Review Board Outcomes for Involuntary Patients in Provincial Psychiatric Hospitals

William J Komer, MD, FRCPC1, Richard L O’Reilly, MB FRCPC2, Zack Cernovsky, PhD3, Sandra Dunbar4


Objective: To identify long-term trends and compare different psychiatric hospitals with regard to outcomes of involuntary certification.

Method: Data on outcomes of involuntary certification were obtained from the London and St Thomas Psychiatric Hospitals for 1987 to 1997, from the Psychiatric Patient Advocate Office pertaining to 10 psychiatric hospitals for 1987 to 1993, and from published data from the North Bay Psychiatric Hospital for 1992 to 1994. Data were compared regarding outcome variables.

Results: There are variable rates and proportions among the psychiatric hospitals for outcomes of involuntary certification, including patients choosing to withdraw their applications to Review Boards, physicians cancelling involuntary certificates by completing Form 5s, and Review Boards rescinding certificates. Overall, few certificates were rescinded by the Boards, a trend that was even more pronounced in recent years.

Conclusions: Patients who are in psychiatric hospitals on an involuntary basis are infrequently released from hospital as a result of a Review Board rescinding their certificate.

(Can J Psychiatry 1999;44:495–498)

Key Words: Review Boards, involuntary certification, Mental Health Act

Although various published studies have investigated Review Board outcomes and clinical and demographic variables associated with involuntary hospitalization (1–7), the studies have not examined long-term trends or compared different psychiatric hospitals. This paper reports data from the London Psychiatric Hospital (LPH) and St Thomas Psychiatric Hospital (STPH) for 1987–1996. These data are compared with those available for 1987–1993 for all provincial psychiatric hospitals in Ontario and with published data from the North Bay Psychiatric Hospital (NBPH).

Method

Information was obtained from the LPH and STPH for the years 1987 through 1996 inclusive regarding the number of individuals applying for a review of their involuntary status (Forms 3 or 4). Information was obtained relating to the outcome of these applications, including whether the patient withdrew the application, the physician changed the patient’s status to voluntary (Form 5), a Review Board convened, and the Review Board confirmed or rescinded the certificate. The hospital database is on an Avion Unix mini-computer-system, and reports can be generated using Forthwriter software customized for the psychiatric hospitals. Information for the fiscal year 1996/1997 was downloaded from the hospital’s database using Forthwriter into a Lotus program. Data specific to the involuntary certificates were converted to a Systat database for statistical analysis.

Data were also obtained from the Psychiatric Patient Advocate Office pertaining to involuntary hospitalizations at all 10 provincial psychiatric hospitals from fiscal year 1987/1988 to 1992/1993 inclusive. Published data from the NBPH for 1992–1994 were also used for comparison (6).

Comparisons of the 10-year data for the LPH and STPH and for the different hospitals were tested for statistical significance using c2.

Results

Between 1987 and 1996, there were 2644 applications made to the Review Board at the LPH and STPH to review involuntary hospitalization (Figure 1). Of these applications, 858 (32.4%) were withdrawn by the patient prior to a Review Board hearing. An additional 670 (25.4%) applications led to the physician completing Form 5 to change the patient’s status to voluntary. During this period, there were a total of 1116 Review Board hearings (42.2%), of which 1011 were confirmed (90.6%) and 105 were rescinded (9.4%).

When comparing the results from the LPH with those from the STPH, significant differences were ascertained (Figure 1). Of the 1719 applications at the LPH, 541 (31.5%) Form 5s were completed, whereas at the STPH, out of 925 applications only 129 (13.9%) (c2 = 97.1, P < 0.001) resulted in the completion of a Form 5. Likewise, at the LPH, 626 (36.4%) applications resulted in a Review Board hearing, whereas at the STPH, there were 490 (53.0%) (c2 = 68.4, P < 0.001) Review Boards. There were no significant differences in the numbers of applications withdrawn by patients prior to the hearing (LPH 33.1%, STPH 33.1%) and rates of rescinded certificates (LPH 10.4%, STPH 8.2%).

Figure 1. 10-year comparison of London Psychiatric Hospital (LPH) and St Thomas Psychiatric Hospital (STPH), 1987–1996. This figure is not availabale online. Please refer to the print copy.

