Abstract
Introduction
Since the 1950s, developments in mental healthcare and the activities of human rights movements has changed the focus from a prescriptive type of treatment and control to one that takes into consideration the views and respects the human rights of mentally ill people. Consequently, individuals suffering from a psychiatric disorder are currently regarded as vulnerable and requiring protection, as well as access to treatment programmes that provide humane care, a substantial degree of choice and respect for autonomy (Harding, 2000). As the previous procedures leading to compulsory treatment are considered to jeopardize the rights of mentally ill people (International Commission of Jurists, 1992) and to constitute a fundamental infringement of their civil liberties (McIvor, 1998), the legal framework for involuntary admission and treatment has been reformed in many countries around the world (Dressing and Salize, 2004; Swanson et al., 2000; Wachenfeld, 1992).
International organizations have published official documents outlining their concerns and safeguards that need to be implemented in compulsory admission legislation and practice to protect patients’ individual rights. In particular, in February 2000 the Steering Committee on Bioethics (CDBI) produced a white paper on the protection of human rights and dignity of people suffering from mental disorders, especially those placed in psychiatric establishments against their will. In 2003, the World Health Organization (WHO, 2003) also published a mental health policy and service guidance package. Both documents endeavour to strike a difficult balance among three often conflicting interests: the basic human rights of the person who suffers from mental illness, his/her need for adequate treatment and the right of the public for safety (WHO, 2003). To achieve this, they offer broad suggestions and generally describe ‘good and politically correct practice’.
On a national level, in Greece, involuntary admissions are regulated by Law 2071, which replaced the previous law in 1992 to bring the country in line with the European prerequisites for joining the EU. When the law was introduced it was recognized as an important, albeit belated by some, step towards acknowledging and securing the rights of people with mental illness. The law recognized, for the first time in Greece, the right of appeal for psychiatrically ill individuals against involuntary hospitalization. It is also worth noting that for the first time in Greek mental health legislation, the courts of law are involved in the process. In particular, Law 2071/92 describes two procedures to be followed: rhe ‘regular’ and the ‘emergency’. The former requires two separate psychiatric assessments by ‘approved’ psychiatrists to be completed before admission. Once the psychiatrists complete their reports, the nearest relative takes them to the public prosecutor who is on duty that day and who is authorized to issue a warrant for the police to escort the person with an acute psychiatric disorder to the hospital for admission. Alternatively, the ‘emergency’ procedure bypasses the initial psychiatric assessments and puts the relatives requesting admission in direct contact with the on-duty public prosecutor. It important to note that the emergency procedure is used almost invariably. According to this, the individual whose relative has requested a psychiatric assessment for involuntary admission is escorted by the police to the psychiatric emergency department that is on call that day.
In the absence of the ‘nearest relative’, the procedure for a mental health assessment to assess the need for involuntary admission is instigated ‘ex officio’. In this case the public prosecutor him/herself makes the application and orders the police to take the individual for assessment. The public prosecutor gives this order in writing after he/she is alerted by the police or a member of the public (e.g. a neighbour). Only in cases of grave emergency can the public prosecutor order the police orally.
Once the person due to be assessed arrives in the psychiatric unit on call, he/she is examined by two qualified psychiatrists. If the following criteria are met, the appropriate forms are completed to be returned to the public prosecutor and the individual is admitted against his/her will:
He/she is suffering from mental illness.
Because of the mental illness, he/she is unable to look after him/herself (refuses treatment, does not accept there is something wrong with him/her).
