2002 - Detention Of The Mentally Ill In Europe - A Review

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Detentionof the mentallvill inEurope-arevlew ZinklerM. PdebeS Dclcntionol lhc menrall)ill in Eurol)1' a rclic\i Acta Psychialr ScaDd2002:106:3 8. e) Blackwell Munksgaard 2002

Priebe MartinZinkler, Sletan r 1,B L n l l d S 0 u a! r d a i r m ! r' r P n d a ! { 1 ja ( r ' e Liid.n 5.ro cr MedLr C@srf,lary!r rrsl! n

Obj€ctive:The nequencyof compulsorlrdmissiorvarieswidel)acrossEurope.Allhoughtherehasbeensomereseafc!ou a nalion widelevel-no uor k hrs beendoneto conpa.enlenlalheaithlegislaiion in differentcountr;es in relationto deienlionfalesand to pal;ents' perception of hospiialdetention Method: Databasesand governrnenistatistics\\'eresearchedfor !rere regional.nationaland Eufopeandata.Legaltuarreworks conpared rnd re\,le$,edm relatio to patlents and professionals Results: Nearly 20-fold varialions ln delenrionrales were found in dilTeren! partsof Exrope Citeria for detertionof tbe mentallyill are (ey*0ids altlude.coe,r0i mnn:menlcl Lln. iegsr.n pojeClcl m4ia.,/; turcoea broadi) snnilar\hen il comesto parientsat risk to thensehesor orhers.Houever differenlrules apply for involuntary ireatmeni ir the DrValr Z nler Unl'oi So.a zd lommriltlps! inleresiof the patieDr's healtb. rh.lfr tasl Fan[4emo,arospl? loloi O 6!8 Conclusion:Varia!ionsin delenlion faresacrossEurope appearto be : influencedb) professjonalselhics aDd atlitudes.sociodelnograpbrc variables.lhe public s preoccupationaboul risk arisrngfrom menial jor pubFtor fe7Ery5 2ll2 illnessand the respeciilelegal framelvork. Am:pted

lntroduclion lnvoluntary admissjonand detentionare *jdely usedto trcal palientswith mental illnessin Europe. Mental heallh legislationon federal and regional leveisprovidescriteria for detentionand treatment. The user riglts rllovementand a focus on colnmutochangesio regulaiions nity basedserviceshaveled and placrice over the last 30 years. For exanple. psycliatric departneDtsin or attached to general hospitals have replacedthe old asylums in nany places. Ho$'ever. psychiatdc patients remain lh.: only client group $ho can be treated against their will. Liltle is kno$n about patients' perception of involuntary adnrisslonir differert couDtries.Legislation varies widely across Europe and a huge variation in delentior rates has been lbund (1). Detention in itself may have adverseeffectson the mental health of patients.Users'initiarivesbave drafted advancedircctives(2) to deterrdne the \\'a_v they are treated in hospital in casethey arc unable t o g r e r . l o n r . e d. o n . e l r l f u r o p e " n i n L c e r " t i o n may warrant the forrnulation of con'llnons!andards ill service provision and rcgulation. To qual1tify

detentioDin pslchialric ho spilalsdelen!i or ratescan be calculaled on a populairon basis per year. H o s e ! e r . o J n d e r . t o n d e l e n t . o rl h. e r e , p e c l i \ e legal framework and the way userspercerveberng detamed ir a hospital in additron 1o tbe aciual corrdruonsof dctcnuon need o bc dkco -lrLo account. The aim of this paper is rherefore lo presentar overview of the current situation rn a *ider conlexl. The paper revjews (A) deteniron mtes.(B) mentalheal!hlegislaljonaod (C) useri and plofessionals'perceplionof dctentionin hospi tal. and finally identiliesfuturc fieldsofrescarch. methods Materialand Lrnbd'c and Medlille ddldb"\e! uere ele, toIi.-detenhor'. alLyscarchedfor paperson coercion. -con iitlnenl.'co1npulsoryadmissjorttreatlnenf. 'rnental healtb legislation'. perceplion of treatmentidetentionrcoercioD' and'in!oluntaLv l1eat men!/adrnission-.The citeria used ilr selection were data on liequency of iilolunlary treatmen!perception of detention and coercron by usels and professionals. infornalion on thc lcgal

