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Table of Contents
EDITORIAL
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 3-5

Involuntary hospitalization review mechanism in Taiwan: Lessons learned from a 12-Year experience


1 Department of Psychiatry, Taoyuan General Hospital, Ministry of Health and Welfare; Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taoyuan City, Taiwan
2 Department of General Psychiatry, Taoyuan Psychiatric Center, Ministry of Health and Welfare, Taoyuan District, Taoyuan City; Department of Psychology, Min-Chuan University, Taipei, Taiwan

Date of Submission31-Jan-2021
Date of Decision01-Feb-2021
Date of Acceptance02-Feb-2021
Date of Web Publication25-Mar-2021

Correspondence Address:
M.D., Ph.D. Ding- Lieh Liao
No. 71, Long-Show Street, Taoyuan District, Taoyuan City 33058
Taiwan
M.D., M.S., Ph.D. Shin- Min Lee
No. 71, Long-Show Street, Taoyuan District, Taoyuan City 33058
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_2_21

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How to cite this article:
Lee SM, Liao DL. Involuntary hospitalization review mechanism in Taiwan: Lessons learned from a 12-Year experience. Taiwan J Psychiatry 2021;35:3-5

How to cite this URL:
Lee SM, Liao DL. Involuntary hospitalization review mechanism in Taiwan: Lessons learned from a 12-Year experience. Taiwan J Psychiatry [serial online] 2021 [cited 2021 May 17];35:3-5. Available from: http://www.e-tjp.org/text.asp?2021/35/1/3/311902



Patients with severe mental illness are persons with disabilities, and their rights to receive timely and appropriate treatment are important. However, they do not usually receive the needed psychiatric treatment either through hospitalization or in the community, because of the lack of insight. The issue of equal and accessible care is important in our position of the Taiwanese Society of Psychiatriy in Taiwan. But the freedom and prejudice-free attitude are also important, and the treatment and medical care should be provided by minimal coercion. It is important for a country to have a high quality mechanism to claim and review the application of patients with severe mental illness to be treated by means of coercion, including both involuntary hospitalization and treatment in the community. This position echos that of the World Health Organization on human rights and health[1].


  Involuntary Hospitalization in Taiwan Top


The Mental Health Act in Taiwan was first legislated in 1990 with objectives “to promote the mental health of the population, prevent and treat mental illnesses, protect patients' rights and interests, support and assist patients living in community” (www. law.moj.gov.tw/ENG/LawClass/LawAll. aspx?). With its amendment including the operation of a review board on involuntary hospitalization and psychiatric treatment in the community, the Taiwanese Society of Psychiatry began to implement the Review Board of Involuntary Admission and Community Treatment to Severely Mentally Ill Patients (BIACMIP) in Taiwan since July 2009. The operation of BIACMIP was under the funding support of the Ministry of Health and Welfare, Taiwan. By sponsoring a training program of the board expert panel, the BIACMIP recruits more than 300 members from professionals including board-certified psychiatrists, psychiatric nurses, occupational therapists, clinical psychologists, psychiatric social workers, and attorney/judge experts, together with representatives of patients' family or personnel of human rights protection. The yearly continuous consensus meeting and training ensures the BIACMIP experts' high consensus. In the real daily review meeting of the BIACMIP, seven members from each professional background review the document about claim of involuntary admission or community treatment, and after a review of case history followed by telephone or online contact with the primary care psychiatrists of the indicated case, a voting of the seven members will decide whether an involuntary psychiatric treatment is permitted. This operation of the BIACMIP ensures a full participation of psychiatrists, psychiatric hospital staff, and the indicated patient. To ensure a successful operation, a devotion of the BIACMIP experts to receive the training and to attend the review meeting has been important in the context of busy psychiatric practice in Taiwan.


  The Work by the BIACMIP in the Past 12 Years Top


In the past 12 years, the BIACMIP has reviewed more than 12,000 case claims, with 100 psychiatric hospitals participating nationwide. In optimizing the operation of the BIACMIP, the Taiwanese Society of Psychiatry has witnessed some trend of the BIACMIP review about the permission of coercive psychiatric treatment.

