精神衛生法之國際比較研究-以台灣、日本及英國為例

To analyse, and explain to Australasian psychiatrists, recent proposed changes to the terms of coercive treatment for mental illness in Tasmania and Victoria and to place the proposals in the context of a broader human rights framework that is likely to impact the future shape of mental health legislation more generally. The Australian law reform proposals are reviewed against the requirements of numerous human rights instruments, including the recently ratified United Nations Convention on the Rights of Persons with Disabilities. Ethical and legal arguments are made to support the proposed changes and to introduce others, taking into account academic commentary on mental health law and recent empirical work on the ability to usefully categorise patients by their likelihood of harm to self and others. The Victorian and Tasmanian draft mental health bills propose a new basis for compulsory psychiatric treatment in Australasia. If they become law, coercive psychiatric treatment could only be applied to patients who lack decision-making capacity. The Tasmanian draft bill also sets a new benchmark for timely independent review of compulsory treatment. However both jurisdictions propose to retain an 'additional harm' test which must be satisfied before patients may be treated without consent. This differs from non-psychiatric cases, where if patients are unable to consent to medical treatment for themselves, they will be entitled to receive coercive treatment if it is in their best interests. The proposed changes under the Tasmanian and Victorian draft mental health bills will ensure that, in line with local and international human rights obligations, only patients who lack decision-making capacity may be coercively treated for mental illness. However the continuing 'additional harm' criteria may breach human rights obligations by imposing a discriminatory threshold for care on patients who are unable to consent to treatment for themselves. This could be avoided by replacing the 'additional harm' test with a 'best interests' test.

This thesis examines whether or not the supported decision-making model provides a conceptual and practical alternative to the traditional substituted decision-making approach to mental health laws. Advancements in international human rights law, in particular the coming into force of the United Nations Convention on the Rights of Persons with Disabilities (CRPD), have generated new ideas and standards in law, policy and practice governing the provision of healthcare and disability support. One of these ideas, ‘supported decision-making,’ is advanced by the CRPD as the preferred response when the legal capacity of a person with a disability is potentially compromised. However, its operation in mental health law and policy and in practical support for people with psychosocial (mental health) disabilities remains unclear. This thesis seeks to identify what form supported decision-making may take, or may already take, in mental health law, policy and practice. The thesis concludes that supported decision-making, as it is advanced in the CRPD, addresses many but not all persistent issues in contemporary mental health laws. In particular, it provides people with psychosocial disabilities with substantive rights to access support services, as well as protecting against substituted decision-making under current laws. Ultimately, as a human rights concept that is embedded in the CRPD, supported decision-making holds promise as a alternative for the substituted decision-making approach of current mental health law. This thesis sets out to refine the conceptual understanding of supported decision-making in protecting the rights of persons with psychosocial disability in legal capacity-related laws, and offers recommendations for creating a ‘supported decision-making regime’ in domestic law and policy.<br>Awards: Vice-Chancellor’s Commendation for Doctoral Thesis Excellence in 2014.

In September 1987 in Japan, the Mental Hygiene Law was amended to the Mental Health Law. This Law emphasizes the protection of human rights of the mentally disabled as well as the promotion of their social rehabilitation. In 1993, Mental Health Law was partially revised in the following four areas: (i) social rehabilitation; (ii) special rules for large cities; (iii) definition of the mentally disabled; and (iv) hogogimusha seido. The Japanese Government amended the Mental Health Law to Mental Health and Welfare Law on 1 July 1995. This law is intended to promote the welfare of the mentally disabled.

An important aim of the new mental health act implemented in the Netherlands in 2020 was to shift the focus from hospitalization to treatment. The act provides an option for patients' compulsory treatment at home (CTH). Unlike compulsory community treatment (CCT), which allows mental health workers to hospitalize patients involuntarily if they do not comply with treatment. CTH is not provided elsewhere in the world. This case report concerns a patient who, to avoid hospitalization, received CTH in the form of compulsory medication and was able to recover at home. Retrospectively, she and the mental health team both positively evaluated this use of CTH. The parties involved all concluded that CTH restricted the patient's autonomy less than hospitalization, it did not influence the therapeutic relationship, and the CTH could be delivered in a way that it did not compromise participants' safety. This case report shows that, in some situations, CTH can avoid hospitalization. Care should nonetheless be taken to assess its appropriateness, to discuss any preconditions, and to evaluate the use of compulsory treatment in dialog with the patient and significant others.