When the first 5 years of the observation period (1987–1991) were compared with the latter half (1992–1996), there was a significant difference in the rate of certificates rescinded (Table 1). Of the 480 Review Boards during the first period, 74 (15.4%) were rescinded, whereas of the 636 Boards during the second half, only 31 (4.9%) were rescinded (c2 = 35.7, P < 0.001).

Table 1. Review Board statistics for London and St Thomas Psychiatric Hospitals, 1987–1991 and 1992–1996

 

1987–1991

1992–1996

1987–1996

Number of certificates confirmed (%)

406 (84.6)

605 (95.1)

1011 (90.1)

Number of certificates rescinded (%)

74 (15.4)

31 (4.9%)a

105 (9.4)

Total

480

636

1116

aP < 0.001.

There were 31 124 Certificates of Involuntary Hospitalization completed at the 10 psychiatric hospitals from 1987 to 1993 (Table 2). Of these, 4953 cases (15.9%) resulted in applications to the Review Board, 1217 (24.6%) resulted in the physician completing Form 5, and the patient withdrew the application in 877 cases (17.7%). For 56 of these applications, the certificate lapsed before the Review Board, and in 76 cases outcome data were unavailable. There were 343 (12.8%) certificates rescinded as a result of 2680 Review Board hearings with known outcomes.

Table 2. Review Board statistics for all provincial psychiatric hospitals, 1987–1993

 


Number of certificates


Applications to the board

Applications withdrawn by
patient (%)


Form 5s
completed (%)


Certificates
rescinded (%)

1992/1993

5626

918 (16.3%)

151 (16.4%)

224 (24.4%)

53 (10.7%)

1991/1992

5808

876 (15.1%)

145 (16.6%)

249 (28.4%)

48 (11.0%)

1990/1991

5091

781 (15.3%)

104 (13.3%)

222 (28.4%)

55 (13.1%)

1989/1990

4993

734 (14.7%)

115 (15.7%)

174 (23.7%)

60 (14.2%)

1988/1989

4643

756 (16.3%)

159 (21.0%)

189 (25.0%)

51 (13.6%)

1987/1988

4963

888 (17.9%)

203 (22.9%)

159 (17.9%)

76 (14.4%)

Total

31 124

4953 (15.9%)

877 (17.7%)

1217 (24.6%)

343 (12.8%)

Data for the LPH and STPH from 1992 to 1994 were compiled for comparison with published data from the NBPH for these years (Figure 2). Although data were not available from all psychiatric hospitals, data from April 1, 1992, to March 31, 1993, were used for comparison. Significant observations were that fewer applications resulted in a physician completing Form 5 at the STPH (12.6%) compared with the other sites (LPH 31.3%, NBPH 38.8%, and all 24.4%). A significantly higher percentage of Form 5s were completed at the NBPH and LPH than at all psychiatric hospitals combined. Patients withdrew their applications to the Review Board significantly more often at LPH (29.4%) and STPH (30.7%) compared with NBPH (10.9%) and all hospitals combined (16.4%). Of total applications to the Review Board, proportionally significantly fewer Board hearings were held at the LPH (39.4%) compared with the other groups (STPH 56.7%, NBPH 50.7%, and all 55.0%). Of the applications heard at the Review Board, significantly fewer certificates were rescinded at the STPH (5.4%) compared with the NBPH (18.4%) and all provincial psychiatric hospitals (10.5%).

Figure 2. Comparison of London Psychiatric Hospital (LPH) and St Thomas Psychiatric Hospital (STPH), North Bay Psychiatric Hospital (NBPH) and all provincial psychiatric hospitals (PPHs), 1992–1994 . This figure is not available online. Please refer to the print copy.

Reviewing the data for April 1, 1996, to March 31, 1997, from the LPH and STPH combined revealed some interesting findings (Table 3). During that time period, 2137 individuals had been inpatients of either facility at least once. Of these individuals, 653 (30.6%) were kept as involuntary patients on at least 1 occasion. Of those certified, 156 (23.9%) applied to the Review Board on at least 1 occasion. There were 242 applications requesting a Review Board by the 156 patients. Of these 242 applications, 100 (41.3%) were subsequently withdrawn by the patient prior to the Review Board. In 54 cases (22.3%), the physician completed Form 5 to change the individual’s status to voluntary. There were 88 Review Board hearings (36.4%), of which 86 (97.7%) confirmed the certificate. Only 2 (2.3%) of all the hearings resulted in a certificate being rescinded. Overall, only 0.09% of all individuals hospitalized at either of these facilities during this 1-year period were released from the hospital as the result of a Review Board rescinding an involuntary certificate. As well, only 0.31% of all individuals kept in either hospital on at least 1 occasion as an involuntary patient were eventually released as a result of their certificate being rescinded.

