion of a home's patients seen by the dominant physician was correlated with the chronic recipient rate (r = .17, p less than .05). These findings provide epidemiologic evidence suggesting misuse of antipsychotic drugs in nursing homes. They illustrate the need for investigations of techniques for patient management in nursing homes which rely less upon psychtropic drugs.

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Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

2009-09-01

Tilman Steinert , Peter Lepping , Renate Bernhardsgrütter +6 more

Psychiatric Disorder in the General Hospital

1986-08-01

Richard Mayou , Keith Hawton

There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric … There have been many reports of psychiatric disorder in medical populations, but few have used standard methods on representative patient groups. Even so, there is consistent evidence for considerable psychiatric morbidity in in-patient, out-patient and casualty department populations, much of which is unrecognised by hospital doctors. We require a better classification of psychiatric disorder in the general hospital, improved research measures, and more evidence about the nature and course of the many different types of problem so that we can provide precise advice for their management of routine clinical practice.

The MacArthur Treatment Competence Study. III: Abilities of patients to consent to psychiatric and medical treatments.

1995-01-01

Thomas Grisso , Paul S. Appelbaum

Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, … Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, as well as three groups of non-ill persons in the community who were matched with the hospitalized patients on age, gender, race, and socioeconomic status. Significant impairments in decisional abilities were found for only a minority of persons in all groups. Both the schizophrenia and depression groups manifested poorer understanding of treatment disclosures, poorer reasoning in decision making regarding treatment, and a greater likelihood of failing to appreciate their illness or the potential benefits of treatment. Deficits were more pronounced, however, among patients with schizophrenia. Implications are discussed for policy designed to protect the rights and welfare of patients with mental illness who are at risk of incompetent refusal or consent when making treatment decisions.

Assessing relationship quality in mandated community treatment: Blending care with control.

2007-12-01

Jennifer L. Skeem , Jennifer Eno Louden , Devon L. L. Polaschek +1 more

Traditional measures of the therapeutic alliance do not capture the dual roles inherent in relationships with involuntary clients. Providers not only care for, but also have control over, involuntary clients. … Traditional measures of the therapeutic alliance do not capture the dual roles inherent in relationships with involuntary clients. Providers not only care for, but also have control over, involuntary clients. In 2 studies of probationers mandated to psychiatric treatment (n=90; n=322), the authors developed and validated the revised Dual-Role Relationships Inventory (DRI-R). The authors found that (a) relationship quality in mandated treatment involves caring and fairness, trust, and an authoritative (not authoritarian) style, (b) the DRI-R assesses these domains of relationship quality, is internally consistent, and relates in a theoretically coherent pattern with ratings of within-session behavior and with measures of the therapeutic alliance, relationship satisfaction, symptoms, and treatment motivation, and (c) the quality of dual-role relationships predicts future compliance with the rules, as assessed by probation violations and revocation. The DRI-R covaries with multiple domains more strongly than a leading measure of the therapeutic alliance, suggesting that it better captures the nature and effect of relationship quality in mandated treatment.

Organizational stressors associated with job stress and burnout in correctional officers: a systematic review

2013-01-29

Caitlin A. Finney , Erene Stergiopoulos , Jennifer Hensel +2 more

Abstract Background In adult correctional facilities, correctional officers (COs) are responsible for the safety and security of the facility in addition to aiding in offender rehabilitation and preventing recidivism. COs … Abstract Background In adult correctional facilities, correctional officers (COs) are responsible for the safety and security of the facility in addition to aiding in offender rehabilitation and preventing recidivism. COs experience higher rates of job stress and burnout that stem from organizational stressors, leading to negative outcomes for not only the CO but the organization as well. Effective interventions could aim at targeting organizational stressors in order to reduce these negative outcomes as well as COs’ job stress and burnout. This paper fills a gap in the organizational stress literature among COs by systematically reviewing the relationship between organizational stressors and CO stress and burnout in adult correctional facilities. In doing so, the present review identifies areas that organizational interventions can target in order to reduce CO job stress and burnout. Methods A systematic search of the literature was conducted using Medline, PsycINFO, Criminal Justice Abstracts, and Sociological Abstracts. All retrieved articles were independently screened based on criteria developed a priori. All included articles underwent quality assessment. Organizational stressors were categorized according to Cooper and Marshall’s (1976) model of job stress. Results The systematic review yielded 8 studies that met all inclusion and quality assessment criteria. The five categories of organizational stressors among correctional officers are: stressors intrinsic to the job, role in the organization, rewards at work, supervisory relationships at work and the organizational structure and climate. The organizational structure and climate was demonstrated to have the most consistent relationship with CO job stress and burnout. Conclusions The results of this review indicate that the organizational structure and climate of correctional institutions has the most consistent relationship with COs’ job stress and burnout. Limitations of the studies reviewed include the cross-sectional design and the use of varying measures for organizational stressors. The results of this review indicate that interventions should aim to improve the organizational structure and climate of the correctional facility by improving communication between management and COs.

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“I'm Going Home”: Discharges Against Medical Advice

2009-02-27

David Alfandre

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Agitated Behaviors in the Elderly: II. Preliminary Results in the Cognitively Deteriorated

1986-10-01

Jiska Cohen‐Mansfield

Agitation was studied in 66 nursing home residents from two nursing units for agitated, cognitively deteriorated elderly. The frequency of occurrence of manifestations of various agitated behaviors was documented by … Agitation was studied in 66 nursing home residents from two nursing units for agitated, cognitively deteriorated elderly. The frequency of occurrence of manifestations of various agitated behaviors was documented by nursing home staff using a seven‐point frequency rating scale. Additionally, the factors of age, cognitive level, activities of daily living (ADL) functioning, frequency of waking up at night, and medication for agitation were monitored, and nurses' attributions for agitation in each individual were reported. Results indicated that: 1) agitated behaviors were strongly interrelated; 2) specific nonaggressive behaviors, such as pacing and constant request for attention, occurred most frequently; 3) in this very agitated and cognitively deteriorated group, agitated individuals did not differ from nonagitated persons in age, cognitive level, and waking up at night; 4) agitated individuals received more medication for agitation and had a higher incidence of falls as compared with nonagitated people; and 5) the most frequent medications given for agitation were thioridazine and haloperidol. The study is viewed as a preliminary effort to understand the phenomenon of agitation. Results serve as indicators for future research and demonstrate the widespread implications of research for handling and preventing agitation as well as for policy planning with regard to placement and reimbursement.

Assessing the New York City Involuntary Outpatient Commitment Pilot Program

2001-03-01

Henry J. Steadman , Kostas Gounis , Deborah L. Dennis +4 more

The study evaluated the effectiveness of a three-year outpatient commitment pilot program established in 1994 at Bellevue Hospital in New York City.A total of 142 participants were randomly assigned; 78 … The study evaluated the effectiveness of a three-year outpatient commitment pilot program established in 1994 at Bellevue Hospital in New York City.A total of 142 participants were randomly assigned; 78 received court-ordered treatment, which included enhanced services, and 64 received the enhanced-service package only. Between 57 and 68 percent of the subjects completed interviews at one, five, and 11 months after hospital discharge. Outcome measures included rehospitalization, arrest, quality of life, symptomatology, treatment noncompliance, and perceived level of coercion.On all major outcome measures, no statistically significant differences were found between the two groups. No subject was arrested for a violent crime. Eighteen percent of the court-ordered group and 16 percent of the control group were arrested at least once. The percentage rehospitalized during follow-up was about the same for both groups-51 percent and 42 percent, respectively. The groups did not differ significantly in the total number of days hospitalized during the follow-up period. Participants' perceptions of their quality of life and level of coercion were about the same. From the community service providers' perspective, patients in the two groups were similarly adherent to their required treatments.All results must be qualified by the fact that no pick-up order procedures for noncompliant subjects in the court-ordered group were implemented during the study, which compromised the differences between the conditions for the two groups, and that persons with a history of violence were excluded from the program.

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

2012-02-01

Janet S. Richmond , Jon S. Berlin , Avrim Fishkind +5 more

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on … Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the "10 domains of de-escalation."

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Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings From a Randomized Trial With Severely Mentally Ill Individuals

1999-12-01

Marvin S. Swartz , Jeffrey W. Swanson , Henry R. Wagner +3 more

The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses.Subjects who were hospitalized involuntarily were randomly assigned … The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses.Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected.In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment.Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.