The disorder will not subside if untreated and as a result his/her life or the life of others is at threat
In an empirical investigation of the implementation of the particular law in Greece, evidence has been disheartening. Before the introduction of the new legislation, compulsory admissions had reached as high as 97% in 1979 (Bilanakis, 2004). Current figures assume involuntary admissions to be as high as 40%–50%, despite the closure of large mental hospitals (Liakos, 2004). One recent study that compared voluntary and involuntary admissions in 1977 with those in 1997 showed that there has been little improvement in the pattern of admissions throughout the years and that it has become routine practice to impose involuntary psychiatric assessment on the patient (Pehlivanidis et al., 2001). The implications of this are obvious. First, patients’ rights are being violated to such an extent that reviewers of the topic set Greece as an example of why there is an imperative need to focus internationally on possible infringements on the rights of mentally ill and establish national data to address this issue (Pallis et al., 2007). Second, such practices contribute to stigmatizing attitudes towards people with mental illness and subsequent discriminatory acts against them (Farnham and James, 2000). For example, a national study on stigma endorsement in Greece has revealed unfavourable public attitudes towards people with serious mental illness and disapproval in the prospect of them residing near their houses (Economou et al., 2009). For these reasons, a further exploration of the associations between several demographic variables and compulsory admissions is necessary to shed light on the various processes.
The present study aims to describe the characteristics of the individuals who are brought in by the police for psychiatric assessment, focusing on matters of ethnicity, violence associated with the procedure of involuntary admission, and standard psychiatric practice during assessment.
Methods
Assessment procedures
A prospective study was conducted of the incident books of the police departments concerning involuntary psychiatric admissions. These books were completed by the police officers who took part in the procedure and who brought individuals to the emergency psychiatric department on call for a psychiatric evaluation. The police officers’ sensitization and training in completing these books had begun three months before the start of the study. Following their input, the decision was made to concentrate on as few parameters as possible because police officers tend to omit medical details and asking them to record many details could lead to inaccuracies. Following consultation with the police, a specific form was developed for the police officers on duty to complete once he/she and the rest of the police team involved in the procedure returned to the police station after a mental health assessment.
The study period lasted six months, from June to December 2005. During this period 2,038 mental health assessments for involuntary admission took place in the whole of Greece. The data collected were: demographic data of the examined person – i.e. gender, age, nationality and various elements concerning the police procedure; the identity of the person asking for the involuntary examination; the length of time the examined person was kept in the police station before being taken to the on-call psychiatric unit for examination; and whether the person was either admitted or released. Some circumstances of the examination were also noted: police officer’s presence during the psychiatric evaluation; resistance of the examined person; and whether family members accompanied the individual. Finally, the outcome of the psychiatric examination was recorded: involuntary admission or not; and whether the psychiatric unit to which the patient was admitted was public or private.
Data analysis
The following tests were used for the statistical analysis of the data. Fisher’s exact test was used for comparison of percentages. The student t-test and one-way analysis of variance (ANOVA) were used for comparison of means of variables. For non-parametric variables, Mann-Whitney U-tests and the Kruskal-Wallis test were used. The level of statistical significance was set to < 0.05. Multivariate analysis was performed using logistic regression. Correlations were tested by the Pearson (r) or the Spearman (rs) coefficients, depending on whether the variables were normally distributed or not.
Results
From the 2,038 involuntary assessments evaluated, 110 were not included in the study because of missing information; therefore, data from 1,928 involuntary assessments were analysed. The mean age of the examined individuals was 42.5 years (range 14–95 years) (Table 1).
Distribution of groups of ages
The total is less that the total studied (N = 1,928) because of missing data.
The sample consisted of 1,859 Greeks (96.4%) (mean age 42.7 years, SD 13.8 years) and 69 foreigners (3.6%) (mean age 36.1 years, SD 10.3 years), with the latter being signicantly younger (t = −5.1, p < 0.001). Their countries of origin are shown in Table 2.
Examined persons’ country of origin
Most of the examined persons were male: 1,327 vs. 601 female individuals (69% vs. 31%). Males were significantly younger (mean age 40.9, SD 12.8 years) than females (mean age 45.9 years, SD 14.8 years) (t = 7.06, p < 0.001).
Almost everyone was admitted involuntarily. From 1,928 assessed individuals, 1,687 (87.5%) were kept involuntarily hospitalized and only 241 (12.5%) were allowed to return home. There was no association between involuntary commitment and age (p = 0.15), gender (p = 0.35) or nationality (p = 0.71).
As expected, most mental health assessments took place at the request of family members (Table 3). When this was associated with nationality, it was found that this procedure was mostly followed for the Greek individuals. Almost half of the requests for mental health assessment of non-Greeks were ex officio (43%). This difference was of high statistical significance (p < 0.001). Nonetheless, the ex officio and family requests for psychiatric assessment resulted in the same percentage of patients being committed to hospital. That is, the mental health assessments led to similar rates of involuntary admission regardless of the status of the individual who requested the assessment (family member or other).