Table 3. Review Board statistics for London and St Thomas Psychiatric Hospitals for April 1, 1996–March 31, 1997

Total persons who were in hospital at least once

2137

Total persons on Form 3 or 4 at least once

653 (30.6%)

Total persons applying to Review Board at least once

156 (7.3% of total)
(23.9% of certified)

Number of applications to Review Board by the 156 persons

242

Number of applications withdrawn by patients

100 (41.3%)

Number of applications leading to Form 5

54 (22.3%)

Number of applications leading to hearing

88 (36.4%)

Number of certificates confirmed

86 (97.8%)

Number of certificates rescinded

2a (2.2%)

a2/2137 = 0.09% of all persons released as a result of certificate being rescinded by Review Board; 2/653 = 0.31% of all individuals kept involuntarily at least once are released by the hospital as a result of the certificate being rescinded by the Review Board.

Discussion

These results show significant differences among the psychiatric hospitals with regard to outcomes of patients who are involuntarily hospitalized. Some of this variance may relate to the different types of patients served but may also reflect differences in physician and Review Board practices. For example, given the number of hospital beds, there are disproportionately more applications to Review Boards at the LPH compared with the STPH for 1987–1996 (1719 versus 925). Also, in 1996/1997 out of 1096 total patients at the LPH, 428 (39.1%) were certified at least once, whereas of 1041 total patients at the STPH, only 225 (21.6%) were certified at least once. These differences may be due to STPH having an Addiction Unit and a dedicated Forensic Unit and serving more primary care patients who more often are not involuntarily hospitalized. However, even among only those that were certified, significantly fewer STPH patients applied for a Review Board hearing than at LPH (18.2% versus 26.9%). In accordance with policy at the LPH, if a patient is to be secluded, a physician must promptly make an assessment regarding certification. Many of these certificates may be canceled by the physician soon thereafter, resulting in higher rates of Form 5 completion at LPH compared with STPH. This difference, however, was not apparent when the 1-year data were compared.

Other possible reasons for physicians completing Form 5s include improvement in the patient’s clinical condition or physician reluctance to attend a Review Board hearing.

A striking finding was that the rate of certificates rescinded has decreased significantly in recent years. This may be related to overall bed reductions, leaving more seriously ill and potentially dangerous patients remaining in hospital, or possibly the Review Board is becoming more conservative in its approach. An additional factor may be that physicians are being better educated regarding certification (7).

The percentage of patients withdrawing applications from Review Boards varies among the facilities, suggesting that the patients in the facilities may be different or have different attitudes or expectations of the Review Board. Patients may withdraw applications if physicians meet their needs in other areas (for example, granting of privileges) or if they expect that there would not be a positive outcome from a Review Board hearing. One might speculate that fewer patients withdraw from Review Board hearings at the NBPH because they expect a better outcome at the Board than do patients at the LPH and STPH. It is noteworthy that a paralegal is available full-time at the STPH to assist physicians upon request with their presentations at Review Board hearings. Similar resources may not be available to physicians at other hospitals.

As the provincial psychiatric hospitals continue to downsize, the percentage of inpatients having more serious mental illnesses and being potentially more dangerous is likely to increase. As a result, the trend toward low rates of rescinded certificates will likely continue, and the stigma of mental hospitals may similarly worsen.

Conclusion

The findings of this study show that relatively few involuntary certificates are rescinded by the Review Board. Further research needs to be conducted to explain the differences among the psychiatric hospitals, particularly related to rates of patients choosing to withdraw applications to the Board, physicians completing Form 5s, and the Review Board rescinding certificates. One can generally conclude from the data that involuntary patients in psychiatric hospitals do meet the criteria for certification and that physicians should have little fear of attending Review Board hearings since certificates are upheld in the vast majority of cases.