Zinkler and Prirbc iianrc\\'ofkfor involuntaryadmrssionin Eulope. The searchexrnincd papcrspublisbcdfrom 1985

Results

In this feview. to oblain cotrparLrblcdrta. delcntionralcsarc dislinguished frour compulsory adlnissionfates.This is because voluDlarilyadnli! ted palicnlscan be dclainedialer or and involun tar rly .rdmit1edpalieDlsmay be dischargedor lnay stay on a voluntary basis. Whefevef necessary detenl;oDrates werc calculatedusing dvailablc T o n u i d l r o r",l i r i . r r . . D a r . r o I l o f c n , r . p d | | r ' wascxcluded. The Sta!isiical Bullelinbv the Bfitish DeparlDleDlof Heal!h(3) and thc Annual Repori b], the Mental Healfi Act MaDagersof Newhan Conrnlunily Health Selvicein London (,1)prolided dala lionr England. Fufthermore. wc used resulls ol prcviouslyunpublisleddata fron Lbe Alpe Adria Associatior for prornolion of Mental Health on compulsorytreatmenrir five European regions: Pofdenone. Trieste. Portogruaro (all llaly). Klagenfurt (Austda) ard Kautbeuren (Gerrnany). This rcsearchwas corducted in 1995 and provrdesdata on all (nonforensic)iivoluntar), patjents lreated over a 6-nonth period in these regions including information on their pslchosocial background.methodsoftreatlnenr and followup arrangements (5). ftrfo-m"lion on Inenlal n(dllh leei.ldLio.rvra. o b l a i | l e dl r o r r 'r h e o ! r a l e g a l e \ r , . C e n n a r \ ard England-information on other countriesfrom scicnti6c publications. Published original articles and re\rielvson users perception of dctcntion in hospital and professionals'atlitudes were selected tiom Enbaseand Medliie Databases.

Table I sbowsdru lrom sonc parrs of Eu|opc. Detentiou ralcs in psychiarrichospilalsldcpal.t nrenlsare calculatedper I00 000 inhabitantsper yerr xrd do not includeforensicpalientsAncarl) - r l - ' ^ l d\ : , r a o n r l l , et r e q L e | | .o) t d e ' p | | o r , J I be found beh'lecnltaly and Firl rd. Onl,vlwo siudics(5.6) obtaineddaLr ftorn diffefentcouD' lncs at the sanc lrme and by the sameDlelhod. E\'cn here rhcfc was a neerly 10 fold difference belweenI$'o Deighbouring and denographically similafregionsiD borh Auslfia and Iu11_. Thc ise i n I L | | r h e fi r , I n l l d n J . r , d A u . r r n r h e- r p r e rs consrstenl on a regioDaland couniry$idelevel A sllnilar1wofold ircreasein involuntarvadlnls sions was found in the Nedrerlandsafter new legislationwas iDtroducedin 1994 (7). Riecher Rdsslerard Rcjsslcrexplainedurban rural differ encesfound by Spenglerand Bdhnc (6) b), special s o c i o . u c t u r acl o n d i r i o r ,(.l l . f h e d e e r o f " r e iD LoDdon is t$ice as high as in olher parrs of EnslaDd(3).

Detanlon rates

Llenla, heath egsator As Riecher-Rdsslerand Rdssler (l) pointed out. srnilar criteria for compulsoryadmissionappll in pnncjple:1) (severe) lnentaldisorder.2)dangerro hinrhersclf or others. 3) (urgcnt) need for treatment. However. nol all rhree criteria arc included in all legal frameNorks. Comparisons of mental ' r e " l l hl e g i . l a . i oinn d i F e r c ncLo u n r e r . h a r e- a r er

