精神障碍患者入院方式和非自愿住院标准

精神障碍患者是一类特殊的弱势群体,其非自愿住院和治疗问题是涉及公共安全、公共卫生、医学伦理和法律的重大问题。为了平衡精神障碍者合法权益与社会公共安全之间的矛盾,全世界将近80%的国家和地区通过制定精神卫生法来规范精神卫生服务,如规范患者的入院方式、非自愿入院的标准及其程序。本文综述不同国家精神卫生立法中所涉及的精神障碍患者入院方式和非自愿住院标准。     

精神卫生法实施前后精神科男性住院患者保护性约束使用情况对照分析

目的了解精神卫生法实施前后男性住院精神障碍患者的保护性约束使用情况,并分析其原因。方法根据患者病历记录、保护性约束观察记录单进行回顾性调查,内容包括保护性约束使用率,保护性约束总人次、总时间、平均每人次约束时间,入院当天约束比率及保护性约束的原因。结果精神卫生法实施前后,男性住院精神障碍患者保护性约束总时间分别为5 364 h和2 231 h,保护性约束总人次分别为452人次和480人次。保护性约束使用率、平均每人次约束时间与精神卫生法实施前比较均明显下降（P〈0.01）;平均每人约束次数较精神卫生法实施前增加（P〈0.01）。精神卫生法实施后,因不合作外走、行为紊乱约束保护的患者例数与实施前比较减少（P〈0.05）;因暴力攻击、自杀自伤因素进行保护的患者例数较实施前增加（P〈0.05）。结论精神卫生法的实施对保护患者合法权益,降低住院患者保护性约束使用率,防止保护性约束的滥用具有积极的意义。     

首次住院儿童青少年精神障碍患儿父母压力调查及干预研究

目的 调查首次住院儿童少年精神障碍患儿父母的心理压力状况,并通过干预指导,改善父母心理状况.方法 采用心理身体紧张松弛测试表(PSTRI)和自编问卷的方法 ,对121例患儿父母的心理压力及对精神障碍相关知识了解程度进行了调查,并对其实施有针对性地干预指导.结果 通过干预,患儿出院时其父母心理压力状况明显优于患儿入院时,有显著性差异(X2=147.02,P<0.01);患儿父母在精神疾病基本知识、药物治疗知识、护理知识、促进康复知识、预防知识掌握上,入院时与出院时相比具有显著性差异(X2=144.39～171.68,P<0.01).结论 首次住院的儿童少年精神障碍患儿父母心理压力普遍较重,对其进行有针对性地干预指导,可有效改善父母心理状况,有助于精神障碍患儿的治疗及减少复发.     

精神障碍非自愿住院患者胁迫体验及其影响因素

目的 初步调查精神障碍非自愿住院患者在入院过程以及住院期间的胁迫体验感知,并 探讨其影响因素。方法 选择2017 年3— 8 月于上海交通大学医学院附属精神卫生中心徐汇院区 的6 个封闭病房内根据《精神卫生法》第三十条要求入住的254 例精神障碍非自愿住院患者,在入院 后的第3 周采用自编的基本情况调查表、简明精神病量表（BPRS）、MacArthur 入院体验主观胁迫分量表 （MPCS）、胁迫体验问卷（CES） 进行问卷调查。根据本次入院前是否征求过本人意见将所有患者分为征求 意见组（115 例）与未征求意见组（139 例）。应用SPSS 22.0 软件进行统计学分析,组间比较采用独立样本 Mann-Whitney 检验或Kruskal-Wallis 检验、χ2 检验, 采用Bonferroni 法校正显著性水平的事后两两比较。 采用相关分析了解MPCS、CES 与BPRS 症状得分的相关性,采用回归分析探索胁迫体验得分的影响因 素。结果 （1）相对精神科的封闭环境,患者的胁迫体验更多源于自我选择和决定权的受限。（2）入院 时未征求意见组患者较征求意见组患者在MPCS 总分［4.00（2.00,5.00）分比1.00（0,2.00）分,Z=8.592, P＜ 0.01］、CES 量表总分［52.00（39.00,81.00）分比44.00（34.00,56.00）分,Z=3.236,P＜ 0.01］及维度分 ［权利限制13.00（9.00,27.00）分比9.00（9.00,15.00）分,Z=3.746,P＜ 0.01;被动14.00（10.00,24.00）分比 12.00（9.00,18.00）分,Z=2.861,P＜ 0.01;负性环境9.00（6.00,13.00）分比8.00（6.00,10.00）分,Z=2.000, P＜ 0.05;负性反应4.00（2.00,6.00）分比3.00（2.00,5.00）分,Z=2.706,P＜ 0.01）］上得分更高。（3）入院 前未征求意见、公安机关送诊、教育程度高是MPCS总分的影响因素（F=25.076,P＜0.01）,经历约束措施、 BPRS 思维障碍严重和入院时胁迫体验高是CES 总分的影响因素（F=5.135,P＜ 0.01）。结论 精神障碍 患者在入院和住院过程中存在一定胁迫体验,这种主观负性体验与多种因素有关,临床上应多加关注, 并采取针对性措施降低患者对胁迫的感知。     

