Argo Daniel, Abramowitz Moshe Z, Lubin Gadi, Barash Igor
Jerusalem Mental Health Center.
Hebrew University, Jerusalem, Israel.
Harefuah. 2019 Jul;158(7):427-431.
The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized can be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. This study attempts to compare the variance between the TP and the DPC decisions in different geographical regions in Israel.
We examined the outcomes of decisions made by the DPC using readmission data - an internationally recognized indicator of the quality of hospital care - and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were taken from the Israel National Register. We also collected information regarding all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in fewer than 30 days, involuntary civil readmission in fewer than 180 days, and involuntary readmission under court order in less than 1 year.
The re-hospitalization pattern was compared in the two groups of patients discharged from psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the success rates of the various regional DPCs and the hospital TP groups, with the TP average (74.5% national success rate) success significantly better than the DPC groups (66.7% national success rate). Moreover, the variance between the decisions made in the different geographical regions in the two groups was also statistically significant (σ2 variance was 80.4 and 27.1 for the DPC and TP groups, respectively).
The results we present indicate that the variance of decision "failure" (readmission) and "success" across the various geographical regions was found to be significantly better in the TP group than in the DPC group. We consider it likely that whereas TPs discharge IPH patients in accordance with well-accepted clinical approaches, the DPC's decisions are based on interpretations of the law (regarding, e.g., the patient posing a physical threat) and on the DPC's understanding of what is meant by the patient's "best interests." We suggest introducing more formal psychiatric training for the legal staff of the DPCs and building a structured and standardized method for reviewing the patient. Moreover, we propose using "soft paternalism" as an approach, which would justify limitations on individual liberties for the benefit of persons being restricted, provided that they are unable to make a choice that would be consistent with their own interests. This is often an appropriate and perhaps a more practical approach, one that the DPC could adopt in place of the present conservative approach, which requires a specific standard of "proof" of major illness to qualify as insanity requiring hospitalization.
1991年的以色列《精神卫生法》规定了非自愿精神病住院治疗（IPH）的程序。如此住院的患者可由主治精神科医生（TP）或地区精神病委员会（DPC）批准出院。DPC做出的决定往往与TP的建议不一致。本研究试图比较以色列不同地理区域TP和DPC决定之间的差异。
我们使用再入院数据（国际认可的医院护理质量指标）检查DPC做出的决定结果，并将其与TP批准出院的患者结果进行比较。2013年因DPC决定导致的所有IPH出院病例（N = 972）均取自以色列国家登记册。我们还收集了2013年因TP决定导致的所有IPH出院病例的信息（N = 5788）。我们将“失败”定义为30天内再次入院、180天内非自愿民事再次入院以及法院命令下1年内非自愿再次入院。
对2013年从精神病住院治疗中出院（索引出院）并分别随访一年的两组患者的再住院模式进行了比较。我们发现不同地区DPC和医院TP组的成功率之间存在统计学上的显著差异，TP组的平均成功率（全国成功率74.5%）明显高于DPC组（全国成功率66.7%）。此外，两组中不同地理区域做出的决定之间的差异在统计学上也很显著（DPC组和TP组的σ2方差分别为80.4和27.1）。
我们给出的结果表明，TP组中不同地理区域的决定“失败”（再入院）和“成功”的差异明显优于DPC组。我们认为，TP批准IPH患者出院可能是依据公认的临床方法，而DPC的决定则基于对法律的解释（例如，患者构成身体威胁）以及DPC对患者“最大利益”含义的理解。我们建议为DPC的法律工作人员引入更正规的精神病学培训，并建立一种结构化和标准化的患者审查方法。此外，我们建议采用“温和家长主义”方法，即只要被限制者无法做出符合自身利益的选择，就可以为了他们的利益而对个人自由进行限制，以此作为限制个人自由的正当理由。这通常是一种合适且可能更实际的方法，DPC可以采用这种方法来取代目前保守的方法，目前的方法要求有重大疾病的特定“证据”标准才能认定为需要住院治疗的精神错乱。