Predicting Medication Noncompliance After Hospital Discharge Among Patients With Schizophrenia

2000-02-01

Mark Olfson , David Mechanic , Stephen Hansell +3 more

OBJECTIVE: The study sought to identify predictors of noncompliance with medication in a cohort of patients with schizophrenia after discharge from acute hospitalization. METHODS: Adult psychiatric inpatients with schizophrenia or … OBJECTIVE: The study sought to identify predictors of noncompliance with medication in a cohort of patients with schizophrenia after discharge from acute hospitalization. METHODS: Adult psychiatric inpatients with schizophrenia or schizoaffective disorder for whom oral antipsychotics were prescribed (N=213) were evaluated at hospital discharge and three months later to assess medication compliance. Comparisons were made between patients who reported stopping their medications for one week or longer and patients who reported more continuous medication use. RESULTS: Of the 213 patients, about a fifth (19.2 percent) met the criterion for noncompliance. Medication noncompliance was significantly associated with an increased risk of rehospitalization, emergency room visits, homelessness, and symptom exacerbation. Compared with the compliant group, the noncompliant group was significantly more likely to have a history of medication noncompliance, substance abuse or dependence, and difficulty recognizing their own symptoms. Patients who became medication noncompliant were significantly less likely to have formed a good therapeutic alliance during hospitalization as measured by inpatient staff reports and were more likely to have family members who refused to become involved in their treatment. CONCLUSIONS: Patients with schizophrenia at high risk for medication noncompliance after acute hospitalization are characterized by a history of medication noncompliance, recent substance use, difficulty recognizing their own symptoms, a weak alliance with inpatient staff, and family who refuse to become involved in inpatient treatment.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

2014-12-04

Steve Kisely , Leslie Anne Campbell

Background There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning. Objectives … Background There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning. Objectives To examine the effectiveness of CCT for people with SMI. Search methods We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, and 2012). We obtained all references of identified studies and contacted authors where necessary. We further updated this search on the 8 November 2013. Selection criteria All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia‐like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre‐existing form of compulsory community treatment such as supervised discharge. Data collection and analysis Review authors independently selected studies, assessed their quality and extracted data. We used The Cochrane Collaboration's tool for assessing risk of bias. For binary outcomes, we calculated a fixed‐effect risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat statistic (NNT). For continuous outcomes, we calculated a fixed‐effect mean difference (MD) and its 95% CI. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table for outcomes we rated as important and assessed the risk of bias of included studies. Main results All studies (n=3) involved patients in community settings who were followed up over 12 months (n = 752 participants). Two RCTs from the USA (total n = 416) compared court‐ordered 'Outpatient Commitment' (OPC) with voluntary community treatment. OPC did not result in significant differences compared to voluntary treatment in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11‐12 months 0.98 CI 0.79 to 1.21, low grade evidence); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11‐12 months 0.97 CI 0.62 to 1.52, low grade evidence); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15, low grade evidence) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89, low grade evidence). However, risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50 CI 0.31 to 0.80). Other than perceived coercion, no adverse outcomes were reported. In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). One further RCT compared community treatment orders (CTOs) with less intensive supervised discharge in England and found no difference between the two for either the main outcome of readmission (1 RCT, n = 333, RR for readmission to hospital by 12 months 0.99 CI 0.74 to 1.32, medium grade evidence), or any of the secondary outcomes including social functioning and mental state. It was not possible to calculate the NNT. The English study met three out of the seven criteria of The Cochrane Collaboration's tool for assessing risk of bias, the others only one, the majority being rated unclear. Authors' conclusions CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or non‐violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non‐effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and evidence we rated as low to medium quality.

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Assessing Decisional Capacity for Clinical Research or Treatment: A Review of Instruments

2006-08-01

Laura B. Dunn , Milap A. Nowrangi , Barton W. Palmer +2 more

Objective: The need to evaluate decisional capacity among patients in treatment settings as well as subjects in clinical research settings has increasingly gained attention. Decisional capacity is generally conceptualized to … Objective: The need to evaluate decisional capacity among patients in treatment settings as well as subjects in clinical research settings has increasingly gained attention. Decisional capacity is generally conceptualized to include not only an understanding of disclosed information but also an appreciation of its significance, the ability to use the information in reasoning, and the ability to express a clear choice. The authors critically reviewed existing measures of decisional capacity for research and treatment. Method: Electronic medical and legal databases were searched for articles published from 1980 to 2004 describing structured assessments of adults’ capacity to consent to clinical treatment or research protocols. The authors identified 23 decisional capacity assessment instruments and evaluated each in terms of format, content, administration features, and psychometric properties. Results: Six instruments focused solely on understanding of disclosed information, and 11 tested for understanding, appreciation, reasoning, and expression of a choice. The instruments varied substantially in format, degree of standardization of disclosures, flexibility of item content, and scoring procedures. Reliability and validity also varied widely. All instruments have limitations, ranging from lack of supporting psychometric data to lack of generalizability across contexts. Conclusions: Of the instruments reviewed, the MacArthur Competence Assessment Tools for Clinical Research and for Treatment have the most empirical support, although other instruments may be equally or better suited to certain situations. Contextual factors are important but understudied. Capacity assessment tools should undergo further empirically based development and refinement as well as testing with a variety of populations.

A New Brief Instrument for Assessing Decisional Capacity for Clinical Research

2007-08-01

Dilip V. Jeste , Barton W. Palmer , Paul S. Appelbaum +6 more

Context: There is a critical need for practical measures for screening and documenting decisional capacity in people participating in different types of clinical research.However, there are few reliable and validated … Context: There is a critical need for practical measures for screening and documenting decisional capacity in people participating in different types of clinical research.However, there are few reliable and validated brief tools that could be used routinely to evaluate individuals' capacity to consent to a research protocol.Objective: To describe the development, testing, and proposed use of a new practical instrument to assess decision-making capacity: the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC).The UBACC is intended to help investigators identify research participants who warrant more thorough decisional capacity assessment and/or remediation efforts prior to enrollment.Design, Setting, and Participants: We developed the UBACC as a 10-item scale that included questions focusing on understanding and appreciation of the information concerning a research protocol.It was developed and tested among middle-aged and older outpatients with schizophrenia and healthy comparison subjects participating in research on informed consent.In an investigation of reliability and validity, we studied 127 outpatients with schizophrenia or schizoaffective disorder and 30 healthy comparison subjects who received information about a simulated clinical drug trial.Internal consistency, interrater reliability, and concurrent (criterion) validity (including correlations with an established instrument as well as sensitivity and specificity relative to 2 potential "gold standard" criteria) were measured.Main Outcome Measures: Reliability and validity of the UBACC. Results:The UBACC was found to have good internal consistency, interrater reliability, concurrent validity, high sensitivity, and acceptable specificity.It typically took less than 5 minutes to administer, was easy to use and reliably score, and could be used to identify subjects with questionable capacity to consent to the specific research project. Conclusion:The UBACC is a potentially useful instrument for screening large numbers of subjects to identify those needing more comprehensive decisional capacity assessment and/or remediation efforts.

Decisional Capacity for Informed Consent in Schizophrenia Research

2000-06-01

W. T. Carpenter

The adequacy of subjects' informed consent to research is the focus of an important public and professional debate. The potential impairment of decisional capacity in persons with schizophrenia is central … The adequacy of subjects' informed consent to research is the focus of an important public and professional debate. The potential impairment of decisional capacity in persons with schizophrenia is central to the discussions. This study ascertains the decisional capacity for informed consent in schizophrenic research subjects, to determine if reduced capacity relates to specific aspects of psychopathologic features and to test the hypothesis that reduced capacity can be remediated with an educational informed consent process.Decisional capacity was assessed for 30 research subjects with schizophrenia and 24 nonill (normal) comparison subjects. Measures of psychopathologic features and cognition were obtained for the subjects with schizophrenia. Subjects who performed poorly on the decisional capacity measure received an educational intervention designed to improve their ability to provide informed consent and were then retested.The patient group did not perform as well as the controls on initial decisional capacity assessment. Poor performance was modestly related to the extent of symptoms but robustly related to cognitive impairments. Following the educational intervention, the performance of subjects with schizophrenia was equal to that of the nonill comparison group.Many persons with schizophrenia may be challenged by the cognitive demands of an informed consent process for research participation. In many cases, their reduced capacity can be compensated by a more intensive educational intervention as part of the informed consent process.

Restraint and seclusion: a review of the literature

1994-11-01

William A. Fisher

The author reviewed the literature published since 1972 concerning restraint and seclusion.The review began with a computerized literature search. Further sources were located through citations from articles identified in the … The author reviewed the literature published since 1972 concerning restraint and seclusion.The review began with a computerized literature search. Further sources were located through citations from articles identified in the original search.The author synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training.The literature on restraint and seclusion supports the following. 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation. 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint. 3) Restraint and seclusion have deleterious physical and psychological effects on patients and staff, and the psychiatric consumer/survivor movement has emphasized these effects. 4) Demographic and clinical factors have limited influence on rates of restraint and seclusion. 5) Local nonclinical factors, such as cultural biases, staff role perceptions, and the attitude of the hospital administration, have a greater influence on rates of restraint and seclusion. 6) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects. 7) Studies comparing well-defined training programs have potential usefulness.

Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial

2013-03-26

Tom Burns , Jorun Rugkåsa , Andrew Molodynski +6 more

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Two scales for measuring patients' perceptions for coercion during mental hospital admission

1993-06-01

William Gardner , Steven K. Hoge , Nancy Bennett +4 more

Abstract Legal and extra‐legal coercion are pervasive in mental hospital admission and there are sharp disputes about its appropriate role. This article presents two scales for measuring psychiatric patients' perceptions … Abstract Legal and extra‐legal coercion are pervasive in mental hospital admission and there are sharp disputes about its appropriate role. This article presents two scales for measuring psychiatric patients' perceptions of coercion during hospital admission and reports data on these scales' internal consistency. We measure patients' perceptions of coercion by asking questions, in either an interview or questionnaire format, about their experience of lack of control, choice, influence, and freedom in hospital admission. Patients' responses to questions about their perceptions of coercion were highly internally consistent. The internal consistency of the scale was robust with respect to variation in site, instrument format, patient population, and interview procedure. Correspondence analysis was used to construct two numerical scales of perceived coercion.