住院老年精神疾病患者的现状调查

目的:对住院老年精神疾病患者的现状进行调查。方法:采用回顾性调查法和整群抽样法,收集四川省5所精神专科医院2013年5月至2013年10月住院的所有老年精神疾病患者的病历记录及一般人口学资料进行统计分析。结果:870例有效数据中,老年精神疾病患病率前3位依次为精神分裂症、器质性精神障碍及抑郁症;男性和女性的抑郁症、物质所致精神障碍、神经症的患病率差异有统计学意义(χ~2=41.142,P0.05);农村与城市在精神分裂症、器质性精神病、躁狂症、神经症及双相障碍的患病率分布差异有统计学意义(χ~2=78.435,P0.05)。Logistic回归分析显示,年龄(OR=1.037,P=0.001)和治疗方式(OR=0.252,P=0.000)对疗效影响显著。结论:住院老年精神疾病患者以农村、女性老人为多;综合治疗效果优于单纯药物治疗。     

基于决策树方法分析住院精神分裂症患者骨密度异常的影响因素

目的 探索影响住院精神分裂症患者骨密度异常的相关因素,为预防骨质疏松和骨折提供参考.方法 选取天津市精神卫生中心2015年1~7月住院的精神分裂症患者,采用自制问卷进行调查,收集被试的社会经济状况、既往病史、治疗史、骨密度、催乳素(PRL)等生化指标及住院期间的饮食、运动情况;按照骨密度是否异常进行分组,采用决策树方法探讨影响骨密度异常的因素.结果 444例住院精神分裂症患者中,存在骨密度异常的有300例(67.57%),其中骨质疏松者156例(35.14%)."有无骨折史"是住院精神分裂症患者骨密度异常的首要影响因素(χ2=46.347,P<0.01),"饮用咖啡浓茶"(χ2=55.424,P<0.01)和"每天室内运动"(χ2=31.191,P<0.01)是二阶节点,三阶节点为"吃豆制品"(χ2=35.801,P<0.01)和"血钙水平"(χ2=25.281,P<0.01).结论 住院精神分裂症患者中,骨密度异常状况严重;既往骨折史对于住院患者预防骨质疏松意义重大,对于有骨折史的患者,适当增加室内运动可以减少骨质疏松的发生;对于无骨折史的患者,除了定期监测其骨钙值以外,还应加强对其膳食习惯的干预.     

纳络酮治疗酒精所致精神障碍临床观察

目的:探讨纳络酮治疗酒精所致精神障碍的疗效及安全性. 方法:酒精所致精神障碍患者98例,随机分为研究组58例(纳络酮联合传统治疗),对照组40例(单用传统治疗).采用临床疗效总评量表(CGI-GI)进行疗效评定. 结果:治疗2周,研究组疗效明显好于对照组(P<0.05或P<0.01),且起效时间显著快于对照组(t=9.91,P<0.01).无明显不良反应. 结论:纳络酮治疗酒精所致精神障碍可减轻戒断症状,提高戒酒的成功率,是治疗酒精所致精神障碍较好的辅助用药.     

