A patrol car that suddenly parked, and an area peeking out from behind closed shutters. A person in any other condition who is being transported “standing up”, sometimes even in handcuffs, to the nearest psychiatric hospital. The practice of involuntary hospitalization, seen by medical professionals as a “last resort,” hit the news after a video was circulated online showing the violent manner in which an elderly woman was being wheeled by a group of nurses who, before putting her into an ambulance they decided to wash her in front of everyone with a hose. Their position aroused public outrage, with the responsible minister explaining that the workers in question did not belong to the SNB.

Although the transfer of the above patient probably did not have a relevant prosecutor’s order, the discussion on best practices for the transfer of patients who do not consent to their hospitalization is already open. “The images reminded me of Leros,” says psychiatrist and president of the Association of Occupational Psychiatrists of Greece, Achilleas Oikonomou, who previously represented our country at conferences on involuntary hospitalization, comments to K. “The legal framework is the same in all countries and speculation about the best approach is common, but the rate of involuntary hospitalization in Greece was higher than the European average,” he tells K. “Often in Greece, the way patients are transported is extremely problematic.”

During 2022, a change was introduced in the implementation of involuntary hospitalization to partially remove the police and involve mental health professionals, however, this legislation has not yet taken shape, although it has caused problems in various aspects of those who work. in field.

“Accident management sounds inhumane in the first hours, but at this moment it is the only way to protect the patient himself, who is in crisis and who came to the hospital without his consent,” says Nurse K. When “de-escalation” methods fail, nurses put the patient in a hospital bed. “Sometimes we put straps on our hands, sometimes on all four limbs, sometimes the right hand is tied to the left and vice versa,” he describes. He is then given a strong sedative. It has happened that nurses, police officers, psychiatrists, and other patients have been injured by a patient in a crisis. “Perhaps he has a knife, a gun or just a sharp object with him,” they describe. “Once I threw a bedside table into the corridor, which people constantly passed by, another broke my colleague’s dentures.” Defense, of course, is associated with the patient’s refusal of treatment, often with ignorance of their mental illness. As a rule, the patient calms down in the next two days. “In the meantime, we are following protocol whereby we have to untie him regularly so he can eat, walk, go to the toilet.”

In order for prosecutors to intervene in cases of involuntary hospitalization, the family usually submits a request to either the police or the district attorney, often along with a psychiatric report; more rarely, this can be done ex officio. The prosecutor’s office, on the basis of a complaint, or the relevant social service initiates proceedings. The task of transport is taken over – until now – by the police.

“Incident management sounds inhumane in the first hours, but at this point it is the only way to protect the patient himself in crisis.”

“Typically, the first—involuntary—hospitalization resulting from a first psychotic episode can occur during adolescence, until then, parents often confuse symptoms with normal adolescent behavior,” says Dr. Sofia Martinaki, professor of clinical social sciences. “K” Eginecio’s staff member and researcher who completed her doctoral dissertation on the topic of involuntary hospitalization. “Also the elderly, about 25 years old, whose families are at an impasse; they may not have accepted or looked for the possibility of mental illness, justify bizarre reactions, “this is a romantic disappointment” or “couldn’t stand the pressure from the army”, and in some major crisis will lead to an involuntary hospitalization decision.” Others will follow during his lifetime, often associated with stopping medication. In essence, this is a vicious circle that is repeated due to the lack of organized public mental health structures that can closely monitor the mentally ill and support his family.

“We must not ignore the fact that most patients are not in a good financial position to be able to approach private individuals,” recalls Dr. Dimitris Kontis, President of the Scientific Council of the National Academy of Sciences and Coordinating Director at the National Academy of Sciences. 4th psychiatric department. “There is also a big problem with patients from the regions that we prescribe, but they do not have a structure in their region that would take them there.”