Withholding and withdrawal of life support in intensive-care units in France: a prospective survey

2001-01-01

Édouard Ferrand , R. Robert , Pierre Ingrand +1 more

The shift of psychiatric inpatient care from hospitals to jails and prisons.

2005-01-01

H. Richard Lamb , Linda E. Weinberger

Far-reaching structural changes have been made in the mental health system. Many severely mentally ill persons who come to the attention of law enforcement now receive their inpatient treatment in … Far-reaching structural changes have been made in the mental health system. Many severely mentally ill persons who come to the attention of law enforcement now receive their inpatient treatment in jails and prisons, at least in part, because of a dramatic reduction of psychiatric inpatient beds. While more high-quality community treatment, such as intensive case management and assertive community treatment, is needed, the authors believe that for many, 24-hour structured care is needed in the mental health system for various lengths of time to decrease criminalization. Another central theme of this article is that when a mentally ill individual is arrested, that person now has a computerized criminal record, which is easily accessed by the police and the courts in subsequent encounters. This may influence their decisions and reinforce the tendency to choose the criminal justice system over the mental health system.

Special Section on Seclusion and Restraint: Patients' Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting

2005-09-01

B. Christopher Frueh , Rebecca G. Knapp , Karen Cusack +7 more

This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector … This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector mental health system.Participants were 142 randomly selected adult psychiatric patients who were recruited through a day hospital program. Participants completed a battery of self-report measures to assess traumatic and harmful events that occurred during the course of their mental health care, lifetime trauma exposure, and symptoms of posttraumatic stress disorder.Data revealed high rates of reported lifetime trauma that occurred within psychiatric settings, including physical assault (31 percent), sexual assault (8 percent), and witnessing traumatic events (63 percent). The reported rates of potentially harmful experiences, such as being around frightening or violent patients (54 percent), were also high. Finally, reported rates of institutional measures of last resort, such as seclusion (59 percent), restraint (34 percent), takedowns (29 percent), and handcuffed transport (65 percent), were also high. Having medications used as a threat or punishment, unwanted sexual advances in a psychiatric setting, inadequate privacy, and sexual assault by a staff member were associated with a history of exposure to sexual assault as an adult.Findings suggest that traumatic and harmful experiences within psychiatric settings warrant increased attention.

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

2004-10-01

Vanessa Raymont , William Bingley , Alec Buchanan +4 more

Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition

2014-10-14

Jeffrey L. Cummings , Jacobo Mintzer , Henry Brodaty +7 more

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no … Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome. The International Psychogeriatric Association formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.The ADWG developed a transparent process using a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as "strongly agree" or "somewhat agree" (68-88% across elements). A majority of the respondents agreed that the definition is appropriate for clinical and research applications.A provisional consensus definition of agitation has been developed. This definition can be used to advance interventional and non-interventional research of agitation in patients with cognitive impairment.

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Assessment of Decision-Making Capacity in Older Adults: An Emerging Area of Practice and Research

2007-01-01

Jennifer Moye , Daniel Marson

The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment … The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment of older adults. In this article we discuss the emergence of capacity assessment as a distinct field of study. We review research efforts in two domains: medical decision-making capacity and financial capacity. Existing research in these two areas provides a first pass at many key questions related to capacity assessment, but additional studies that replicate, extend, and improve on this research are urgently needed. An agenda for future is detailed that recommends studies of a wide range of capacity constructs, focusing on clinical markers of diminished capacity, methods to improve clinical assessment, and the many intersections of law and clinical practice.

Is This Patient Taking the Treatment as Prescribed?

1993-06-02

Barbara Stephenson , Brian H. Rowe , R. Brian Haynes +2 more

<h3>CLINICAL SCENARIOS</h3><h3>Case 1</h3> A 28-year-old woman presents to the emergency department in acute distress with a 3-day history of worsening asthma. Her prescribed medications include an inhaled β<sub>2</sub>-agonist and an … <h3>CLINICAL SCENARIOS</h3><h3>Case 1</h3> A 28-year-old woman presents to the emergency department in acute distress with a 3-day history of worsening asthma. Her prescribed medications include an inhaled β<sub>2</sub>-agonist and an inhaled steroid. When questioned, she breathlessly admits to "occasionally" missing her medications but indicates that this is "maybe only once or twice." <h3>Case 2</h3> A 55-year-old man with posttraumatic seizure disorder has been taking phenytoin since his injury. His seizures were initially adequately controlled but he recently has been having weekly seizures. In an office visit he resentfully denies missing any of his medication. <h3>THE IMPORTANCE OF CLINICAL EXAMINATION</h3> Physicians should measure compliance for patients prescribed a self-administered treatment because noncompliance is common and physicians can help patients to improve their compliance<sup>1,2</sup>and increase the benefit they derive from therapy. Compliance with long-term self-administered medication therapy is approximately 50% for those who remain in care.<sup>3</sup>

Assessing Patients' Capacities to Consent to Treatment

1988-12-22

Paul S. Appelbaum , Thomas Grisso

Abstract The right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions … Abstract The right of patients to accept or refuse recommended treatment requires careful reassessment when their decision-making capacities are called into question. Patients must be informed appropriately about treatment decisions and be given an opportunity to demonstrate their highest level of mental functioning. The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally. Since competence is a legal concept and can be formally determined only in court, the clinical examiner's proper role is to gather relevant information and decide whether an adjudication of incompetence is required. Treatment for impairment of mental functioning can sometimes restore patients' capacities, making it unnecessary to deprive them of their decision-making powers. (N Engl J Med 1988; 319:1635–8.)

Medical decision-making in children and adolescents: developmental and neuroscientific aspects

2017-05-08

Petronella Grootens‐Wiegers , Irma M. Hein , Jos M. van den Broek +1 more

Various international laws and guidelines stress the importance of respecting the developing autonomy of children and involving minors in decision-making regarding treatment and research participation. However, no universal agreement exists … Various international laws and guidelines stress the importance of respecting the developing autonomy of children and involving minors in decision-making regarding treatment and research participation. However, no universal agreement exists as to at what age minors should be deemed decision-making competent. Minors of the same age may show different levels of maturity. In addition, patients deemed rational conversation-partners as a child can suddenly become noncompliant as an adolescent. Age, context and development all play a role in decision-making competence. In this article we adopt a perspective on competence that specifically focuses on the impact of brain development on the child’s decision-making process. We believe that the discussion on decision-making competence of minors can greatly benefit from a multidisciplinary approach. We adopted such an approach in order to contribute to the understanding on how to deal with children in decision-making situations. Evidence emerging from neuroscience research concerning the developing brain structures in minors is combined with insights from various other fields, such as psychology, decision-making science and ethics. Four capacities have been described that are required for (medical) decision-making: (1) communicating a choice; (2) understanding; (3) reasoning; and (4) appreciation. Each capacity is related to a number of specific skills and abilities that need to be sufficiently developed to support the capacity. Based on this approach it can be concluded that at the age of 12 children can have the capacity to be decision-making competent. However, this age coincides with the onset of adolescence. Early development of the brain’s reward system combined with late development of the control system diminishes decision-making competence in adolescents in specific contexts. We conclude that even adolescents possessing capacities required for decision-making, may need support of facilitating environmental factors. This paper intends to offer insight in neuroscientific mechanisms underlying the medical decision-making capacities in minors and to stimulate practices for optimal involvement of minors. Developing minors become increasingly capable of decision-making, but the neurobiological development in adolescence affects competence in specific contexts. Adequate support should be offered in order to create a context in which minors can make competently make decisions.

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Shunned: Discrimination Against People With Mental Illness

2007-04-26

S. Guzofski

The (mis)measurement of restraint: An analysis of conceptual and psychometric issues.

1988-02-01

Todd F. Heatherton , C. Peter Herman , Janet Polivy +2 more

A comparison of the validity of three scales for the assessment of dietary restraint.

1989-11-01

Reinhold G. Laessle , Reinhard J. Tuschl , Britta C. Kotthaus +1 more

The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup

2012-02-01

Michael P. Wilson , David Pepper , Glenn W. Currier +2 more

Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use … Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic agents, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multifocal or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause for the agitation. If agitation results from a medical condition or delirium, clinicians should first attempt to treat this underlying cause instead of simply medicating with antipsychotics or benzodiazepines. [West J Emerg Med. 2012;13(1):26–34.]

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Beendigung von Reanimationsmaßnahmen – welche Empfehlungen helfen bei der Entscheidungsfindung?

2025-06-25

| retten!