急性脑卒中患者血清白蛋白水平与近期预后的关系

目的 探讨急性脑卒中患者血清白蛋白(Alb)水平与近期预后的关系.方法 对242例急性脑卒中患者入院时和住院期间每2周检测血清Alb 1次,比较低Alb组(Alb<35 g/L)和正常Alb组(Alb≥35 g/L)脑卒中并发症的发生率、死亡率以及好转率.结果 242例患者中入院时低Alb 38例(15.7%),住院期间出现低Alb 105例(46.5%).与入院时正常Alb组比较,入院时低Alb组的死亡率、卒中后并发症的发生率明显增高,出院时病情好转率明显下降(P<0.05～0.01);与病程中正常Alb组比较,住院期间低Alb组的死亡率、并发症的发生率明显升高,出院时病情好转率明显降低(P<0.05～0.01).入院时Alb水平与死亡率呈负相关,与美国国立卫生研究院卒中量表(NIHSS)评分差值正相关(r=-0.297,r=0.282;均P<0.01).住院期间Alb水平与肺部感染发生率、死亡率呈负相关(r=-0.545,r=-0.336),与NIHSS评分差值呈正相关(r=0.274;均P<0.01).Logistic回归分析显示,排除年龄、病情因素后,急性脑卒中患者入院时及住院期间血清Alb水平对近期预后影响显著. 结论血清Alb水平是影响急性脑卒中患者近期预后的因素.     

精神障碍患者非自愿住院实施现况调查的国内外进展

现代精神病学中,基于对精神障碍患者个人权利的保护和对公众安全的维护,非自愿住院及相关治疗成为不可或缺的一部分.但非自愿住院的实施历来广受争议,为平衡精神障碍患者合法权益与公共安全之间的矛盾,各国通过立法对非自愿住院的实施加以规范,本文简要介绍国内外针对精神障碍患者实施非自愿住院的相关调查研究,为有关政策法规的制定研究以及机构依法开展非自愿医疗提供参考.     

综合医院与精神专科医院抑郁障碍患者的临床特征比较

目的 比较不同性质医疗机构精神科门诊抑郁障碍患者的临床特征和治疗情况.方法 使用一般情况调查表和简明国际神经精神访谈对综合医院和精神专科医院精神科门诊100例抑郁障碍患者进行调查,对不同性质医疗机构患者的临床特征和治疗情况进行比较分析.结果 综合医院精神科门诊抑郁障碍患者的年龄和首次抑郁发作的年龄都大于精神专科医院患者(P ＜ 0.01).综合医院患者抑郁发作时有不典型症状的比例高于精神专科医院(P ＜ 0.05),而精神专科医院患者中有焦虑症状(P ＜ 0.05)、复发性抑郁(P ＜ 0.01)和有精神病性症状(P ＜ 0.05)的比例均高于综合医院,自杀风险的等级也高于综合医院(P ＜ 0.05).综合医院精神科门诊抑郁障碍患者使用苯二氮类药物的比例较高(P ＜ 0.05),而精神专科医院心境稳定剂的使用比例较高(P ＜ 0.05).两类医院中抗精神病药物的使用和是否有精神病性症状的内部一致性均不高(Kappa ＜ 0.4).结论 综合医院的抑郁障碍患者的临床表现更多不典型的特征,抑郁障碍的药物治疗情况也与专科医院不同,值得临床注意和深入分析.     

天水市城市与农村普通人群精神卫生知识知晓率及对精神疾病的态度

目的比较天水市城市与农村普通人群的心理健康、精神疾病预防知识知晓率及对精神疾病的态度。方法于2016年3月1日-4月30日采用多阶段分层整群随机抽样方法抽取天水市≥15岁的500名城市和1000名农村普通人为调查对象。采用精神卫生工作指标调查评估方案中的《普通人群心理健康知识和精神疾病预防知识知晓率问卷》、《病例测验》、《精神疾病有关态度问卷》进行调查,并比较农村和城市人群的各问卷结果。结果实际完成调查的城市与农村人口分别为485名、968名。城市人群对精神卫生与心理保健知识的知晓率高于农村(88.2%vs.65.4%,χ~2=99.89,P0.01),对精神疾病态度好于农村[(36.74±6.43)分vs.(35.83±7.62)分,t=2.27,P0.05]。城市人群对抑郁症、阳性症状为主精神分裂症、躁狂症及强迫症的知晓率均高于农村人群(35.5%vs.30.2%,40.2%vs.31.1%,65.4%vs.41.9%,77.1%vs.39.1%,χ~2=3.92、11.93、70.88、187.49,P0.05或0.01),对阴性症状为主精神分裂症的知晓率城市与农村人群差异无统计学意义(12.3%vs.14.3%,χ~2=0.59,P0.05)。结论天水市农村人群心理健康知识知晓率低于城市,对抑郁症、阳性症状为主精神分裂症、躁狂症、强迫症的知晓率低于城市人群,农村人群对精神疾病的态度有待提高,应加强对农村人群精神卫生知识的宣传力度。     