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Dclcntionof thementalhill bccnproducedand,wher cxamincd.colsidcronll two countriesrt ol1ctine. lLotlgersand Lepping (9. l0) have exanrncd r - r ' : , 1 l , ( b l r llrc ! . . l r r i o dn d ' c d ' , . 1 p r . ' c t i . e . t ' I n g l . ' u d . , nCde n r r . t r . l rC' r r d n . . r t , d r ri ,r c r l wili if sheihe onl] receivclrcal]nentagainsthis.rher is found 1o be unableto corsert.A shccr'Dccdlbr I r e b l ri.r I u u u l d r , u l ' u l l 1 . Pr . o r , f d l h e r ei r , ^ innninenl and se\,ercdanger lo hiniherself or olhers. In England. compulsoryadnission lbr trcatncnl is possible in the inlereslsof h!\iher heallh... (if) it cannolbe provjdedu lessheishejs detained'(Mental Heal!h Ac! 19E3).The nrosr renarkable diffefence thcy found \\,as. that iD England psychiatricpfolessionals(doclors aDd socialworkers)and relatives decideor compulsory admission.whilst in Gernany a court alwayshas to be involved. Van Ll-dseberrer aDd lgodt (ll) have recently compared English and Belgian leglslaljoD.French and English psychialric legislation have been examiredby LaffontaDdPriest(12).Mentalillness in the defilitior of lhe English Mertal Health Act does not include all psychiatricdisordersof the ICD 10.It is reslricledto conditionswith psychotic symptoms or cogniljve impaimrent. Patients wrth leaning disabllitles and penoraiil).Mdisorderscar only be detained for'abnollnally aggressrveor scriousl)'.irresponsibleconduct (Mcnral Heahh Acl 1983)and ifmedical treallllenl is likely to alleviate or prevent a deterioration of thejr condilion. In France and Bclgium nental illness is not further defined. A similarity in French and English legisialion is the prominenr rolc of lhe nearestrelative, who can apply for adnission and has the rjght to dischargea patient. as long as there 1sno risk lo public safetyor. in England,lo dre patienfs safety. (7. l5) Both Austria( 13,14)and the Netherlands havc introduced new psychiauic legisiationin the early ninetjes.The new menlal hcalth laws empha s u c du . c r ' r . g ' t . a I d L . e r . l ( g d lr c p r e . ( r t a l i ot|o| safeguard lbeir individual freedom. ln Auslria seious danger to the heallh or lifc of the palient ol nental ilhess or sorreorc elseas a coDsequence is rhe prerequisitefor compulsory admission.Tuo mdependerl medical recommendalionsfrom ps]cliatrisls are required. A connilled palienl has hisr'her advocate to rnake use of his/her rights. usually a social worker. who is nor enployed by the hospital but by an independen{association. He/she will be seenby a magistmle wirlin 4 dals after adlnissiorlto decideon the lawfulnessof lhe detention.Afler anotlrer l4 days a tlird indepeDdent psychiatic rccommendaiionhasto be obtarred. P d a d o \ . J l \ a f t c rt h e r e w l e g i ' a ' o n $ " . ' n r r o duced detention rates in both countDes rosc

in Austria shrrpl] (5 7. ll) Man] psychialrisls a r r Jt l r . \ . r h c r l r n d ' t . e I r r J i " f l r .\ F t . . r l r " r l and afe concerncdthil they cannolacl rn the best inlercsLs of lheif palients(14. l5). ln Finl.rnd.a countrywilh a relativelyhigh rale (16. l7) all thrcc crtcrLr oi inloluntarl-D admissioD adlnission apply. A patient suflef for involunll.trl, illness in Deedol tfealrnent1() iDg fronr mental prelent hislhcr dclcriomlion can be referred1() hospilalif no other serviccsarc sumcicDl1()lreal irdc hirriher A writrenmedrcalrccoDrnendalron pendenrfrom lhe psychiatfichosprlalis sulticienl. The chicf psychialrist of the hospiial decides $heihef the paticnl remains detarnedor nol. P - l i c n l a r ee ' l r i r - erd^ b f n ( d l u l h c a d r r i | | i s l r d r i \ L regrnerol' cou11.Finlandkeepsa cenlraldischarge restraint.phlsrcal all coercilemeasuresi seclusion. holdirg, compulsory lnedication- feslrictions on learingthe ward and othefs. Percepton Dfdetention n hospLta wc identified sevenpapers examiniDguscrs pcrspectiveand attitudesio delentior in hospital (18 24). live of these(19. 21 24) comparirg voluDlary ard con'lnitted patients. Two sludies soughl ro determjnewhether detenlion in hospital is related to post{raumalic slrcss(25, 26) Professionals pcrspectivesand attitudes are exanined or discussedin four papers(2. lE. 27- 26) two of these discussing capabiljt,v of consent to treatmenl (18,27). Rooney et al. (19) oonpared atliludes tor,ards psychiatricadmissionin voluntary and involuntary paiienrs ii heland. \early half ol the involuntary patients did not know. that they \\,ere admitted informall-v.while more than 50% of involuntary patjents and olcr 20% of the voluntary patients r n u I d h e r n pI n t r o . p i r a' l: m i r " rr ^ \ e i n ! i n f r i ' o n . Forty percent of the voluntary patients vleu,ed their admission as a positjve experience.Of the jn\olur,t"rp \ r r e r l . | 0 o ' i e u e d r h ea d r n i s . i odn. a positiveexperience.lhis roseto 329; ai the end of their admission. Westrin (21) found in 100 committed and 99 voluntary patrents in Sweden that 80% of the commirted and 7'fi, of the iDvoluntary palrenls thought they were conmitted- and 65% of th€ commitled patientsreportedmeasufesagainsltheir u i l l \ . . 2 q o o f r h e\ o l u n . a r i l )a d r i l e J p a t i e l l I . . Smolkaet al. (22)irterviewedall patientsadDitied to a psychratric department in Berlin oler a 6nontb period m 92193.who were subjected to ill\'olunlary treatlnent(, = 8l) and comparedtheir views wirh a \olxrtary conlrol grouF (r:29). Aboul 33% ofthe in\,olunlarypatientsarrdl47o of