Involuntary psychiatric hospitalization is a contested issue in mental health care provision. Despite indications of very high rates of involuntary hospitalizations in Greece, no valid national statistical data has been collected. After reviewing current research on involuntary hospitalizations in Greece, the paper introduces the Study of Involuntary Hospitalizations in Greece (MANE), a multi-centre national study of the rates, process, determinants and outcome of involuntary hospitalizations, conducted in the regions of Attica, Thessaloniki and Alexandroupolis, from 2017 to 2020, and presents some preliminary comparative findings regarding the rates and process of involuntary hospitalizations. There is a major difference in the rates of involuntary hospitalizations between Alexandroupolis (around 25%) and Athens and Thessaloniki (over 50%), that is possibly related to the sectorized organization of mental health services in Alexandroupolis and to the benefits of not covering a metropolitan urban area. There is a significantly larger percentage of involuntary admissions that end in involuntary hospitalization in Attica and Thessaloniki compared to Alexandroupolis. Reversely, of those accessing the emergency departments voluntarily, almost everyone is admitted in Athens, while large percentages are not admitted in Thessaloniki and in Alexandroupolis. A significantly higher percentage of patients were formally referred upon discharge in Alexandroupolis compared to Athens and Thessaloniki. This may be due to increased continuity of care in Alexandroupolis and that might explain the low rates of involuntary hospitalization there. Finally, re-hospitalization rates were very high in all the study centers, demonstrating the revolving-door phenomenon, especially for voluntary hospitalizations. The MANE project came to address the gap in national recording of involuntary hospitalizations, by implementing, for the first time, a coordinated monitoring of involuntary hospitalizations in three regions of the country with different characteristics, so that a picture of involuntary hospitalizations can be drawn at national level. The project contributes to raising awareness of this issue at the level of national health policy and to formulating strategic goals to address the problem of violation of human rights and to promote mental health democracy in Greece.

ABSTRACTSince the 1960s significant differences in the mental health profile of men and women have been observed, but not adequately explained. The accepted pattern is that women are more likely to be diagnosed with high prevalence disorders and men are more likely to be diagnosed with serious low prevalence disorders. Clinical research has pursued physiological or psychosocial explanations for women’s mental health problems, while feminist perspectives have emphasised the pathologisation of women’s experiences. Recent research has refocused attention on the distinct mental health needs of women and men related to the experience of violence. The emphasis on violence in new mental health research, however, is matched by a curious silence in mental health law and policy with respect to the mental health impact of violence. This article recognises the need for a robust response to the experience of violence for both men and women. With respect to the experience of women, it calls for the adoption of a women centred, trauma informed approach to the development of law, policy and service provision in mental health. Such approaches should engage with the emerging recognition of intersectionality in the research literature, the aspirations of the consumer movement and human rights frameworks.

Objective : The purpose of this study was to explore how stigma is perceived and experienced by people with mental illness who are legally required to use mental health services while living in the community. Method : Interviews were conducted with 91 people with mental illness who were receiving compulsory community mental health treatment in British Columbia, Canada. An inductive thematic analytic framework was used to identify predominant themes and recurring patterns in the qualitative data. Results : Participants’ narratives centered around six primary themes: (a) compulsory treatment; (b) feeling/being knocked down; (c) public (mis)understanding; (d) social identity/location; (e) social disadvantage; and (f) passing-managing-overcoming. Compulsory community treatment was entangled with a myriad of other stigma-producing factors associated with the direct effects of mental illness and social disadvantage. Conclusion : Compulsory community mental health treatment is not the predominant issue that produces stigma among people with mental illness, but it may contribute to such experiences by creating situations where people are likely to feel powerless, devalued, and oppressed.