Neuropsychological differences between first-admission schizophrenia and psychotic affective disorders

OBJECTIVE: The study compared the neuropsychological functioning of patients with first-admission schizophrenia with that of patients with first-admission psychotic affective disorders. METHOD: Data came from the Suffolk County Mental Health Project, an epidemiological study of first-admission psychotic disorders. Subjects with a diagnosis of schizophrenia (N=102) and psychotic affective disorders, including bipolar disorder with psychotic features (N=72) and major depressive disorder with psychotic features (N=49), were compared on a battery of neuropsychological tests administered 2 years after the index admission. RESULTS: Subjects with schizophrenia performed worse than those with the psychotic affective disorders, even after adjusting the results for differences in demographic characteristics and general intellectual functioning. The most consistent differences were on tests of attention, concentration, and mental tracking. The two psychotic affective disorder groups were indistinguishable in performance on the neuropsychological tests. CONCLUSIONS: Even early in its course, schizophrenia is distinguishable from psychotic affective disorders by global and specific neuropsychological deficits. These deficits might contribute to the disability and poor outcome associated with schizophrenia in the mid- and long-term course.     

精神分裂症患者对住院的态度及影响因素分析

目的探讨精神分裂症患者的入院态度及其影响因素。方法对158例精神分裂症患者的入院态度及影响因素进行评估，并对影响因素作logistic回归分析。结果自愿入院率为12．7％，非自愿入院率为65．1％，强迫入院率为22．2％。入院态度多因素logistic回归分析显示，自知力、BPRS总分、文化程度进入了回归方程，标准回归系数分别为1．4314、0．5762、-0．3248。结论精神分裂症患者非自愿入院率高，入院态度受多种因素影响。本研究为我国精神卫生立法有关条款的制定提供事实依据。     

The dilemma of civil rights versus the right to treatment: questionable involuntary admissions to a mental hospital

Admission to a close ward was analyzed at the Department of Psychiatry, University of Oulu using 888 patients and their 1861 assessment and treatment episodes. Of all referrals for involuntary assessment (n = 237, 12.7% of all episodes) a total of 44 (2.4%) used "questionable" juridical criteria: the final diagnosis was not psychosis. In the follow-up, the admission of the questionable patients was mainly considered a clinical necessity, and at least one third of them were diagnosed as being psychotic and 2 committed suicide. An elevated probability of belonging to the questionable group was seen among patients in their first treatment episode, with minimal professional education, female sex, short treatment time, or residence in a rural area. The result suggests that some inequality existed between women and men, less and more educated and residents of urban and rural areas. The results also reflect conflict between the ethics and clinical practice of involuntary commitment, and the phrasing of the law, especially its diagnostic limitation to psychotic states only.     

Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients

Background The objective of this analysis was to determine the ways in which patients’ legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables. This study specifically investigated differences between patients who were voluntary during both admission and discharge, patients who were involuntary on admission but voluntary on discharge (having converted to voluntary status during hospitalization), and patients who were involuntary during both admission and discharge. Method Data were collected from the charts and treating clinicians of 227 consecutively discharged patients from two psychiatric units in a large, urban, county hospital in the southeastern United States. Based on results of bivariate tests, sociodemographic and clinical factors were entered into a polytomous logistic regression model to determine effect estimates (adjusted odds ratios). Results In the bivariate analyses, 15 variables were significantly associated with the trichotomous legal status. In the model, three factors were independently significantly associated with legal status, while controlling for four potential confounders: (1) whether or not the patient was experiencing psychotic symptoms at discharge, (2) whether or not the patient had documented medical problems requiring medication at discharge, and (3) the number of psychiatric medications. Conclusions A generalized lack of treatment engagement and adherence among involuntary patients likely underlies significant differences between the groups in terms of psychotic symptoms, diagnosed medical problems requiring medications, and number of psychiatric medications at discharge. Studying legal status (and the process of legal status conversion from involuntary to voluntary) and its correlates is an important topic for further research.     