Zinkler and Pricbe the coDtrolgroup srid they lad been subjcct1{) cocrcion.McKcrnil el xl. (21) conprrcd thc pcrccplionofhospilalrdnissionin 69 deLrincdard 69 voluDlarily adrriLled paticnls in Ner Zealand. 'lnvolurtafy palicnts had a slrongcr scnsc of coerclonthan inlbnral p licnir- bu1 coercronls fcll bt intb,nrel palicnls as well. Poulseo(24) invcstigatcddifltrcDccs in perceiveddeLcrlron anronginlolunrarilyadrrittedpaticnls.volunlarily admilledbul hLcf dclriDedpaiient\and a coDtrol group ofvolunlary palicn{swithoul rny delenlion A11paLicnrswere adnittcd oD closedwards and expef'enccdcoercionto vafiablc degrees.Perceived coercionwas signillcantlyhigber in invoiunlaril)' adrnirledparienlsthan in voluriary palieDtswith molc those bcing detainedlater on experrencrng voluniarjly. coercionlhan thosestaying Priebecl al. (25) and Mcyef el al (16) did not esiabhsha clear link bel$ccn rnvoluniaryadnrs ' r o r " r r d . u b . e q u et P I S D s J r n p l o l r r . i frzr l i r r r r . suflering froln schizophrenia.Therc is alr oveflap of symptom scoresfor schizophreniaand PTSD. ard cnduringPTSD symptomsmight be relaledto the irightening nature of psycholjc sympLomsas such rather than to delention in hospital. Kullgren et al. (27) eranlined atlitudes towards compulsory trealment among 197 Swedishpsychralnsls by presentrngcase scenaros ln a quesl]onnaire. Whilst 98% regarded it as ethical 1o hospilalize a patienl against hisiher will who is a dangef 1o himtherself or others. only 6l% would use depo! neuroleptics in a chronrc psycholrc patielt \fho refusesnedication and 46'7dfound it unethical io hospitalize a patienr againsl hls/her will who is no! a danger 1o him/hcrself or others. Femalepsychiatristslessoften suggesledthe useof physicalrestmirts and the conpulsor! useofECT. Amering et al. (2) asked 174 menlal health professionals to draft adlance directives' for psychiatric irpalient treatment as suggesledb) an Ausrrian use$' ini!iative. Specifictreatnent meth ods were faroured by sonreand rejectedby olhers: 30yo of pfofessionals $ould reject the use of anlipsychotics.10% would requestthen, and 2 0 0 , o p t e d f o r l r e d l m e n $l i t l ' b e r/ o d i a , e p i n ( \ Forty-five percentwould prefer to be treated wrlh ECT \"hen necessar r-.22-q;rejectedthis trealment. Vrcente e1al. (28) compared lnenlal hcalth professiondis-attitudes to psychiatry in Chjle. England and lialy. A strong medicallnodcl of nental illness ir Chile correspondedwilh a lower satisfaction \L'ith their work, less lolefance to dcviaDl belavjouf in the com1nunity. and a higher needfor psychiatdcbeds.In conlfast hlliian personnelopenly and explicilly supportedcoDnnu nil) based services.English professio als held an 6

inlcnn€dia1e Dosilion Hoycr (18) corcludedID a fof rcccnrlvoublishcdrevicu on lhe iLrsiificalion 'raluesard bclicfsln thc civil commitmenLlhat ncnlill heallh care slslcn seenl 10 bc n]ore inporianl dclcrninanLsfor civll conlrnllmenL rlles than thc spccifccritcri.rstutcdin tbc lcgrs-