A survey of attitudes and knowledge about advance healthcare directives amongst inpatient psychiatry service users in Ireland

2025-06-25

Maria Redahan , Catherine Rock , Michal Grudzien +1 more | Irish Journal of Psychological Medicine

Abstract Objectives: To investigate levels of knowledge and attitudes towards advance healthcare directives among inpatient psychiatry service users in Ireland. Methods: A survey was completed among adult inpatient psychiatry service … Abstract Objectives: To investigate levels of knowledge and attitudes towards advance healthcare directives among inpatient psychiatry service users in Ireland. Methods: A survey was completed among adult inpatient psychiatry service users ( n = 47) in Tallaght University Hospital, Dublin. Results: Just over one in ten (11%) inpatient psychiatry service users had heard of advance healthcare directives. None had created an advance healthcare directive, but over a quarter (25.5%) had written down or verbally told someone what they would like to happen when they became unwell. When asked ‘if you were supported by your healthcare provider to make an advance healthcare directive, would you like to make one?’, over two thirds responded either ‘definitely yes’ (34%) or ‘probably yes’ (34%). On multi-variable testing, future willingness to make an advance healthcare directive was significantly associated with younger age but not with ethnicity, gender, education, employment status, or prior knowledge of advance healthcare directives. All respondents would involve someone else in making an advance healthcare directive. There was high confidence that healthcare practitioners would respect an advance healthcare directive (87%). Conclusions: There are high levels of interest in advance healthcare directives, but low levels of knowledge and use among inpatient psychiatry service users in Ireland. Our findings indicate a need for educational initiatives and resources to increase awareness. Such efforts could usefully focus especially on appropriate use of advance healthcare directives in psychiatric care and seek to bridge the gaps between evidence of benefit, legislative reform, and their use in mental healthcare.

Improving Equity at Premature Discharge: Reframing Discharge Against Medical Advice Using the Structural Competency Framework

2025-06-25

Sydney Katz , Amanda K. Ramsdell | Journal of General Internal Medicine

The impact of physical restraints on mental health and quality of life in ICU patients – Response to Sheng et al.

2025-06-24

Paul Rood , L Francken , Mark van den Boogaard | Intensive and Critical Care Nursing

Sentencing Offenders with Mental Disorders, Developmental Disorders, or Neurological Impairments in England and Wales

2025-06-24

Sally Kennedy , Clare S. Allely , Ian Warren | Routledge eBooks

General medicine wards and the mental health crisis: invisible and unsafe

2025-06-24

Cindy Towns , Kay Hodgetts , Philippa Shirtcliffe +6 more | Internal Medicine Journal

Abstract The behavioural and psychological symptoms of dementia (BPSD) are common and include physical and sexual aggression. Unlike delirium, BPSD is a purely psychiatric presentation with no additional medical condition … Abstract The behavioural and psychological symptoms of dementia (BPSD) are common and include physical and sexual aggression. Unlike delirium, BPSD is a purely psychiatric presentation with no additional medical condition requiring treatment. New Zealand has a paucity of psychiatry beds for older adults, but despite the ageing population, limited attention has been given to this growing problem. BPSD patients present acutely to hospital when their behaviour becomes unmanageable. They need specialist attention and facilities. However, despite inappropriate design and no resourcing, hospitals routinely expect medical wards to accept these patients when no psychogeriatric bed is available even when the presentation is complicated by physical or sexual violence. The authors contend that this practice is unsafe and unethical. It breaches the Code of Rights for all patients and places physicians at medico‐legal risk.

Factors Affecting Psychiatric Bed Utilisation by People With Intellectual Disabilities: A Time Series Analysis Using the English National Mental Health Services Data Set

2025-06-23

Atiyya Nisar , Paul A. Thompson , Harry Boer +2 more | Journal of Intellectual Disability Research

ABSTRACT Background In 2015, the Building the Right Support programme was launched for England in an attempt to reduce the number of psychiatric inpatients with intellectual disabilities and/or autism by … ABSTRACT Background In 2015, the Building the Right Support programme was launched for England in an attempt to reduce the number of psychiatric inpatients with intellectual disabilities and/or autism by 35%–50%. This target, and subsequent targets, were missed, and for 2025–2026, the government further committed to reducing numbers by 10%. Considering these continued targets, we aimed to investigate psychiatric bed utilisation over time, and to further understand factors that may influence psychiatric admissions and discharges of people with intellectual disabilities and/or autism, by utilising time series modelling with national English data to explore the relationship between a set of chosen sociodemographic, clinical and service‐related predictor variables and the following outcome variables: (1) total monthly number of hospital spells, (2) total monthly number of discharges, (3) total monthly number of admissions, (4) ratio of community to non‐community discharges, (5) number of inpatients with a length of stay under 2 years, (6) number of patients with a length of stay over 2 years and (7) total number of distinct individuals who had been subjected to restraints. Methods Using data from the publicly available Mental Health Services Data set, we utilised linear regression (with moving average or auto‐regressive errors) to examine the relationships between variables over time, from February 2013 to January 2024. Results Over time, the number of inpatients decreased by an average of 4.55 patients per month. The number of inpatients with a length of stay greater than 2 years reduced over time. Periods of time when the number of inpatients was greater were associated with more inpatients under the age of 18 years. Periods of time when hospital stays, admissions and discharges were higher were associated with fewer White inpatients relative to non‐White inpatients. Periods of time with more patients detained under Part II of the Mental Health Act were associated with more admissions and the increased use of restraint. Conclusions Over the last 11 years, the planned closure of psychiatric inpatient beds has been unsuccessful. Our findings indicated that periods of increased psychiatric bed utilisation were associated with more admissions of younger people, non‐White inpatients and those likely to be experiencing a crisis. Future research should explore how psychiatric beds can be utilised more effectively alongside community‐based services and long‐term trajectories using participant level data.

Reasons for patients leaving against medical advice in emergency department at a tertiary hospital, Nepal

2025-06-23

Ram Prasad Sharma G , S Adhikari , Laxmi Rajbanshi | Journal of Gandaki Medical College-Nepal

Introduction: Leaving Against Medical Advice (LAMA) presents significant challenges in planning and delivering healthcare services. It often leads to worsened patient outcomes and increased rates of readmission. This study aimed … Introduction: Leaving Against Medical Advice (LAMA) presents significant challenges in planning and delivering healthcare services. It often leads to worsened patient outcomes and increased rates of readmission. This study aimed to identify the reasons behind patients leaving against medical advice in the emergency department of a tertiary hospital. Methods: A descriptive cross-sectional study was conducted at a tertiary hospital in central Nepal from February 1, 2024 to July 31, 2024. Patients who requested to leave the healthcare setting without complete treatment and arrange further care or treatment elsewhere were included; 214 participants were included in this study. Data were collected using a self-structured questionnaire developed based on a review of previous studies and analyzed using SPSS version 20 for descriptive statistics. Results: Among the 214 participated in this study. LAMA cases were predominantly observed among men (62.1%), married individuals (83.6%), those who were employed (68.7%), and those who were self-paying (97.7%). Two important reasons for LAMA were financial constraints (30.8%) and the perception of improved health (26.2%). Other reasons included personal issues such as caregiving and work commitments (10.7%), lack of health insurance (8.4%), preference for outpatient treatment (6.1%), dissatisfaction with high hospital charges (3.3%), delays in specialist consultations (1.9%), and poor communication about the treatment plan (0.5%). Conclusions: Financial difficulty was identified as the primary reason for LAMA followed by the perception of feeling better. These findings can help healthcare providers plan targeted interventions and implement measures to reduce LAMA rates and improve patient outcomes.

Patient Race and Preferred Language Influence the Use of Physical Restraints in Non-intubated ICU Patients

2025-06-20

S. Mcgowan , Hayley B. Gershengorn , Andrew Sudler +7 more | Annals of the American Thoracic Society

Physical limb restraints are commonly used in intensive care units (ICUs) to protect patients and staff but are associated with increased morbidity. While many intubated patients in the US are … Physical limb restraints are commonly used in intensive care units (ICUs) to protect patients and staff but are associated with increased morbidity. While many intubated patients in the US are physically restrained, predictors for restraints in non-intubated patients remain less clear. To identify whether patient race, ethnicity, and preferred language are associated with restraint use in non-intubated patients across multiple ICUs in a large US hospital system. We performed a retrospective cohort study using electronic health record (EHR) data across five ICUs within the University of California, San Francisco from 2013-2022. We included adults ≥18 years of age. We excluded patients who received mechanical ventilation during their ICU stay. Our primary independent variables were primary language and race. The outcome of interest was restraint use, defined as at least one restraint order placed during the patient's ICU stay. We modeled any restraint use using a multivariable logistic regression adjusted for sociodemographic and clinical covariates and explored interactions of our two primary exposures using sensitivity analyses and Wald testing. Across 22,259 unique ICU admissions, we identified 11,676 non-ventilated patients. Of these, 2,411 (20%) received an order for physical restraints. In a multivariable regression model, compared to English language, Chinese language (All Dialects) (OR 1.57 [95% CI 1.31, 1.87]) and a language other than Chinese, English or Spanish (OR 1.60 [95% CI 1.36, 1.89]) were associated with increased use of restraints. Patients identifying as Black or African American were also more likely to be restrained at least once during the encounter (OR 1.51 [95% CI 1.27 - 1.79]) compared to Non-Hispanic White patients. Dialysis (OR 9.15 [95% CI 7.74, 10.83]), tube feeds (OR 4.65 [95% CI 3.44, 6.29]), and SOFA score (OR 1.17 [95% CI 1.15, 1.19] per 1 point increase) also independently increased odds of restraint use. Patients preferring a language other than English or Spanish and those identifying as Black are more likely to be restrained in the ICU when not intubated. Interventions to minimize the use of unnecessary physical restraints could improve an inequity known to be associated with downstream harms.

