[Long and short stays under ASPPI: Comparison of clinical and non-clinical data from 250 initial certificates]

On July 5, 2011, France introduced a law permitting the involuntary admission of patients considered to be in "imminent danger" into psychiatric care without the consent of the family. This is known as "admission en soins psychiatriques pour péril imminent"(ASPPI). ASPPI authorizes all physicians to hospitalize a patient without his or her consent nor the consent of a third party. This differs from previous measures as only one certificate is needed. The law also requires involuntarily admitted patients to present themselves before a judge specialized in Liberties and Detentions (juge des libertés et des détentions), 12 days following their admission. Although there has been an increase in the number of ASPPI admissions when compared to other types of involuntary admission, patients admitted by ASPPI have been hospitalized for a shorter time than others. Some authors, however, have pointed out that decision criteria are frequently interpreted in a loose manner by physicians. This study was conducted at Sainte Anne hospital in Paris.

This study tried to determine if there were different clinical and non-clinical characteristics associated with the length of hospitalization under ASPPI.

This study analyzed all administrative files for patients admitted under ASPPI from January 1, 2015 to December 31, 2015. These files contained the medical certificates and the court orders. The sample was split into two groups: patients hospitalized for a shorter stay and who did not present themselves to the judge and patients hospitalized for a longer stay and who did present themselves to the judge. The certificates were analyzed with a criteria grid, which includes clinical and non-clinical items. Clinical items were taken from the French High Authority of Health (Haute Autorité de Santé) 2005 recommendations. These include suicidal risk, risk to others, drug abuse, delusions or hallucinations, mood disorder and lack of selfcare. Non-clinical items include other information found in the certificate and sociodemographic information found in the administrative file.

Among the 250 certificates analyzed, 172 (68.8%) were associated with a long stay and 78 (31.2%) with a short stay. A bivariate analysis found no significant differences between the two groups for non-clinical characteristics and for drug abuse and mood disorder. When no suicidal risk was present, the stay was short in 21% of the certificates and long for 79%. When a suicidal risk was present the stay was short in 43% of the certificates and long for 57% (P=0.0002). When a risk to others was present the stay was short for 19% of the certificates and long for 81% (P=0.003). When delusions and hallucinations were present the stay was short in 15% of the certificates and long in 85 % (P=5×10e^-14). When a lack of selfcare was present the stay was short in 10% of the certificates and long for 90% (P=0.01).

This study identified two types of situations linked with the length of hospitalization for patients under ASPPI. In one situation, associated with a longer stay, we found acute psychiatric disorders exhibited by more delusions, hallucinations, drug abuse, and lack of selfcare. In the second situation, associated with a shorter stay, this study found more episodic situations with suicidal risk. This study suggests that some involuntary admissions could be avoided if physicians could monitor episodic situations in appropriate structures. Moreover the criteria grid we used in this study should be validated to further analyze the quality of the certificates in order to lead to more precise recommendations.