Request for mental health assessment
The total is higher than the total studied (N = 1,928) because it refers to all requests for assessment.
Foreigners were hospitalized more often in public than in private hospitals compared to Greeks (1,577 Greeks vs. 66 foreigners in public hospitals and 226 Greeks vs. 2 foreigners in private hospitals, χ 2 = 12.8, p = 0.012). Relatives were present (they escorted their relative and the police officers to the mental health unit) in 852 of the 1938 assessments (43.9%).
Multivariate analysis logistic regression was performed considering ‘involuntary admission’ as the dependent variable and ‘age’, ‘gender’, ‘nationality’, ‘resisting assessment’, ‘who initiated the mental health assessment procedure’ and ‘family escort’ as independent. Age, resistance and nationality were associated with involuntary admission. According to this, younger patients (p = 0.03), Greeks (p = 0.022) and those who resisted (p < 0.001) were more likely to be admitted.
The rule in most of the cases was that the individual taken for involuntary assessment did not offer resistance (82.3%). Nevertheless, in over half of the cases (58.1%) the police officers stayed with the person during the psychiatric examination (Table 4). Even when the 159 cases where the individual was resistant were excluded, police officers were present during 900 assessments (49.4%). This finding had no relationship with gender, nationality or the examined person’s resistance to the procedure. Of those who did offer resistance, only 3.7% had their behaviour rated as ‘serious’ by the police officers and needed physical force (pushing or pulling) or physical restraint (handcuffs) in order to be taken to the hospital. ‘Serious’ resistance was associated with male gender but not with nationality.
Presence of police and examined persons’ resistance
The total is less that the total studied (N = 1,928) because of missing data.
Discussion
In this study, involuntary admissions were investigated in relationship to demographic characteristics and other variables related to the police involvement in bringing the individuals for assessment against their will. The main findings were that the vast majority (87.5%) of the individuals brought in for mental health assessment were admitted against their will. This is not the case in most European countries where the percentage of involuntary admissions is considerably lower (Salize and Dressing, 2004).
Younger males are more likely to be admitted and immigrants, as far as the present data can ascertain, are treated in a similar way to Greeks. It is noteworthy that the police were found to be unnecessarily present in the majority of the mental health examinations. Younger age and male gender were found to be associated with involuntary psychiatric assessment. In this respect, these results are not different from those of other countries (Lee et al., 2008). The finding that immigrant status was associated with younger age of involuntary psychiatric examination can have many explanations, one being that immigrants overall are younger. Greece received an influx of immigrants from the Balkan states at the beginning of the 1990s. The majority of the first immigrants were from Albania but in recent years the number of immigrants from Iran, Iraq and Afghanistan as well as Africa has increased.
The percentage of immigrants examined is low, bearing in mind that there are over 1 million immigrants in Greece (9% of the total population). The lower than anticipated percentage can be associated with the difficulty in accessing the public prosecutor, the difficulties and suspicion that immigrants have towards the authorities and the fact that some reside illegally, making access to services problematic. This could also explain the finding that almost half of the health assessments for non-Greeks were ex officio initiated. Other explanations could be a lack of local and family support for these individuals, who are most likely first-generation immigrants, and the fact that immigrants with psychiatric problems do not receive psychiatric assessment but are diverted, because of the language barrier and racial issues, towards the penal system. Research in this area should be a high priority for the Ministry of Justice.
The fact that there is no statistical significance in the nationality of people admitted involuntarily is encouraging, bearing in mind earlier reports that indicated that psychiatrists tended to involuntarily admit immigrants disproportionately (Mulder et al., 2006). The different economic status of Greek citizens and immigrants is reflected on the observation that the majority of immigrants were involuntary admitted to state psychiatric units, where treatment provision is free of charge.