Exploring pathways to compulsory detention and ways to prevent repeat compulsory detentions in England; clinician perspectives

2025-06-20

Ariana Kular , Mary Birken , Lisa Wood +7 more | PLOS mental health.

Rates of compulsory detention in psychiatric hospitals have risen over several decades in England and some other higher income countries. This study explores clinicians’ perspectives on how service users come … Rates of compulsory detention in psychiatric hospitals have risen over several decades in England and some other higher income countries. This study explores clinicians’ perspectives on how service users come to be compulsorily detained in psychiatric hospitals and their suggestions for reducing these detentions in the future. Semi-structured qualitative interviews were conducted with 23 clinicians working with individuals who have been compulsorily detained under the Mental Health Act in England. Interviews were carried out by telephone or videoconference. Data was analysed using template analysis, which involved developing a structured framework to organise and analyse data and to develop themes. Three major themes were identified, with multiple sub-themes (a) service user factors that increase the risk of compulsory detention, including high levels of risk, previous/underlying trauma, medication non-adherence, service user perceptions of their mental health state, disadvantage and discrimination, and lack of stability and involvement from family and social networks; (b) service-level reasons for being detained, including lack of communication and continuity of care, historical inability to obtain trust and confidence from parts of population, clinician biases and assumptions, lack of resources, lack of treatment and care variety, and systemic/institutional barriers to engagement; and (c) potential pathways to reducing compulsory detention, including increasing care quality and patient/family level interventions, investing in services, offering choice regarding medication, offering alternatives to detention, and improving discharge planning. Our study advances the literature by highlighting systemic, patient-level, and service-level factors perceived as driving practice. Better-resourced community services and care planning and strategies to address unconscious bias are identified as potential routes to reducing detentions. However, significant limitations are a preponderance of London-based psychiatrists in our sample, which may affect the generalisability of the findings to other roles and locations, and a lack of corroboration of perceived causality with more objective data.

Evolving trends in psychiatric emergency services in Southern China: a seven-year retrospective analysis

2025-06-18

Cuiling Zhang , Sui-yun Weng , Xiaoyu Zhang +3 more | International Journal of Emergency Medicine

A historical comparison of the success rates and viability of venipuncture in restless patients with differential restraint methods in clinical nursing

2025-06-18

Hongfan Wang , Mei Zhang , Jimin Qiao +1 more | Research Square (Research Square)

<title>Abstract</title> <bold>Background: </bold>Agitated patients in emergency settings face challenges during venipuncture due to unpredictable limb movements, leading to procedural failures and injuries. Physical restraint methods are commonly used, but comparative … <title>Abstract</title> <bold>Background: </bold>Agitated patients in emergency settings face challenges during venipuncture due to unpredictable limb movements, leading to procedural failures and injuries. Physical restraint methods are commonly used, but comparative data on their efficacy, time efficiency, and clinical outcomes remain limited. <bold>Methods: </bold>This retrospective study analyzed data from 387 agitated patients requiring upper limb venipuncture in an emergency department (January 2022–December 2024). Patients were categorized into three restraint groups: elastic band fixation (n=137), splint-band fixation (n=122), and manual hand-holding (n=127). Key outcomes included first-attempt success rate, total procedural time, fixation stability, and complications. <bold>Results:</bold> Device-based restraints (band and splint groups) showed significantly higher first-attempt success rates compared to manual restraint (P<0.05), with no notable difference between the two device groups. Repeated puncture attempts were more frequent in the hand-holding group (P<0.05). The band group required the shortest total operating time, while the splint group demonstrated superior stability (lowest loosening incidence: 9.8% vs. 29.4% ecchymosis in the manual group). Pain scores were comparable across groups, but splint users reported better comfort. <bold>Conclusion: </bold>Splint-band fixation offers optimal stability but demands longer setup time and additional personnel, limiting its practicality in urgent scenarios. Elastic band fixation balances efficiency and success, making it preferable for emergency use. Manual restraint suits mildly agitated, cooperative patients but requires backup strategies. A tiered restraint protocol, tailored to agitation severity and clinical urgency, is recommended to improve outcomes and patient safety.

An Experiential Curriculum and Clinical Care Pathway to Advance Equity for Patients Hospitalized while under Correctional Control

2025-06-18

Carmen Black , T. Bain , Lisa B. Puglisi +2 more | NEJM Catalyst

Shared decision-making when considering hyperbaric oxygen therapy: a systematic review

2025-06-18

Joost R Meijering , Nurseda Risvanoglu , J.H. Nederhoed +3 more | Diving and Hyperbaric Medicine Journal

Introduction: Hyperbaric oxygen therapy (HBOT) is a treatment modality used for various non-acute medical conditions, ranging from ischaemic diabetic ulcers to late post-radiation damage. Despite its wide application, HBOT is … Introduction: Hyperbaric oxygen therapy (HBOT) is a treatment modality used for various non-acute medical conditions, ranging from ischaemic diabetic ulcers to late post-radiation damage. Despite its wide application, HBOT is often time-consuming, requires multiple sessions, and can be physically and psychologically challenging for patients, contributing to high drop-out rates. In addition, treatment results can vary significantly. These challenges suggest the need for more patient-centred approaches, such as shared decision-making (SDM), to improve patient engagement, satisfaction, and adherence to treatment. SDM, which involves patients in the decision-making process, could potentially improve outcomes and reduce dropout rates. This systematic review presents currently available evidence on the extent of SDM in patients eligible for HBOT. Methods: A comprehensive literature search was conducted in the Medline, Embase, TRIP and Cochrane Central databases, from inception up to 29 August 2024, to find all studies with original data on SDM when considering HBOT as a treatment option. Study selection was conducted by two reviewers independently. Desired study outcomes were the application and observed levels of SDM. Results: The search yielded 988 articles of which 24 appeared eligible. After assessing the inclusion criteria and outcomes in the full text articles, zero remained for inclusion: none reported on patient involvement in the decision-making process regarding HBOT. However, six articles did mention that SDM should be an important element when developing clinical practice guidelines for HBOT. Conclusions: Despite the obvious need for preference-sensitive decision-making in HBOT, there is no scientific evidence available on this topic. Possibly, physicians and patients consider HBOT as a last-resort or even the only treatment option. Consequently, involving the patient’s preference regarding HBOT in the decision-making process is rarely documented. Hence, more awareness of the need for SDM is advocated when considering HBOT, which should be corroborated by research in this area.

Comparison of Intramuscular Pharmacological Treatment Options for Acute Agitation: A Multicenter Retrospective Cohort Study

2025-06-18

Ananya Sri Thiriveedhi , Joshua Chang | medRxiv (Cold Spring Harbor Laboratory)

Abstract Objective Acute agitation in psychiatric settings presents significant clinical and safety challenges. Pharmacological management is often necessary when de-escalation strategies fail, but optimal medication regimens remain unclear. This study … Abstract Objective Acute agitation in psychiatric settings presents significant clinical and safety challenges. Pharmacological management is often necessary when de-escalation strategies fail, but optimal medication regimens remain unclear. This study evaluates the safety, efficacy, and adverse event profiles of commonly used intramuscular (IM) pharmacologic regimens for acute agitation in a multicenter cohort. Methods We conducted a retrospective cohort study using de-identified data extracted from the HCA Healthcare corporate database. Adult psychiatric patients who received PRN intramuscular medications for acute agitation were included. Patients were stratified into four treatment groups based on administered medication: (1) haloperidol monotherapy, (2) haloperidol + lorazepam, (3) haloperidol + diphenhydramine, and (4) haloperidol + lorazepam + diphenhydramine. Outcomes assessed included frequency of PRN use, benztropine administration, and incidence of hypotensive and hypoxic episodes. Generalized linear modeling was used for statistical analysis. Results The combination regimen of haloperidol + lorazepam + diphenhydramine (Group 4) was associated with significantly higher odds of receiving multiple PRN administrations compared to haloperidol alone (Group 1). However, this regimen, along with the diphenhydramine-inclusive group (Group 3), was linked to a significantly lower likelihood of requiring benztropine, suggesting a reduction in extrapyramidal symptom burden. No statistically significant group differences were observed in hypotensive or hypoxic episodes. Conclusion Triple-agent regimens may be associated with increased treatment intensity but offer benefits in reducing extrapyramidal symptoms without increasing cardiovascular or respiratory risk. These findings support the thoughtful use of combination IM regimens, particularly those including diphenhydramine, in the management of acute agitation in psychiatric settings.