Le devenir des soins psychiatriques sans consentement : suivi à deux mois de 510 cas

IntroductionThe French Mental Health Act was reformed by the law of July 5th 2011, adding new and useful tools in the therapeutic management of the mentally ill, such as the possibility of involuntary admission to a psychiatric ward in case of an “imminent danger” and involuntary psychiatric treatment in outpatient settings. In France, these measures concern over 100,000 hospital stays a year. We wished to test the hypothesis that there is no statistical distinction between groups of patients with different types of admission orders.Material and methodsWe designed an observational, retrospective, single-centre study. Inclusions in the sample concerned all adults (aged 18 or above) involuntarily admitted to the specialised psychiatric centre of the Sarthe county between November 1st 2013 and October 31st 2014. A single follow-up took place 60 days after the admission order had been pronounced and included data extracted from administrative and medical files.ResultsFor the purpose of the study, each new admission was treated as a new “case”. Thus, 510 cases have been included in the main sample: 342 admitted upon a third persons’ application (67.1%), 115 for imminent danger (22.5%) and 53 upon the state's representative decision (10.4%). Follow-up data showed the average duration of involuntary treatment to be significantly higher between the first two groups, 31.8 vs. 26.1 days respectively (p = 0.03). The state's representative group shared distinct clinical characteristics (p ≤ 0.05) in terms of sex-ratio, initial application setting, length of involuntary treatment and hospital stay, as well as diagnosis, history of suicide attempt, rate of judicial hearings and care programming upon discharge from hospital.DiscussionOur initial hypothesis was rejected. The type of measure was indeed significantly associated with different outcomes 60 days after admission. As was the case in other recent studies, the “imminent danger” group made up a significant part of the sample, highlighting its usefulness in emergency settings. This subgroup benefited from shorter hospital stays and had a significant tendency to see their admission order revoked at an earlier stage than in the case of a third party's application. This suggests that the incapacity to consent to treatment is less likely to last in the “imminent danger” group, although overall clinical characteristics are shared with the “third party” sub-sample. On the contrary, the combined “state's representative decision” group differed significantly from the rest of the sample on clinical grounds, especially a higher prevalence of psychotic disorders and a lower one for mood disorders. This could contribute to the higher rate of outpatient care programmes.ConclusionOur study points out some of the differences involving admission groups in psychiatric centers and is coherent with previous findings. However, given its single-centre approach and the notorious disparity of clinical practices over the national territory, it would be useful to include larger, nationwide samples, in order to assess the new Health Act's impact and to guide future public health decisions.     

Mental health legislation in Ireland: a lot done, more to do

Mental health legislation is necessary to protect the rights of people with mental disorders, a vulnerable section of society. Ireland's new Mental Health Act 2001 was fully implemented in 2006 with the intent of bringing Irish legislation more in line with international standards, such as the European Convention on Human Rights and United Nations Principles for the Protection of Persons with Mental Illness. The new legislation introduced several important reforms in relation to involuntary admission, independent reviews of involuntary detention, consent to treatment, and treatment of children and adolescents. It also presented significant challenges in terms of service delivery and resources within Irish mental health services. Both mental health service users and providers reported a range of difficulties with the new legislation. In this article, we analyze the Irish Mental Health Act focusing on the enhanced protection that it provides for patients, but also highlighting some areas of concern such as the conduct of mental health tribunals, consent and capacity problems, resource allocation, and disruptions in mental health service delivery.     