Discussion 0eienlon rates A criticalfeviewof the araihble daLror co,rpul' sory ireatnelri in psychiatricbospilalsrn Elrrope revealshugc differenccsin dctentionrateslhat need l , r - l h e e \ p l ar d r o I D . ( r ' r ^ n - r l . ' _ e r i i ' . t . . . 'Ihe fe.r' England.Austia aDd lbe Nelherlards. sonsmay diflef. ln England.SzmukleraDdHoilo' u : r ) ( 1 4 . r e L e , , r l .r.. r r i b , . e d r c . r ( - e , . e i r l con'rpulsoryadnissions to a preoccLrpalionwith ''public safety" and a lerdency to seek neans of exertingconlrol over patients"'.Turner and colleagues{ll) suggestseparatingrnedical treallnenl treat and conlrullity supervisior:'psychiatflsts people.but it is nol lheir job to be responsiblefor indiridual citizens' behaviour in the conlmunrty. which is an issue fof the courls and slatutoty aulhoitics. However. changesin ]nental heahh Iegislation are likel)-. io focus on compulsory tlealncnt rn rhe communit) and detention ol patienrsperceiredto be dargerous(32). In Ausrria and the NetherlaDdsdelention rates rosc sharply despite changes in legislation that emphasized us€rs' dghrs. adequate infonnation of patienls and lhelr legal represenlalion. Mental Health practicein Gc nany varies signilicantlyand relati\'ely poor qualil)'. of dala is available. Low deterlior rates in certain areas of ltal) ma)-r mirror a strong focus on comnunily work. a denedicalized model of mental illncss and the abolishmentof as)-lumsby la*' in 1978. High detention mtes in urban areasseen lo irror tl're vulnerabie liviug conditions of a highly rnobile. deprjved and multicultural popuialion. Legrs at!n Cfiteria for involun!ar!, adlnission arc largely similar in Europe \.hen it comesto patientsat isk to thenrselvesor others. WheD this risk is not p r e . e r r ir|.l r o l u n t " r tl r e d . n r e ni nr l h e b e ' i r r e r e . l It is possiblc of palients beafthis controversial. uuder English legislalior- bur i! \r,ould depend on l n c f . r L n l . r r b . l i l r r o ! . \ c i n l o _ n e J. o r , . e n 'r' r Gerlnany.and would not bc possiblelll Austria.In England and Finland. whcre patienls can be

Det€ntionof thr mcnlalh ill - - . - : - r n t o r r , < r r . ' , r r ' l r " r ' l t l r . c r r d l . . so f h e i r

ing of lhc dillefenl connoLrlionsrcquircsgood knowlcdgeabout thc gi!cn heallhcitreand juslicc

" , ' " , , r e l, l . r i t e , ' , ' i ' i l b r ) h i ' ;;0,.'. r c r r nr n ) ,|c loL d Nrrllrbo-rrnu r ii'.n'i"n rt.' d c r e r ' r i o r d rr r ' l d -r l r ' r J c ' l ^ s e . " ' . 1".r. '" . . , r l ' l o \ \ r D i cl o r D : r . r c n l I . . \ r GuJr,lidn.lrp Fr' A chrrr' | .' - r U t . u f ' ' . i r , l o r r r , ccdo n $hdl n lhc be r r o f d r l n r z c J ooerariona health trcans ighl boLh palienl s lhe ;terest of alnong usergroups susplcron and rcduc€resistance conparatrve researcl'r' useful and facilitalc