Replacing Seclusion & Restraint Practices in Psychiatry With Sensory Rooms

2025-06-17

Emma Costain | Columbia Social Work Review

The use of seclusion and restraint (S/R) in acute psychiatric inpatient settings persists as a controversial practice, causing significant harm to patients and stress to staff. This policy brief examines … The use of seclusion and restraint (S/R) in acute psychiatric inpatient settings persists as a controversial practice, causing significant harm to patients and stress to staff. This policy brief examines the ethical, financial, and systemic implications of S/R and advocates for replacing S/R with sensory rooms—an evidence-based approach fostering emotion regulation, patient autonomy, and trauma-informed care. Recognizing that eliminating S/R may not be immediately feasible, this brief proposes an incremental approach through a hypothetical pilot program at Jackson Behavioral Health Hospital: converting an isolation room, or a room where a patient receives intervention separately from other patients, on each psychiatric inpatient unit into a sensory room, alongside incentives to reduce overall S/R usage. Sensory rooms can then be evaluated as a humane and cost-effective alternative to S/R practices. This policy brief aims to advance knowledge on patient-centered interventions in mental health care and underscores the ethical imperatives and financial incentives for legislative and organizational policy reform in psychiatric care. Keywords: seclusion, restraint, sensory rooms, psychiatric inpatient care, policy reform, trauma-informed care, social justice

The Best Interests of Juveniles: Evaluating Jordanian Juvenile Law Against the Convention on the Rights of the Child

2025-06-17

Ibrahim Al-Shawabkeh | Access to Justice in Eastern Europe

Background: The principle of the "best interest of juveniles" is a cornerstone of Jordanian law, reflecting the country's commitment to safeguarding the rights and welfare of children. Anchored in the … Background: The principle of the "best interest of juveniles" is a cornerstone of Jordanian law, reflecting the country's commitment to safeguarding the rights and welfare of children. Anchored in the Juvenile Law No. 32 of 2014 and international obligations under the United Nations Convention on the Rights of the Child (UNCRC), this principle ensures that the rights, development, and protection of juveniles are prioritised in judicial, social, and administrative decisions. Jordanian law emphasises rehabilitation over punishment, focusing on the social reintegration of juvenile offenders while considering their psychological and developmental needs. Methods: This paper examines how the best interest of juveniles is operationalised in Jordanian law, analysing its strengths, challenges, and alignment with international standards. It highlights the importance of a multidisciplinary approach involving legal, social, and psychological perspectives to ensure that juveniles' rights are upheld in all phases of criminal proceedings. Given the nature of the study, multiple research approaches were employed, including an analytical approach to examine all legislative Articles related to the subject, aiming to identify their content, implications, and objectives. Additionally, a comparative approach was used to analyse relevant domestic laws and international conventions concerning juvenile offenders, providing critical analysis and commentary. Results and Conclusions: The paper's findings indicate that the principle of the child's best interest functions as a fundamental right, a key interpretative legal standard, and a procedural framework. Yet, its application varies across the stages of criminal proceedings under Jordanian law, with the trial stage exhibiting the strongest adherence to this principle compared to earlier stages of the criminal process. It is recommended that the Jordanian Juvenile Law be revised to include explicit provisions ensuring legal representation for juveniles at all stages of criminal proceedings, covering all types of offences, rather than limiting it to felonies during the trial phase. The law should also restrict the authority of public prosecutors to extend juvenile detention, expand the jurisdiction of juvenile conciliation courts to include all misdemeanours not only those punishable by up to two years of imprisonment—and exempt juveniles from the application of flagrante delicto rules.

A pragmatic and ethical guide for addressing life‐sustaining treatments in patients with suicidal thoughts or behaviors

2025-06-17

Nurlan Aliyev , Chad Vokoun , Lou Lukas | Journal of Hospital Medicine

Administering Parenteral Medications in Managing Patients with Acute Arousal in the Behavioral Assessment Unit of the Emergency Department in Hospital Settings

2025-06-16

M. L. Harshini , K Boyce , Yiting Gong +3 more | Clinics and Practice

Background/Objectives: The administration of parenteral medications is essential in managing acute arousal within the Behavioral Assessment Unit (BAU) of the emergency department (ED), where timely and effective intervention is critical. … Background/Objectives: The administration of parenteral medications is essential in managing acute arousal within the Behavioral Assessment Unit (BAU) of the emergency department (ED), where timely and effective intervention is critical. This study aims to evaluate current practices surrounding the use of parenteral medications for patients with acute agitation, focusing on adherence to protocols, medication safety, documentation accuracy, and patient outcomes. Methods: A retrospective analysis was conducted on 177 cases from December 2023 to February 2024. The study assessed the demographics, diagnoses, treatment protocols, and patient outcomes, with a particular emphasis on the use of parenteral medications such as benzodiazepines and antipsychotics. The relationship between medication administration and involuntary admission, mechanical restraint usage, and patient outcomes was also explored. Results: The majority of patients were aged between 21 and 30 years, and there was a predominance of male patients across both groups. Schizophrenia was the most common diagnosis, with a higher prevalence in the parenteral group (34%) compared to the oral-only group (24%), and personality disorders were more frequent in the parenteral group. Intramuscular (IM) medication administration was strongly associated with the use of mechanical restraint, with patients receiving IM medication being 35 times more likely to require restraint, emphasizing the link between more intensive treatment approaches and behavioral challenges. The most frequently administered medications were diazepam (40.6%) and olanzapine (36.5%), with olanzapine, droperidol, and diazepam most commonly used parenterally. Documentation of physical assessments prior to parenteral administration was present in most cases, though comprehensive evaluations such as ECGs were inconsistently performed. Conclusions: Parenteral medications, including benzodiazepines and antipsychotics, were effective in rapidly stabilizing patients, but the study emphasizes reducing dependency on mechanical restraints. Tailoring treatment to patient characteristics and employing alternative de-escalation strategies can improve safety and align with recovery-oriented care. This study highlights the need for evidence-based practices to optimize care and improve patient outcomes in ED settings. Further research is needed to explore long-term outcomes and refine non-coercive care approaches.

Intranasal Drug Administration for Psychomotor Agitation as a Safe and Effective Prehospital Intervention: An Integrative Review

2025-06-16

Amaya Burgos-Esteban , Valvanera Cordón-Hurtado , Marta Giménez-Luzuriaga +7 more | Nursing Reports

Introduction: Psychomotor agitation represents a complex medical emergency, particularly challenging in prehospital settings. Since March 2020, the incidence of psychomotor agitation has significantly increased. Rationale: Emergency Medical Services (EMS) frequently … Introduction: Psychomotor agitation represents a complex medical emergency, particularly challenging in prehospital settings. Since March 2020, the incidence of psychomotor agitation has significantly increased. Rationale: Emergency Medical Services (EMS) frequently serve as the first point of contact, bearing the critical responsibility of effectively managing these situations. Objective: This was to assess the feasibility and suitability of the intranasal route for administering pharmacological therapy in the prehospital management of patients experiencing psychomotor agitation. Materials and Methods: An integrative review of the literature was conducted to evaluate the use of the intranasal route for drug administration in patients with psychomotor agitation in prehospital settings. The review was carried out between September 2022 and July 2024. A total of 454 articles were identified, 15 of which met the inclusion criteria. These were supplemented by an additional 10 records, resulting in the analysis of 25 studies. Results: Seventeen studies outlined protocols for managing agitated patients, five described the correct technique for intranasal drug administration, and eleven identified drugs suitable for this route. Conclusions: The intranasal route is a safe, rapid, and accessible method for the pharmacological containment of agitated patients in prehospital settings, particularly for individuals who are uncooperative.

Harm Reduction in Inpatient Hospital Settings: An Ethics (Principlist) Analysis

2025-06-14

K A Birkness , Cheryl Forchuk , Jonathan Serrato +1 more | Health Care Analysis

Determinants of mechanical restraint and the role of verbal de-escalation techniques in patients with schizophrenia during involuntary hospital transfer

2025-06-14

David Córcoles , Francesc Roma i Casanovas , Jordi León‐Caballero +6 more | Journal of Psychiatric Research

Does Compulsory Community Treatment for Discharged Forensic Hospital Patients Work? The Recent Evidence Base

2025-06-13

Melinda DiCiro , Melanie J. Scott | CNS Spectrums

Measures of healthcare decision-making ability in cognitive aging: a scoping review from the Advancing Reliable Measurement in Cognitive Aging and Decision-Making Ability (ARMCADA) research initiative

2025-06-12

Molly A. Mather , Berivan Ece , Tatiana Karpouzian‐Rogers +7 more | Frontiers in Public Health

Introduction Declines in decision-making (DM) ability are often observed with increasing age and pose significant risk for negative health, financial, and functional outcomes. The Advancing Reliable Measurement in Cognitive Aging … Introduction Declines in decision-making (DM) ability are often observed with increasing age and pose significant risk for negative health, financial, and functional outcomes. The Advancing Reliable Measurement in Cognitive Aging and Decision-making Ability (ARMCADA) research initiative aims to improve measurement of DM ability in aging to facilitate early detection of cognitive and functional decline. This scoping review summarizes the extant literature on DM measures in aging, focusing specifically on measures relevant to healthcare decision-making (HCDM). Methods We identified articles published between 2018 and 2023 using keywords related to DM abilities in aging populations. Titles and abstracts were first reviewed by two trained reviewers, followed by full-text review and extraction. Results of the current scoping review are reported in adherence to PRISMA-ScR guidelines. Results The scoping review identified 16,286 articles across multiple domains of decision-making, 705 of which met criteria for extraction, and 246 of which were related to healthcare decision-making. There were 86 unique measures across these articles, and 18 of these measures directly targeted decision-making ability. Most measures were administered to clinical groups in English and in-person with a trained examiner. Measures of healthcare DM ability tended to consist of semi-structured interviews or performance-based items, though there were also several self-report measures. Discussion The most commonly used measures to assess HCDM ability require trained administration of a semi-structured interview to assess ability to reason about health-related scenarios and are often time-intensive. Creation of a streamlined, standardized measure to assess HCDM ability will benefit both research and clinical care for the aging population.