The high level of admissions against the will of the patient following psychiatric assessment (87.5%) is a cause for concern. This is in line with previous findings in Greece (Bilanakis, 2004; Pehlivanidis et al., 2001) and in sharp contrast to corresponding European rates, which are far lower (Salize and Dressing, 2004). A possible explanation for this is the underdevelopment of primary psychiatric care in Greece (Bowers et al., 2005; Karastergiou et al., 2005). Another explanation is the degree to which patients with serious mental illness are being stigmatized in Greece (Economou et al., 2009) and their family’s reluctance to refer them to the psychiatric services until the situation is very grave.
The most surprising finding from this study is the large percentage of mental health assessments at which the police were present (58.1%). This finding is more troublesome considering that the individuals assessed did not offer resistance in the vast majority of cases (82.3%). Only 3.7% of individuals who resisted had their behaviour rated as ‘serious’ by the officers involved, resulting in handcuffing or use of physical force. Even when patients were not resistant, police officers remained present during the assessment. Assessing the patient in the presence of a police officer is certainly a breach of confidentiality. The psychiatrist is highly unlikely to succeed in forming a rapport with the individual examined. More worrisome regarding confidentiality is the fact that the police officers who perform the task following the duty prosecutor’s instructions come from the police station that is nearest to the ‘patient’s’ abode. As police officers are not bound to confidentiality, the individual examined, unless totally out of touch with reality, will be even more unwilling to express delusions or admit to hallucinations.
Unless there are strong indications of impending immediate violence from the patient, such as fighting with the police officers during the transport, serious threats towards the psychiatrist or the staff, known history of violence towards mental health staff or the police, one cannot but condemn the practice of mental health assessment in the presence of the police. The psychiatrists who perform mental health assessments in the greater Athens area reported that the practice of police presence during mental health assessment is not common in the capital. It appears that psychiatrists working in rural areas with limited psychiatric resources and an even greater shortage of nursing staff are more likely to accept police presence during assessment. A likely explanation for this finding is that the psychiatrist does not ask the police officers to leave the examination room because he/she is concerned about his/her own safety. If this were the case, it can also offer an explanation for the high percentage for involuntary admission recommendations that the on-call psychiatrist makes. However, the fear of personal safety without clear indications that this is realistic underlines that stigmatizing attitudes are common among psychiatrists in Greece. This raises grave concerns and underlines the need for continuous education and support.
It is worth noting that no difference was found with regard to the percentage of patients involuntarily admitted to private or state psychiatric hospital, indicating that psychiatric assessment is not influenced by the socio-economic status of the patient.
Overall, the data from this study suggest that at least 1,687 psychiatric beds in Greece were used for involuntarily admitted patients during a period of six months. The vast majority of these beds were from the state sector. Taking into account that involuntary hospitalizations are not usually of short duration, this presents a serious burden for mental health services (Wierdsma and Mulder, 2009). These findings lend support to previous studies that show an increase in the number of involuntary admissions against a background of reductions in the number of Greek psychiatric beds (Priebe et al., 2005).
Police participation in mental health assessments for involuntary admission is the norm in European countries and worldwide. Once the procedure involves the legal system, the police (representing the state) will be involved. Although police contact with people suffering from mental illness has been studied to some extent in some developed countries (Harding, 2000; Strauss et al., 2005), Research so far provides limited information about the influence police presence might have during the process of assessment for involuntary hospitalization. There is limited knowledge in the role of the police in the psychiatric emergency room as people are transferred from the street or their home to the hospital. The role and duties of police officers acting with individuals who may be suffering from a psychiatric disorder are clearly delineated in some countries. The present study shows that this is not the case in Greece since police officers in almost half of the cases consider it as part of their duty to be present during psychiatric examination. Research is needed from developing countries in order to clarify whether police presence is common practice during emergency mental health assessments.
Conclusion
The psychiatrists in Greece who perform mental health assessments under the Greek Mental Health Law admit the majority of individuals they assess. Their decision does not appear to be influenced by the nationality or the socio-economic status of the person they examine, but they seem to accept the presence of a police officer during the assessment more often than expected, undermining their alliance with the patient and raising grave concerns about their understanding of the importance of confidentiality. This issue needs to be addressed immediately by means of better training and support of psychiatrists.