Indications for involuntary hospitalization for refusal of treatment in severe anorexia nervosa: a survey of physicians and mental health care review board members in Japan

Results for treatment providers of eating disordersCharacteristics of physicians

Fifty-five valid responses were obtained from physicians in Japan who specialize in treating eating disorders (25.9% response rate). The physicians included 21 psychosomatic physicians, 24 psychiatrists, and 10 adolescent medicine physicians. Psychosomatic physicians are trained in internal medicine with additional psychiatric-psychosomatic training. Both psychosomatic physicians and psychiatrists treat eating disorders in Japan. Most physicians had 10 to 19 years of experience, while some had more than 30 years of experience. Most physicians treated 50 to 99 patients in a year, while some treated 150 to 199 patients in a year.

Physician attitude to treatment refusal (n = 55) (Table 1)Table 1 Attitudes of physicians towards treatment refusal by patients with severe anorexia nervosa

Case A: The patient with AN was 15-years-old with a 6-months disease duration and refused treatment for a life-threatening condition. If the family consented that the patient should be treated, most respondents (58%) opted for HMCP. Even if the family did not consent to treatment for the patient, 47% physicians chose HMCP. Only 2% of the respondents selected CH.

Case B: The patient with AN was 20-years-old with a 6-months disease duration and refused treatment for a life-threatening condition. If the family consented that the patient should be treated, most respondents (56%) chose HMCP. When the family did not consent to treatment for the patient, 53% physicians chose HMCP; however, only 2% respondents selected CH.

Case C: The patient with AN was 40-years-old with a 24-year disease duration, multiple life-threatening events, and refused treatment for a life-threatening condition. If the family consented to treatment, most respondents (65%) chose HMPC. Even when the family did not consent for the patient to be treated, 44% physicians chose HMCP; no one selected CH.

There were no significant differences in response trends among cases A, B, and C where the family members consented for the patient to be treated and where the family members did not consent for the patient to be treated (p = 0.95, χ2 = 7.18, df = 4 and p = 0.794, χ2 = 3.12, df = 6, respectively).

Results for the mental health care review board

Responses were received from 23 (34.3%) of the 67 MHCRB. Questionnaires were also individually distributed to 180 members of the MHCRB, and responses were obtained from 77 members (42.8%).

Organization of the mental health care review board (n = 23)

The median number of MHCRBs was 3 (min: 1, max: 8) and the median number of reviewers per MHCRB was 18 (min: 10, max: 40).

Characteristics of reviewers (n = 77)

Of the total reviewers, 59% had an academic background in psychiatry (n = 45), 9% had an academic background in law (n = 7), 27% had other academic backgrounds (n = 21), and 5% provided no response (n = 4).

Review by mental health care review board for 1 year

The median number of CH during the year (from n = 22 responding facilities) was 19 (min 0, max 97), of which none were for patients with AN (from n = 19 responding facilities). The median number of HMCP (from n = 22 responding facilities) during the year was 2259.5 (min: 968, max: 8947), of which 7 (min: 0, max: 25) were for patients with AN (from n = 18 responding facilities). The median number of discharge claims (from n = 23 responding facilities) was 27 (min: 5, max: 344) and the median number of admissions with unjustified admission or transition of admission status (from n = 23 responding facilities) was 1 (min: 0, max: 16). Of these, the median number of discharge requests by patients with AN (from n = 22 responding facilities) was 0 (min: 0, max: 1), and the median number of cases of inadvertent hospitalization or transition of admission status (n = 19 responding facilities) was 0 (min: 0, max: 1).

Mental health care review board decisions of indication for involuntary hospitalization for refusal of treatment by AN (n = 77) (Table 2)Table 2 Psychiatric review board members' judgement of indication for involuntary hospitalization after patients’ treatment refusal

For Case A, if the family members consented to treatment for the patient, most respondents (69%) decided that only HMCP was indicated. In cases where the family did not consent to treatment for the patient, 44% answered that neither CH nor HMCP would be indicated, while another 44% answered that only CH would be indicated.

For Case B if the family members consented to treatment for the patient, most respondents (67%) decided that only HMCP was indicated. In cases where the family did not consent to treatment for the patient, 44% answered that neither CH nor HMCP would be indicated, and 39% answered that only CH would be indicated.

For Case C, if the family members consented to treatment for the patient, most respondents (69%) decided that only HMCP was indicated. In cases where the family did not consent to treatment for the patient, 55% answered that neither CH nor HMCP would be indicated.

There were no significant differences in response trends among cases A, B, and C where the family members wished the patient to be treated and where the family members did not wish the patient to be treated (p = 0.83, χ2 = 2.87, df = 6 and p = 0.70, χ2 = 3.81, df = 6, respectively).

Applicable to mental disability (n = 73)

When asked whether AN applies to mental disorders treated under the Mental Health and Welfare Law, 69 (94%) MHCRB members responded that this condition applies to mental disorders, and 4 (6%) responded that it does not.

Applicable to self-injury behavior

When asked whether refusal of nutritional treatment constituted self-injurious behavior as treated under the Mental Health and Welfare Law, 46 (62%) responded that it constituted self-injurious behavior, while 28 (38%) said that it did not.

Mental capacity

The assessment of mental capacity for the presented case (see Additional file 2) was “full mental capacity” for 8 (11%), “partially impaired but has good mental capacity” for 40 (55%), and “lack of mental capacity” for 25 (34%) respondents. Further, the 25 respondents who indicated “lack of mental capacity” were asked about the reasons for their response. Two (8%) respondents stated decreased level of consciousness due to undernourishment, 22 (88%) stated decreased mental capacity due to AN psychopathology (desire to be thin, fear of obesity), and one (4%) had other reasons. When 48 respondents, who assessed the presence of mental capacity, were asked to confirm whether the patient’s self-decision to refuse treatment should be respected, eight (20%) answered that it should be respected and 40 (80%) replied that it should not. When the same question was asked of physicians treating patients with AN (n = 53), six respondents (11%) indicated that the patients had full mental capacity, 35 (66%) indicated that “partial impairment but good mental capacity,” and 12 (23%) indicated that the patients lacked mental capacity. No significant differences were found between the reviewers and the physicians with respect to their assessment of mental capacity (p = 0.16, χ2 = 1.99, df = 1).

Factors influencing the decision to indicate involuntary hospitalization

When the family members consented for the patient to be treated, neither the presence of mental capacity applicable to mental disorders nor to self-injury had a significant effect on their decision to support involuntary inpatient treatment (Table 3). If the family did not consent for the patient to be treated, in cases where the MHCRB members considered AN behaviors to be self-injurious, the decision to hospitalize involuntarily was 34.7 times higher in Case A (odds ratio: 34.71 [7.89–152.72] p < 0.001), 34.7 times higher in Case B (odds ratio: 34.71 [7.89–152.72] p < 0.001), and 14.9 times more likely in Case C (odds ratio 14.91 [3.65–60.89] p < 0.001). In these instances, the self-injurious nature of the behavior was considered to be an indication for involuntary hospitalization.

Table 3 Factors influencing involuntary hospitalization indication after treatment refusal by patients with severe anorexia nervosa

留言 (0)

沒有登入
gif