Co-Production of Care Plans to Improve Safety on High-Dependency Rehabilitation Psychiatric Wards

2025-06-01

O. Malik , Arup Kumar Misra | BJPsych Open

Aims: Care plans are the cornerstone of Rehabilitation Psychiatry. These were not being completed collaboratively with patients during monthly ward rounds, leading to impaired communication, lack of patient involvement in … Aims: Care plans are the cornerstone of Rehabilitation Psychiatry. These were not being completed collaboratively with patients during monthly ward rounds, leading to impaired communication, lack of patient involvement in risk reduction strategies, and frustration. This contributed to volatility and increased risk incidents. This Quality Improvement Project aimed to Co-produce Care Plans with staff and patients with primary outcomes relating to reducing risk incidents and secondary outcomes aiming to improve Staff and Patient engagement with Care Plans. Methods: Baseline questionnaires (Likert scale and open-ended questions) were conducted with clinical staff and patients to assess care plan satisfaction. Feedback revealed concerns about care plan length (average of 40–60 pages), user-friendliness, appropriateness and engagement with patient/carer views not captured conspicuously. This feedback was discussed with the Senior Management Team and care plan survey participants. A report with graphs was sent to Maple ward staff and stakeholders and later presented at the National Steering Rehabilitation Cygnet group meeting. A new care plan template was co-produced in two focused group meetings (8 paged). The ward round format was changed to being care plan-based, aligned with Cygnet’s rehabilitation standards. A multimedia screen was purchased to support collaborative care plan completion. The new care plan featured columns for verbatim patient views, relevant discipline feedback, goals, and evaluations. The rows included sections for Treatment (Psychology, Occupational Therapy, Nursing, Social Needs, and Medical), Safety (Risk Management Plan), Recovery (Discharge Planning), Physical Health, Well-being (Spiritual, Cultural, Protective Factors), and Monthly Patient Progress Feedback. Results: Primary outcomes showed a substantial reduction in physical restraints (65.5%), rapid tranquillisations (90%), and physical aggression (35%). However, verbal aggression incidents increased by 311%, though they did not escalate to restraints or tranquillisations, indicating improved ward safety. The project led to a significant positive impact: 100% of patients now read their clear, concise care plans. Secondary outcomes showed an increase in patient satisfaction with care plans (57%), staff views on care plan effectiveness (60%), and a reduction in care plan length (62%). Conclusion: Patients, carers, families, social workers, and advocates actively collaborated with multidisciplinary staff and Community Mental Health Teams to achieve shared goals and provide real-time feedback. To support co-production initiatives, infrastructure must be in place, and processes should be streamlined to ensure efficient embedding of quality improvement learning, including policy updates. Given the successful outcomes of the pilot, the project is being considered for national rollout across Cygnet Healthcare’s rehabilitation wards.

The Monitoring of Physical Health Observations After the Administration of Rapid Tranquillisation

2025-06-01

Viktoria Turimatsova | BJPsych Open

Aims: Rapid tranquillisation is a restrictive practice used to manage acute behavioural disturbance, where medication is given in the form of an IM injection. The first-line medication used is lorazepam. … Aims: Rapid tranquillisation is a restrictive practice used to manage acute behavioural disturbance, where medication is given in the form of an IM injection. The first-line medication used is lorazepam. There is an increased risk of the emergence of serious side effects (sedation, loss of consciousness and respiratory depression/arrest) from giving lorazepam via the IM route. MPFT SOP states that physical observations must be checked at a specified frequency and duration and recorded on the restrictive interventions monitoring form found on the RIO IT system. The monitoring at Norbury House (PICU) in Stafford (MPFT) is often incomplete. This audit evaluates the current adherence to the SOP by reviewing the monitoring of physical observations after the administration of rapid tranquillisation, identifying some of the reasons for incomplete monitoring and areas of practice that require improvement. This audit aims to demonstrate the importance of physical health monitoring and focus on improving patient safety by ensuring stricter adherence to monitoring protocols. Methods: Data was collected between 8 September and 8 November 2024. To assess the current compliance with the SOP, data will be collected from the EPMA and RIO IT systems to check that the physical observations have been recorded at the correct frequency and duration as per SOP. To identify some of the reasons for incomplete monitoring, a Microsoft form questionnaire will be sent to staff members at Norbury to complete anonymously. The collected data will be used to identify areas of practice that require improvement. Results: From twenty-one cases, there was one case where monitoring was completed, five cases where no monitoring or documentation was recorded, eleven cases where monitoring and documentation were recorded but not completed and four cases where monitoring and documentation were partially completed. Based on the eleven questionnaire responses, three responses outlined the SOP correctly, four were unsure, and the remaining four were incorrect. Barriers to completing monitoring included patient agitation, time restrictions, forgetting to document, no computer access and low staffing levels. Suggestions for support included education, appropriate delegation of tasks, EPMA alerts, adequate staffing levels and frequent re-auditing. Conclusion: There is evidence that the current adherence to monitoring protocols is below the set standard. The data collected demonstrates that monitoring is often incomplete. The questionnaire responses highlighted the gaps in knowledge of the SOP and the existing barriers to completing the monitoring. Measures that could be taken may include staff education, alerts and frequent re-auditing.

Effectiveness of Zonal Observation in Reducing Restrictive Practices on a Male Psychiatric Intensive Care Unit (PICU) Over a One-Year Period

2025-06-01

Yetunde Arowora , Faizaan Syed , Shantala Satisha | BJPsych Open

Aims: We aimed to reduce the use of seclusion, 1:1 and 2:1 observations in our PICU, without compromising safety, by introducing zonal observation levels which is considered less intrusive, allowing … Aims: We aimed to reduce the use of seclusion, 1:1 and 2:1 observations in our PICU, without compromising safety, by introducing zonal observation levels which is considered less intrusive, allowing greater privacy for the patient and better engagement. Hypothesis: We expect a reduction in number of enhanced observations with no change in levels of aggression with a further reduction in the second survey as staff become more confident in using zonal observations. Background: PICUs often rely on enhanced observations, such as 1:1 or 2:1, to reduce violence and aggression. However, these practices have limited evidence of effectiveness and are frequently perceived negatively by staff and patients. At Willow Suite, a 12-bed male PICU, zonal observations were introduced in January 2024 as a less restrictive alternative. This approach involved designating staff to specific zones for proactive engagement with patients while maintaining safety and improving patient experience. Methods: Data were collected from clinical records and incident reporting systems for three periods: pre-implementation (November–December 2023), immediate post-implementation (January–February 2024), and 10 months after implementation (November–December 2024). Key metrics included incidents of violence, seclusion episodes, and the duration of enhanced observations. Results: The duration of enhanced observations reduced significantly, from a total of 51 days to 22 days in the first 2 months and maintained the same 10 months later. The average length of enhanced observations decreased by 58% immediately post-implementation, from 8.5 days per incident to 3.6, and further reduced to 3.1 days after 10 months. Seclusion episodes initially increased from 6 to 11 as staff were adapting to the new system, but the average length of seclusion dropped from 3.2 to 2.2 days with 55% of seclusions lasting a day or less. After 10 months, seclusion incidents had reduced further to 10 with average length of 2.5 days. The length of all restrictions combined reduced from 70 days (average length 5.8 days) to 17 (average 2.7) in the first 2 months and to 11 (average 2.9) 10 months later. There was no increase in incidents of violence and aggression in the initial 2 months and a reduction 10 months later. Conclusion: The results suggest that zonal observations successfully maintained safety while reducing restrictive practices in our PICU over a one-year period. Other benefits observed were improvement in staffing consistency, increased staff confidence in managing clinical risks as well as patients reporting improvement in overall experience and engagement.

To Prescribe or Not to Prescribe: A Quality Improvement Project in Improving Resident Doctors’ Confidence in Managing Acute Behavioural Disturbance

2025-06-01

Zareen Ahmad , Rahat Ali , D. G. ff. Edward | BJPsych Open

Aims: The management of acute behavioural disturbances necessitates an appreciation for the potential methods, risks, and monitoring requirements needed following assessment and initiation of management. A previous quality improvement project … Aims: The management of acute behavioural disturbances necessitates an appreciation for the potential methods, risks, and monitoring requirements needed following assessment and initiation of management. A previous quality improvement project highlighted variability in clinicians initiating rapid tranquillisation agents in response to the same clinical vignette. This study aimed to improve Resident doctors’ confidence in deciding to use pharmacological or non-pharmacological methods in managing acute disturbance by 25%. Methods: Initially, a fishbone diagram was created to help visualise the possible causes contributing towards lack of confidence in managing acute behavioural disturbance via word-of-mouth conversations. Subsequently, a quantitative survey was circulated amongst 25 resident doctors in a single district general hospital. The survey consisted of questions using a 5-point Likert Scale, with scores of ‘1’ representing ‘no’ and ‘5’ representing ‘extremely’. Following this, a teaching session was organised as part of the local foundation programme teaching series to help clarify common queries. A second questionnaire was then circulated, and feedback was gained to investigate changes in confidence, as well as inform future interventions. Results: A total of 25 people had completed the baseline questionnaire. Confidence in utilising non-pharmacological approaches improved by 21%. Confidence in prescribing in acute disturbances improved by 32%. Overall confidence in managing a delirious patient improved by 26%. Conclusion: Post-intervention, Resident doctors’ confidence in managing acute disturbances improved by 26%. Following feedback, a poster has been developed, and Resident doctors’ confidence will be re-audited.