Neuropsychological function and dysfunction in schizophrenia and psychotic affective disorders

Background: Mounting evidence suggests that compromised neurocognitive function is a central feature of schizophrenia. There are, however, schizophrenia patients with a normal neuropsychological (NP) performance, but estimates of the proportion of NP normal patients vary considerably between studies. Neurocognitive dysfunction is also a characteristic of other psychotic disorders, yet there are inconsistencies in the literature regarding the similarity to impairments in schizophrenia. NP normality in psychotic affective disorders has not been systematically studied.Methods: Data came from the Suffolk County Mental Health Project, an epidemiological study of first-admission patients with psychotic disorders. Respondents with a diagnosis of schizophrenia (N = 94) or schizoaffective disorder (N = 15), bipolar disorder (N = 78), and major depressive disorder (N = 48) were administered a battery of NP tests assessing 8 cognitive domains 2 years after index admission. Patients’ performance profile was compared, and their NP status was classified based on 3 previously published criteria that vary in their stringency.Results: The 4 diagnostic groups had comparable NP performance profile patterns. All groups demonstrated impairments in memory, executive functions, and attention and processing speed. However, schizophrenia patients were more impaired than the other groups on all cognitive domains. Results were not attenuated when IQ was controlled. Prevalence of NP normality ranged between 16% and 45% in schizophrenia, 20% and 33% in schizoaffective disorder, 42% and 64% in bipolar disorder, and 42% and 77% in depression, depending on the criterion employed.Conclusions: Evidence suggests that differences in NP performance between schizophrenia and psychotic affective disorders are largely quantitative. NP impairment is also common in psychotic affective disorders. A significant minority of schizophrenia patients are NP normal.     

Short-Term Hospitalization Underlies the Similarity between Involuntarily and Voluntarily Admitted Patients: A One-Year Cohort Study

This study compared individuals admitted to a psychiatric hospital under a civil involuntary commitment order (IA) and patients admitted voluntarily (VA) using a one-year, shortest-stay cohort. Data were collected for 439 patients consecutively admitted to a university-affiliated Mental Health Center from March 1, 2012, to February 28, 2013, and discharged within seven days (one-year, shortest-stay cohort). A cross-sectional comparison between IA (n = 106) and VA (n = 333) groups was conducted. Mean length-of-stay was found to be slightly longer (4.7 ± 1.7 days) for the IA group compared to the VA group (3.8 ± 1.9 days; p = 0.019). Both IA and VA groups were similar regarding age, gender, marital status, age of onset, illness duration, and diagnosis. An acute psychotic state as reason for admission was observed 3.4 times more (p < 0.001) for IA compared to VA, whereas suicidal thought (p = 0.002), major depressive episode (p < 0.001), and hallucinations (p = 0.014) were found less frequently among IA patients. About one quarter of the patients (26.6 percent) in the study cohort were discharged for lack of adequate reason to remain hospitalized. There were no significant differences between IA and VA inpatients. The shortest length of stay underlies the similarity between involuntarily and voluntarily admitted patients. The obtained data point toward the need for more accurate assessment of the criteria for involuntary admission.     

脑出血患者血清NSE、S100β蛋白水平变化及其意义研究

目的分析脑出血患者血清神经元特异性烯醇化酶(NSE)、S100β蛋白的变化特征及与患者神经功能缺损程度的关系。方法选取本院收治的100例脑出血患者作为病例组、100例年龄、性别与之匹配的健康人群作为健康组,分别检测病例组入院时、治疗3d后、治疗7d后的血清NSE、S100β蛋白水平,并分析血清NSE、S100β蛋白水平入院时水平与美国国立卫生研究院卒中量表(NIHSS)评分的关系。结果病例组的血清NSE、S100β测定值在入院时、治疗3 d后、治疗7d后均显著的高于对照组且差异有统计学意义(P0.05);病例组患者的血清NSE、S100β测定值在治疗第3天时达到高峰,显著的高于入院时和治疗7d后(P0.05);病例组的患者依据不同出血量分组,结果显示在入院时、治疗3d、治疗7d后,血清NSE、S100β测定值组间比较为出血量≤15ml、患者出血量15~30ml、患者出血量≥30ml差异均具有统计学意义(P0.05);NSE、S100β与NIHSS评分呈现显著的正相关关系(r=0.419、r=0.338)(P0.05)。结论脑出血患者血清NSE、S100β蛋白随着治疗时间发生显著变化,并且与患者神经缺损程度具有一定的关系。