l h c r c l c , , r . , r " ' c o - r r ' r i c . f ' r e . er e d i . r r o feprescnlaLivc for Furope bul rathcr lndicrli!c ol where data was arailablc. Figureson a locrl. regurDal.rnd nationalle\'e1could faciliuic nalur d r,ri. c^rnf'ar"r\. t-drc. . ilizinr I'e e' t. variancc for idenlil,ing innucntial faclors and effecls.Afeas fol furlber research\hould includc the exlentof hiddencocrcionin pstchiar'ichospF lals. Users views could bc nore adequalel! wouid lnolc on hon explorcd if researchers conceptsof compliarceand rnsighLto uscr-led rcsearci!o delerniDethc tfeatmentrequrredand acccpled by users under circunlslancesthai fulfil thc lcgal criteria for detcntion.Tlre inpacl of advrnce dirccrivesin fiis processis largcly un known bLrlappearsto be a pronisingapproach ln r . . a l . J nr o n c u e PJ a l i o r r I. c d s o r rJ' b r l h e r r ' e detention fales in sonleparls ol Europe Deedlo be can be exploredbeforemeDtalhealtb )egislation harnonizedin the EuropearUnron.

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0raisperspect!e Us€rsandprofess Detenlion practiccappcarsto be determinedmore by mental hcalth prolessionals beliefs and values than by legal requirements.Patients perceptjonof hospilal adnlissiondoes ro1 aiways correlate wrth their legalslatus.Hidden cocrcionin psychiatric hospjtals has rarel) been addresscdbul could be delined as being subject1o compulsory adnnssrorr and/orcoefcionwithoul a ibrnal lrealmentrdetention order as provided il1 rclevant la\r. A substantial proporlion ofvoluntary patjenls report to bave been subjccted to coercion and feel detained in ro.^eoward.. Parrcrr.or prole..iora' r.ra orefer infornal admissionto avoid being stigmatizedor for other reasons.For examplein regional legislarlon of Bavaia. south Gerrnany.a detentionorder subsequenllyLeadsto an investigatioD01a palient's r ' n e * o o r i \ e d " r d h r . d u r i n g l i . e n c e_ r ' g h l be recalled. It is comnon practice therefore to Jd! .e p"Uenl' o a!cepl inform?l admi.\'o"r lo afoid thjs procedure.Variatiors in deterlion rales might also be subject to the circumstancesof adm,-ion and "dver'e treatr ent condil'on. r hospitals.Lauber et al. (31) found in a represenlative conmLrnity su ey that the general popu' l " l i o r a r , d p a . , e n l sw ' t h l r e r ' ' , e n ' e \ p e ' e n c e r(.o!.r,,er Ihc ncrd for .ompul.o-y admi.'ior in caseof mental illness.However. treatment condilions in hospitals var) and might thereibre afiect an individual palients' decisionwhether to accept ln-pa!jent treallnenl. A clear linitation of this review was that detention lares are rot roulinely docunrented and publishedusingcomparabledennitionsin all I U . ' e m h e r, r d r e \o r i n d l l f u r o p e . I c o u r l r i e , . Conpadsons across Europe are fulther complicated by-.problens of lranslation.Usjng English Lennssuch as detenrion' fbf cornpulsory admrs' sions in diflercnl countries does not recessarrl)'. irrpl] thal like is comparedwith like. Temrin ology is embeddedln nationalcultufesincludlng the legal fra$ework: and the preciseurdeNlend'

Acknowledgements 'Wc

ihrnk Dr T Phrz. \.lenral Hcrll| Serlices. Kla-lenlu.L. Aust.ia, Dr L. lore!Di. MenLalHeal$ Se.lrces.Mer... lla J and Prol \. Lchlirr!. \ar,onal Delelopmetrt and Rcsc!rch Cenfe for Hellth ard wellare. Helsinki. Flnia.d lor prolidrne nguresnot freriousl! publislled rDlcrra.ondllr_