Little attention has been directed to the equally important question of whether there are significant numbers of patients who should be kept in hospital involuntarily but are not. Political and fiscal pressures not to admit patients to hospital should be avoided when hospitalization is clinically indicated. As further cuts to beds are planned within the psychiatric hospitals, there will continue to be a need to provide adequate and necessary services for patients, particularly for those who need to be involuntarily hospitalized.

Clinical Implications

Limitations

Acknowledgements

The authors thank Irene McCarthy, Legal Coordinator, STPH; Marg Gould, Review Board Secretary, LPH; Donna Essey, Inpatient Data Control Clerk, LPH; Debra MacLain, Rights Advisor, STPH; and Pat Curtis, Forensic Secretary, STPH.

References

1. Gray J, Clark A, Higenbottam J, Ledwidge B, Paredes J. Review Panels for involuntary psychiatric patients: which patients apply? Can J Psychiatry 1985;30:573–6.

2. Higenbottam J, Ledwidge B, Paredes J, Hansen M, Kogan C, Lambert LA. Variables affecting the decision making of a review panel. Can J Psychiatry 1985;30:577–81.

3. Chandrasena R, Smith S. Regional Review Boards of Ontario: a medico-legal review. Can J Psychiatry 1986;31:643–8.

4. Paredes J, Ledwidge B, Beyerstein D, Cashore J, Higenbottam J. The Review Panel process: interpretation of the findings and recommendations. Can J Psychiatry 1987;32:444–7.

5. Ledwidge B, Glackman W, Paredes J, Chen R, Dhami S, Hansen M, and others. Controlled follow-up of patients released by a Review Panel at one and two years after separation. Can J Psychiatry, 1987;32:448–53.

6. Adams SJ, Pitre NL, Cieszkowski R. Who applies to Regional Review Boards and what are the outcomes? Can J Psychiatry 1997;42:70–6.

7. O’Reilly RL, Komer W, Dunbar S. Why are patients discharged by Review Boards? Can J Psychiatry 1999;44:259–63.

Résumé

Objectif : Discerner les tendances à long terme et comparer les différents hôpitaux psychiatriques en ce qui concerne les résultats des certificats d’admission en cure obligatoire.

Méthode : Les données sur les certificats d’admission en cure obligatoire ont été obtenues auprès des hôpitaux psychiatriques de London et St. Thomas de 1987 à 1997, ainsi que du bureau de l’ombudsman de 10 hôpitaux psychiatriques de 1987 à 1993, et tirées de données publiées de l’hôpital psychiatrique de North Bay, de 1992 à 1994. Les données ont été comparées par rapport aux variables des résultats.

Résultats : Il existe des taux et des proportions variables parmi les hôpitaux psychiatriques au chapitre des résultats des certificats d’admission en cure obligatoire, notamment des patients qui choisissent de retirer leur demande à la Commission d’examen, des médecins qui annulent les  certificats d’admission en cure obligatoire en remplissant des formulaires numéro 5 et la Commission d’examen qui annule des certificats. En général, la Commission annule peu de certificats, et cette tendance s’est davantage prononcée au cours des dernières années.

Conclusions : Les patients en cure obligatoire dans les hôpitaux psychiatriques ne reçoivent pas souvent leur congé de l’hôpital par suite d’une annulation de certificat par la Commission d’examen.

Presented at the Ontario Psychiatric Association, Annual General Meeting, Toronto, Ontario, January 1998.

Manuscript received August 1998, revised, and accepted October 1998.

1Forensic Psychiatrist, St Thomas Psychiatric Hospital; Assistant Professor, Department of Psychiatry, University of Western Ontario, London, Ontario.

2Coordinator of Research and Education, London/St Thomas Psychiatric Hospital; Associate Professor, Department of Psychiatry, University of Western Ontario, London, Ontario.

3Psychologist, London/St Thomas Psychiatric Hospital; Associate Professor Department of Psychiatry, University of Western Ontario, London, Ontario.

4Clinical Audit Coordinator, London/St Thomas Psychiatric Hospital, London, Ontario.

Address for correspondence: Dr WJ Komer, Ministry of Health, St Thomas Psychiatric Hospital, 467 Sunset Drive, PO Box 2004, St Thomas, ON  N5P 3V9

email: bill.komer@sympatico.ca

Can J Psychiatry, Vol 44, June 1999