Outcomes of inpatients detained under holding powers in an Irish Psychiatric Hospital

Abstract

The power to temporarily detain voluntarily admitted patients from leaving a psychiatric hospital is common to mental healthcare systems globally and is known as a “holding power”. In Ireland, the power is contained in S.23(1) Mental Health Act 2001 (S.23(1)) and provides that within 24 hours of its initiation by a doctor or a nurse on the staff of the hospital, the patient held must be assessed by a consultant psychiatrist who shall either discharge the patient or order a second consultant psychiatrist review, the outcome of which shall either be discharge of the patient or their detention on an involuntary basis. Little is known about the risk factors for voluntary patients who are detained under holding powers with the bulk of national and international research focussed on involuntary detention – where patients are formally detained either from the outset of their admission or following the regrading of their temporary detention under a holding power. In this retrospective study, all 167 voluntarily admitted patients who were detained under S.23(1) at two university psychiatric hospitals in Dublin between 2018 and 2020 were characterised. The use of S.23(1) was rare, occurring in 2% of total admissions over the study period. In Study 1 this cohort of patients are compared against 334 controls who were never detained during their voluntary admission. Predictors of detention under S.23(1) included the presence of impaired insight, psychotic symptoms, suicidal ideation or diagnosis of bipolar disorder. While the median length of stay was longer for patients held under S.23(1) as compared to the control group, they had similar outcomes in terms of Clinical Global Impression – Improvement Scores and readmission rates over the one-year period post-discharge. In Study 2, the use of S.23(1) on those 167 admissions on whom it was used was described and the 77 patients regraded to involuntary status compared against the 90 patients who were not. Throughout the study period, there were 205 initiations of S.23(1), there being multiple uses on a single admission 27 times. 53% of initiations occurred outside normal working hours and the median length of time between admission and initiation of S.23(1) was 10 days. The median time to review by a consultant psychiatrist was 14hrs 59mins. The majority of initiations (72.7%) were made by nursing staff. Of the 205 initiations of S.23(1) during the study period, 111 (54.1%) were regraded to involuntary status. Of those that were not, 91/94 (96.8%) chose to remain in hospital as a voluntary patient. Predictors for the regrading of a S.23(1) holding power to involuntary status included it being initiated during working hours, by a consultant psychiatrist or if the patient had a diagnosis of bipolar disorder. Outcomes, measured by total length of stay, one-year readmission rates and Clinical Global Impression – Improvement scores, did not differ significantly between the groups. To our knowledge, this study is the first of its kind to characterise and compare those detained under psychiatric holding powers and adds to our understanding of the risk factors and outcomes associated with its use.