1 Rrt.H.R RossLtrRA- RossLLr w CoDpuho.y admission olpsychlalflc paLient\ dn inlerhallonai compdrson Acta ls_lchi.lr Scan 1993:87:231216. : A v ! t u r c l l t . D r \ ( E . G R r E l c LH . S r s r z l . S r s r \ r P Psychla1ncwilh ofnenr.lheahh prote$ionais a surve! ol opinrons tgardhg adran.c direchles in tsrchiarl SLrc Psychrdlr! Pslchialr Epldc$jol l999rl4l(ll,1 I Depd.unenr of Hcllth slaLrstrc.l bulletin. ln Patierl: Fo.nallj" Detaircd r. llotpilals Lrder rlle Msrhl HcilLh E.n g l a n dl 9 8 E 8 9 i o 1 9 9 8 A c Ll 9 8 i a r d O t | [ r L e g r s l a t l o n 99. GolorDrenral slatrsricalServicc,1999.l5 ,1.\cwhaDr Communn! Healrh ScNrc$ N ll S T, un Ann uar reporl lor LheLiusLboard. Lo.donr Itterlal Publicalion. 2000 (avarlableirorn the aunrot -i ToRtssiNL. Plrrz'1. ZrN{LrR M Inte.ralronal research coe Adr, .e.o'. o| ro p' o) unpublished d!ia 1995(peson.l cornmunrc!tloD) 6 NoR.rLo B TorLsrr L. Epidennoloej_.l comtulsor! health rrerrnenls i. AIl)c-Adnr a I'relidin.O .nalvsis of a rese!rch criiicd oul in Slov€n,d,Carnti!. .nd Fnulr vd,ezia Giuli!. Pslchillru Drnubina l994rli? 182. 7 N L v ^ \ H L I A . C ^ N ! p .I M L C . R ^ l r L L r D l ' . l D c r e d s rcl Lhe nunber of in\o|!DLar! adDissioDs T,]dFhtii voor P , ! . h i x L i e 1 9 9 9 : 2 : i 0 3l 0 r . 8. Sf$cLLR A. BoHMr K VesorghgsctideDLologNche Aspekre do sontrLilen Lnrerbri,rguns \c,vena.zr 1 9 8 9 i 6 0 : 2 226l l .

Zinkler and Prirbc V . K r . r L i r Tl l . 5 . H t t R N ( , t s . l ^ r N i m ( i r L Z$rng$n!llndhnci or dcr Pslchialric rrs dd Sich' d$ Pi(ierlcn \cf!cDrrrl l9r)i:68:li8li li95 'lM \\ P l r L c n lrr c r M.K!NN^ BG. S MAoNAIf. t-^rDL cqllidr .l co$cion or rlinl\siot 1o .tul. tsv.hralnc sc' lrccs ln( J Llr Ps)'chirrrr-l99tr22 l4l L5:l Pr)Lrisr\ llD Pcrcc\ed dc(cnliof aoon! toDnillcd i . r ' . l r ' l l " . r t F n . I n l l . l 1 9 9 9 i 2 2 : 1 6l7l 5 . ' P ' \ Br'- VL, IS lr"lr"..dr, and tosll.rumatc slrcss drntdct in schtzolhrcnr( taric.Ls. Comf Plr-cbirlr\ l99ltl9:210 12,1 Mri'LR H. T\r\ri\rN T. V(.r,r T Aua ^ A. HL,rNI s ll Pos(n!nrxlic sLrcssdrnrrder svnitto.n rcldlcd to Ps! c h o s r s . n d x . L t c i n r o l u D h r r h o s p L r a l i s r L i oi nn \ c h i r o MenL Dr fhrcnic rnd deluionll p.rlcnLs J \e 1999ir87rl4l -i2. KILr.CRLN G . J ^ . o R s o NL . L y N o L N K o r I N R . I - , \ \ ! | ' . 'i i | 'r .olt .-'d P.r. '( . rr'd! reeardjDgthc clhics ol coDpuhor! Lre.Lincrl. Acta Psrc h i a r rS c a n d1 9 9 6 : 9 3 1 8 .91 9 6 Vnf\I B VLrLv^ M. Jr\rtn FA. Mr7lr\^ R. LLL^r.\s I ALtiLudesol prolessionelInenralhcdhh ro.Lers lo Ps! c h i a t r y I n LJ S o . P s l - c h i a llr9 9 l i 3 9 : l 3 l 1 4 1 srLr^.K CH. MTLLER CH. B^{\As C. K!n2 M. ScH! sLrr H. HjNTERHUBER H. CoDtulso.) adDission and liequen.! deLcnLronaL l\y.biarnc bospilal in Tyrol a n a l l s i so r e r l l ! e . s . N i e . s K l i n j s c h ew o c h e r s c h i r l L 1 9 9 0 : 1 3 : 1 7188 3 . F Relorm of Lhe )len(al SzMUKLERG. Hollow^r Heafth Ac1: hcalrr or srfetyl Br J Pslcbralry 200011?7 r96 200 TLR\ER T. SALTERN1, DEAHr-M Mental HealLh Act reforn. should psfchrairsls go on being responsiblel PsychiatdcBull I9991235i8 581 Defa.tnent ofHeallb. Relormine $e MeDtal Hcaltlr AcL Whire Paper. 2000 (hr{p ri\ww doh gov ukimenralheah