  • The BIACMIP reaches a high consensus of permission in review. For a case permitted to receive coercive treatment, two-thirds of out of the seven members in the same meeting have to give a positive voting after a document review and online contact with the patient and the treatment team in the hospital. No discussion was arranged in the meeting to ensure the independent decision from each member in the BIACMIP. In most of the cases, the members reached a voting result with 7 to 0, 6 to 1, or 5 to 2 in general. The cases which were voted 4 to 3 and less will be later discussed by the senior executive team, then presented in the consensus training program the following year. By this convergence in consensus, the permission rate of the case claim to involuntary admission or community treatment reached as high as 90% permission by the BIACMIP voting. It is a result of an effort of consensus among the treatment staff and the external review rather than a result of biased decision.
  • An increasing rate exists that the BIACMIP meeting uses online video access for a more precise evaluation of the patient's condition, and the clarification of reasoning why a coercion of treatment is inevitable. In view of human rights protection, the BIACMIP encourages their members to use online video or telephone contact because a consensus by de facto evaluation is more unbiased than a gross discussion (or persuasion if biased) led by a chairperson during the meeting.
  • A decreasing trend exists in participating psychiatric hospitals and decreased claims for the review. If a high consensus and high permission rate mean an abuse of coercion in psychiatric practice in Taiwan, the claims should be increasing during the past decade. The result was the contrary. In Taiwan, the annual incidence of involuntary admission was about 3/100,000 population, much lower than the median incidence (106.4/100,000) of 22 countries surveyed in a recent study including Europe, Australia, and New Zealand[2]. In exploring the psychiatrist's opinions about the BIACMIP operation, we found that one possible explanation to the decreased use of the coercion measure may be lack of sufficient resources allocated to the psychiatric hospitals. Some hospitals therefore trim the team for the involuntary admission treatment, while many more hospitals stop providing the service of involuntary community treatment. When compared to the condition in 2009 when <20% of qualified hospitals did not submit any coercion treatment applications, the rate reached to more than 40%. Furthermore, the case claims to involuntary treatment in 2020 is <700, roughly 40% of the figure in 2010. COVID-19 has little impact to Taiwan in providing psychiatric care. Our data shows that the number of the BIACMIP case claims is roughly 90% compared to that in 2019. In the long run, sufficient incentives including the reimbursement of this time-consuming psychiatric service may be urgently needed.
  • The repeated involuntary treatment is not a big issue of resource consumption. In an analysis of the BIACMIP permission data, about 15% of the patients have more than 1 involuntary admission, and < 5% of patients have more than 3 involuntary admissions, although repeated admission is relatively common for the patients with severe mental illness especially in those with schizophrenia, either involuntary or voluntary re-admissions[3],[4].



  Conclusion Top


The BIACMIP operation in Taiwan helps balance the patient's welfare to receive appropriate psychiatric treatment and to protect human rights. To achieve a successful operation of the BIACMIP, we have to consistently improve the consensus of the BIACMIP expert panel members by high-quality training programs, a high attendance rate of the BIACMIP review meeting, a participation of the hospitals to use the mechanism of coercive treatment for the patient, and routine use of online access to the patient and the treatment team in each case claim review.

The BIACMIP operates six-days-a week throughout the year. Recently, the human rights protection is gaining higher visibility together with the Convention on the Rights of Persons with Disabilities implementation in Taiwan. It may be the next step that the amendment of the Mental Health Act will change the process of coercion treatment permission: the court may take over the responsibility of decision of permission and form of involuntary treatment. The rôle and the mechanism of the psychiatric professionals in helping the court make an appropriate decision about coercive treatment are yet to be determined. Hopefully, a good-quality review process can be maintained in the coming amendment for Mental Health Act in Taiwan. Furthermore, full support from government and the hospital is also needed in the optimal balance of in-time psychiatric treatment and minimizing coercion (www.wpanet.org/alternatives-to-coercion)[5], without compromising the treatment outcome[6], both of which are equally important for the benefit of patients with severe mental illness.


  Acknowledgements Top


The opinions expressed are authors' personal opinions. They unnecessarily reflect as those of any institution or society. Both authors contributed to writing this editorial equally.


  Financial Support and Sponsorship Top


None.


  Conflicts of Interest Top


The involuntary admission review project receives annual funding support from the Ministry of Health and Welfare, Taiwan. The authors declare no conflicts of interest in writing this editorial.



 
  References Top

1.
World Heath Organization: Human Rights and Health. Generva, Switzerland: World Heath Organization, 2017.  Back to cited text no. 1
    
2.
Rains LS, Zenia T, Dias M, et al.: Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study. Lancet Psychiatry 2019; 6: 403-17.  Back to cited text no. 2
    
3.
Lin CE, Chung CH, Chen LF, et al.: Compulsory admission is associated with an increased risk of readmission in patients with schizophrenia: a 7-year, population-based, retrospective cohort study. Soc Psychiatry Psychiatr Epidemiol 2019; 54: 243-53.  Back to cited text no. 3
    
4.
Hung YY, Chan HY, Pan YJ: Risk factors for readmission in schizophrenia patients following involuntary admission. PLoS One 2017; 12: e0186768.  Back to cited text no. 4
    
5.
Herrman H: The practice of psychiatry in health care and sustainable development: progress on the WPA Action Plan 2017-2020. World Psychiatry 2020; 19: 256.  Back to cited text no. 5
    
6.
Schneeberger AR, Kowalinski E, Fröhlich D, et al.: Aggression and violence in psychiatric hospitals with and without open door policies: a 15-year naturalistic observational study. J Psychiatr Res 2017; 95: 189-95.  Back to cited text no. 6
    




 

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