How Robust Are Our Care Plans for Patients Detained Under Community Compulsory Treatment Orders?

2025-06-01

Louisa Adam , Stan Houston , Suzanne Galloway +2 more | BJPsych Open

Aims: The Mental Welfare Commission (MWC) released a report in February 2024 recommending the use of audit to ensure good clinical practice in the use of community Compulsory Treatment Orders … Aims: The Mental Welfare Commission (MWC) released a report in February 2024 recommending the use of audit to ensure good clinical practice in the use of community Compulsory Treatment Orders (cCTO) as part of the Mental Health (Care and Treatment) (Scotland) Act 2003 (MHA). One particular area of concern was the use of care plans under section 76 of the Act. An audit was performed across NHS Lanarkshire Mental Health services to determine if all patients on cCTOs had Section 76 care plans in place that were valid and compliant with the minimum standards set out by the MWC. Methods: Medical records administration staff were contacted across all of the psychiatry specialities within the health board, to supply a list of patients on cCTOs. Their electronic medical records were reviewed and relevant data collated by the authors to determine if the appropriate paperwork was in place, was valid, and met the minimum standards, as set out by the MWC. Results: Within NHS Lanarkshire, there were 89 patients on cCTOs. 87 of these had a Section 76 care plan in place, though one of these was considered invalid. Only 24% of the care plans were found to meet all of the minimum standards. There was noted to be a high degree of variability in which of the minimum standards were met, how the care plans were documented and the quality of the information contained within them, across the specialties and between individual psychiatrists. Conclusion: This was the first audit looking at cCTO Section 76 care plans carried out in NHS Lanarkshire. It demonstrated there is a need for standardisation of these care plans across mental health services, to ensure that as a minimum, all statutory information is documented. Recommendations from the audit included the use of a proforma to capture the information required to meet the minimum standards, as well as provide prompts for additional information to improve the quality of the care plans. It has also been recommended that each psychiatry specialty sets up their own annual audit of care plans, and an audit tool for this has been provided.

A Clinician’s Guide to Ethical Challenges in Discharge Planning: Proportionality, Risk, and Justice

2025-06-01

George Chengxi Bao , Sydney Katz , Debjani Mukherjee +1 more | The American Journal of Medicine

Prescription of Antipsychotic Medications in Delirium in Older Adults in a General Hospital Setting

2025-06-01

Mete Demir , Daniel Waheed , Katie French +1 more | BJPsych Open

Aims: Assess whether antipsychotics were prescribed according to MHRA (2021) and NICE (2023) guidelines. Identify areas requiring improvement in clinical practice. Methods: Retrospective case audit of older adults (65+ years) … Aims: Assess whether antipsychotics were prescribed according to MHRA (2021) and NICE (2023) guidelines. Identify areas requiring improvement in clinical practice. Methods: Retrospective case audit of older adults (65+ years) referred to Liaison Psychiatry at Chesterfield Royal Hospital for confusion/delirium between 01/08/2023–31/05/2024. Data was extracted from patient records and analysed in Microsoft Excel. Ethical approval obtained from Derbyshire Healthcare NHS Foundation Trust (26/04/2024). Results: Haloperidol was the most used antipsychotic (65.38%). Lorazepam (4 cases) or no medication (1 case) was used instead when contraindications were present. Antipsychotic use was predominantly guided by clinical presentation, with most cases aligning with best practice recommendations. Patients who did not receive haloperidol had documented contraindications, emphasising appropriate clinical decision-making. 100% of patients who received antipsychotics had documented distress or risk to self/others. •Baseline ECG compliance was suboptimal (47.06%), highlighting an area for improvement. Repeated ECG monitoring after dose escalation was infrequent (5.88%), indicating a gap in guideline adherence. Some documentation gaps may have contributed to apparent non-compliance. Conclusion: The assessments done by Liaison Psychiatry team were mainly compliant with the standards provided by the MHRA and NICE. Most patients (65.38%) who received an antipsychotic were prescribed haloperidol as per NICE guidelines. It was clearly documented in the medical records for all patients that their presentation was a possible risk to others or themselves. Compliance to ECG requirement and recording previous ECG were weaker; though, it is important to acknowledge that in some instances, severe patient agitation made obtaining an ECG challenging. It was felt that the urgency of situation, patient’s level of agitation and distress caused to other ward patients were the most common causes that prompted Liaison team and Acute Trust staff to prescribe haloperidol without first obtaining an ECG. It is also important to consider the possibility that lower compliance might be related to lack of documentation rather than ECG not being done. Recommendations: Ensure ECG is performed and documented before prescribing antipsychotics. Record reasons if ECG is not feasible due to patient agitation. Repeat ECG after every dose increase to monitor QTc prolongation. Liaison team nurses to receive ECG interpretation training. Poster to remind staff to ask for and document ECG. Create and distribute a guideline summary to the team. Explore feasibility of including ECG specific reminder in the new core assessment/letter template (e.g. prompt).

An Audit on Did Not Attend (DNA) Rate in the Learning Disability Outpatient Mental Health Setting, BCHFT

2025-06-01

Aliyah Rehman , Joseph Vella | BJPsych Open

Aims: Service users not attending outpatient clinics without prior notification are considered as DNA. We intended to identify the factors contributing to DNA in ID patients, with a view to … Aims: Service users not attending outpatient clinics without prior notification are considered as DNA. We intended to identify the factors contributing to DNA in ID patients, with a view to mitigate the risks and safeguarding concerns associated with it and also to assess staff compliance with the Trust’s DNA policy. Methods: Trust DNA policy states that “Ring patient after DNA, to check if the patient was aware of the appointment, and discuss the barriers of non attendance and then document accordingly.” Using this policy as standard, we retrospectively evaluated the electronic patient notes who did not attend their appointments over the period of 2 months. Data regarding demographic details, diagnosis, neuropsychiatric comorbidities, social circumstances, treatment modalities and post DNA actions were collected. Results: Out of the total 117 appointments over 2-month period, 35 (29%) patients didn’t attend scheduled appointment. 69% of these patients were males, 47% live with their family, 38% in residential settings, 13% in supported living and 3% live alone. The severity (mild, moderate or severe) of intellectual disability was distributed approximately equally comprising about one-third each, with 3% needing diagnostic formulation. 51% have co-morbid autism, 14% have epilepsy and another 14% have depression. Only 3% have comorbid psychotic illness. 91% are on regular psychotropics, 6% on as-required medication and 3% are receiving psychosocial interventions only. In terms of post DNA actions, staff contacted 34% via telephone after the DNA, however no details aligned with the policy were being documented. No contact made for 57% of the patients, and for 9% there was no documentation on electronic progress notes. 83% were offered another appointment, 17% got discharged back to the care of GP. Conclusion: Non-attendance at appointments is most significantly influenced by male gender, living with family and having neuropsychiatric comorbidity, which appeared as the dominant contributing factors. Compliance with the trust’s policy is below standard, recommendations were suggested to adapt DNA policy for this patient group and to increase awareness among divisional staff during the Induction programme.

Challenges and Best Practices in Consent to Treatment at University Hospital Wishaw

2025-06-01

Saba Ansari , Laura Inglis | BJPsych Open

Aims: We aimed to assess adherence to the Mental Health Act Code of Practice within University Hospital Wishaw’s inpatient psychiatry setting, focusing on the documentation of consent to treatment for … Aims: We aimed to assess adherence to the Mental Health Act Code of Practice within University Hospital Wishaw’s inpatient psychiatry setting, focusing on the documentation of consent to treatment for patients under Compulsory Treatment Orders (CTO). Compulsory Treatment Orders (CTO) authorize the treatment of mental disorders under specific legal and ethical guidelines, requiring meticulous documentation of consent. Initial reviews highlighted poor electronic documentation standards for patients under CTOs, prompting a proposed practice change to include scanning and filing consent forms electronically. Methods: An initial review was conducted in December 2022 across three inpatient wards at Wishaw General Hospital, covering 57 patient records to establish the presence and adequacy of T2 and T3 documentation. A follow-up review in January 2025 re-examined 65 records to assess improvements in electronic record-keeping and documentation practices following the implementation of the proposed changes. Results: The 2024 review showed that all patients under CTOs had their T2B or T3B forms properly documented in physical and electronic formats. However, only 70% had their consent status adequately recorded in the electronic clinical notes. This marked a significant improvement in electronic record-keeping from the initial 2022 review. Conclusion: The integration of scanned consent forms into electronic records has enhanced the accessibility and quality of documentation, allowing for better coordination of care across multiple units. Despite these improvements, the consistent documentation of patients’ capacity and consent status during clinical reviews remains a challenge. Ongoing education for medical staff and further reviews are recommended to ensure continuous adherence to the Mental Health Act Code of Practice and improve documentation practices.

Lethal Means Management Innovations in Community Pharmacies: A Pre-Implementation Study in Six States

2025-06-01

Jill E. Lavigne , Jennifer West , Delesha M. Carpenter | Journal of the American Pharmacists Association