9 R r ) rr ( , f ! ! l l l t . L ! p p r N (P , Z { r n g s r n l e r b r i i C u n !! i d b t hirdluDg !s!ch\.h K nkcr in Gfttih.iLxnnicr und D e u $ . h | r n d P s l c l ] r r tP . r x 1 9 9 9 : 2 6l l ! l ' 1 1 L 0 R r ) i r ( i r n i H R L. r j j ' N ! P T r c ! l D e n r o (f h c n r c f u l l r r l l r D Bu l rhc Fcdcrrl Retublic of Gcnn,n\ l\!.hirl.c

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V ^ N I - r s f r i . r r N T l . o D r P . C o D r p u l s . . yp \ \ c h r i l . c ldnissior a conrfarison oi Lrglish and BclAj!D legish' 6ri rLor Psychint,icBrll 2000:24:116 l l L ^ r r o \ r l . P N L s r R G . A c o n r f r r i s o n o f F r e n c h a . d8 r n n l l c d 1 9 9 2 r 2 2 : l 48l 5 0 m c r L r l h c a l L hl e g i s l r r i o nP s y c h oM l l G r , R , s , { { i r R C . s r o . n : RS c r r M r D r N d r8i . D a N / L N ( r ! ,R .Auswi*ungen dcs llnLerbringuiesg$ct7-csaui Aulnahnr.n rn dcr PslcnraL.c in B!rd$hid Salzburs \curop s y c h i a l r i c1 9 9 6 t 1 0 l r:2 1 9 5 . l4 II^! RHjTN EM RLnM^\NsRLRcrR Il UnJi.rwiihge c nr ! n k c n h r u s d i c S i L u a ( r o r A u l n r h m ci m p s t c h i a L i i s c h K L r a x 1 9 9 6 : 2 3 r l l 91 4 2 . r n O s r c r . i c b F s y c h r rP 15. KoRrM^\ FAM Q)mpuko.! adnissior in pslchirlrlr righis oJ patrcrts and Code of Prlcllcc Trtds.htili \oor P\J'chiatne| !95:17:759-768. l 6 K ^ L r ^ r ^ H L r N oR . K o R K D T ^J . T t x r M ^ r r C . T l o R r T . LlHrnEN V. Cooclor and resLncLionsnl pslchrahc r y0 0 0 : 1 5 : 2 l l2 1 9 . i n p d l i e r rr r e a l m c D lE. u r P s y c h r a L 2 1 7 . N L N o N E !M . P J j ^ N ' ! r , L s R { $ L ^ ' N E NI M i c h n r c r l c } den haididen horto Slonressa l9l8 l99E Trclnrcn1 ol menr.l disord* in Finknd l9l8 1998.NaLionll Kesearch and Developmcnl CeDlie lor welfac and Heahh. SL!11+ ric.l rpon l, 2000 (a!ailable Iron Lheaulho 18 Hoy.R G Or th€tusLificaLionfor cilil conD,nDent AcLa Pslchrarr Scand 2000:101:65ll 1 9 . R o o N ! ! S . M L R p H yK C . M r L ! ^ \ L y F , o C A L L A C H AEN. LaRKTNC A conrFrrison ol volunrary and rnlolurta.! p a t r e n t s a d n r i l l et odb o s p i l a l l r J P s y c h M c d 1 9 9 6 1 1 3 : l : 1 2 lll 20. NoBLELM, DoLcL\s BC. N.wNr^N SP. $ha1 do pal1en6 want and do we want to know? A reliew of paocnrs' reque(s ol psychialric serlices Act! PsychrdLrscard 1999i100:3:1.32t. 21. WEsrRr\ CG Conpuhorr psychiattc care aD arena lot conflrctsand reselrch. Nord J PslchrrLry 1997:51(Suppl. 3 9 ) : 5 16 1 .

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t l L^IBER C. F^L.aro L. RossLER$

lliludes ro coD puhor! admlsion in psychiatry Lrncet 2000.3552080