Involuntary hospitalization becomes a trauma both for the patient himself and for his relatives, the family is forced to ask for it, but then is tormented by guilt. “Usually relatives ask us in polyclinics how to activate involuntary hospitalization, but when they see a police car near their house and understand what is happening, they break up,” says Dr. Martinaki, 32. stay in Eginetio. “As a rule, during the first or second hospitalization, relatives are present, even friends regularly come,” he notes. “They want to know the exact diagnosis, where they themselves can be to blame, if it is hereditary, they are ready to start psychotherapy…”. The climate has changed over the years. “When it comes to the 5th or 6th hospitalization, relatives seem more distant, they don’t even accompany a patrol car, they follow the beaten path.” However, she believes that the attitude of significant others is critical in the development of the mentally ill. “Psychiatric drugs can control symptoms such as delirium or hallucinations, but they have little effect on so-called “negatively expressed emotions,” he emphasizes. “If a person constantly hears around him “you are lazy”, “why don’t you find a job to help with the housework?”, “We have never seen you with a girl”, then he will be led to mathematical accuracy to a relapse. The average length of stay in Aegina is 20-22 days.

Twice a week, when the General Psychiatric Hospital of Attica is on duty, more than 20 admissions are made. “Of these, 70% are unintentional,” notes Dr. Kontis. According to the hospital’s own statistics, in 2022 there were 1,831 involuntary hospitalizations and 852 voluntary admissions, while in 2021 the corresponding figures were 1,549 and 825. However, the number of involuntary hospitalizations has been increasing over time, from 1,251 in 2013 to 1,251 in 2013. to 1,831 in 2022. Of the 2,683 patients admitted to ARCA in 2022, only 1,587 had this for the first time. The large number of involuntary hospitalizations is undoubtedly related to the pandemic that is being observed in the world. But he has other reasons as well. “One of them is that through involuntary hospitalization, a mentally ill person can find a bed for himself, given that beds for emergency hospitalizations have drastically decreased over time,” says Dr. Kontis “K”. “And for those who live in provincial cities, this process is a one-way street.” If a person in need of psychiatric help is generally difficult to convince to go to the hospital, then arguments seem insufficient when he knows that he will have to leave for another city, and it is also difficult to transport someone who is experiencing a psychotic episode in a simple car.

When trying to login for the wrong reasons

Those who worked in the country’s psychiatric hospitals have also witnessed involuntary hospitalizations, the motives for which vary. “It happened that there was an incident that, according to psychiatrists, did not require hospitalization, which we sent to the prosecutor’s office in writing,” notes Dr. Martinaki. “It was about some kind of complaint from neighbors with rather vindictive motives.” Accordingly, there has been a trend in the past for older people, especially if they had a dementia problem, to “park” in mental hospitals. “It was common during summer holidays and vacations,” recalls Dr. Martinaki, “relatives were lost and we didn’t know who to turn to.” However, “an insane older person may have a psychotic episode and require hospitalization,” explains Dr. Kontis. For many homeless people, involuntary hospitalization was the only way to provide shelter and food for several days…

“In Greece, the percentage of involuntary hospitalizations has always been 70-75% of the total,” says retired psychiatrist Theodoros Megaloykonomu to K. “This is a violent decision that could have been avoided if we had public mental health structures, one per 100,000 inhabitants, so that there is a stable therapeutic relationship between the psychiatrist and the patient and constant monitoring of cases.” Through a relationship of trust and therapeutic continuity, the patient can be persuaded to voluntarily admit him to the hospital or, if realistic, to carry out therapeutic treatment at home. He tried to implement a different approach when he was the director of the 9th division of the PSNA and the Agios Anargyro Mental Health Center, which were interconnected. “We gradually limited the immobilization of patients in the 9th OPNA and canceled it within 2-3 years,” he recalls, “just as we stopped locking the doors.” Discharged patients were cared for by a multidisciplinary team from the Agioi Anarjiro Mental Health Center while they resided in areas under its jurisdiction. “The percentage of those who needed involuntary hospitalization “dropped” to 27%,” he adds, “of course, this was preceded by systematic home visits by a psychiatrist and a nurse from our team.”

According to the data of that time, in 2007 the number of visits to KPSY by adult users reached 2357, in 2008 – 3856, in 2009 – 4140, in 2012 – 6609. Conversely, home visits in 2007 amounted to 195, in 2008 – 195. they rose to 801, in 2009 to 1,047, and in 2012 to 2,210. In the past, the “model” for managing “complex” incidents was the UK, “where the percentage of involuntary cases was only 10%”. However, “the gradual understaffing of psychiatric structures has led to a large increase there as well, today the proportion of involuntary is 50%.”

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