Chapter 1 introduces the key question asked by the book: whether mental health law should be abolished or reformed and defines all the key terms (e.g. mental health law, mental impairment, involuntary detention and treatment, voluntary treatment, abolition and reform, etc). It puts mental health law into its wider social context pointing out that while at least 20 per cent of the community in any given year and 50 per cent in their lifetime have a mental health problem, mental health law only applies to a relatively small number of persons with severe mental health problems who are medically assessed to be at risk of harming themselves or others. It sets out the background to the fierce controversy about the future of mental health law during the United Nations Convention on the Rights of Persons with Disabilities (CRPD) negotiations and since its entry into force in 2008. It explains the conceptual framework for the book being human rights treaty interpretation and the jurisprudential or ethical analysis consistent with Ronald Dworkin of three core CRPD and human rights concepts—dignity (including autonomy), equality, and participation—to create the ‘interpretive compass.’ It discusses the social model of disability, the medical model, the human rights model, and the interactive model. It defines the scope of the book in that it excludes consideration of mental health specific criminal law doctrines like fitness to plead and the insanity defence and clarifies that the focus is on mental health law rather than other forms of substitute decision-making like guardianship. It explains the structure of the book.

Compulsory community treatment and ethnicity: Findings from a culturally and linguistically diverse area of Queensland

Mental health is one of the major causes of disability worldwide, and mental health problems such as depression and anxiety are ranked among the top 25 leading causes of disease...

Background: COVID-19 prevention and mitigation efforts were abrupt and challenging for most countries with the protracted lockdown straining socioeconomic activities. Marginalized groups and individuals are particularly vulnerable to adverse effects of the pandemic such as human rights abuses and violations which can lead to psychological distress. In this review, we focus on mental distress and disturbances that have emanated due to human rights restrictions and violations amidst the pandemic. We underscore how mental health is both directly impacted by the force of pandemic and by prevention and mitigation structures put in place to combat the disease.Methods: We conducted a review of relevant studies examining human rights violations in COVID-19 response, with a focus on vulnerable populations, and its association with mental health and psychological well-being. We searched PubMed and Embase databases for studies between December 2019 to July 2020. Three reviewers evaluated the eligibility criteria and extracted data.Results: Twenty-four studies were included in the systematic inquiry reporting on distress due to human rights violations. Unanimously, the studies found vulnerable populations to be at a high risk for mental distress. Limited mobility rights disproportionately harmed psychiatric patients, low-income individuals, and minorities who were at higher risk for self-harm and worsening mental health. Healthcare workers suffered negative mental health consequences due to stigma and lack of personal protective equipment and stigma. Other vulnerable groups such as the elderly, children, and refugees also experienced negative consequences.Conclusions: This review emphasizes the need to uphold human rights and address long term mental health needs of populations that have suffered disproportionately during the pandemic. Countries can embed a proactive psychosocial response to medical management as well as in existing prevention strategies. International human rights guidelines are useful in this direction but an emphasis should be placed on strengthening rights informed psychosocial response with specific strategies to enhance mental health in the long-term. We underscore that various fundamental human rights are interdependent and therefore undermining one leads to a poor impact on the others. We strongly recommend global efforts toward focusing both on minimizing fatalities, protecting human rights, and promoting long term mental well-being.

Mental health legislation authorises involuntary psychiatric intervention in certain circumstances. Although human rights concerns are becoming more prominent, debates among legal experts, clinicians and activists continue to swirl around people's rights to equal recognition before the law, such as described in the (United Nations Convention on the Rights of Persons with disabilities, 2006). This qualitative descriptive study aimed to better understand diverse views of people known to hold a critique of coercion in mental health services, on the practical expression of upholding human rights in the context of mental health laws. Individual semi-structured interviews were conducted with 15 key informants from five different countries and data was analysed using an inductive, thematic approach. Overall, informants characterised mental health laws as discriminatory, harmful and unjustifiable. Three themes and six sub-themes were identified. This study reports on the major themes which include: an ethical position (focusing on the present harms associated with mental health laws), strategies, (an expression of the opportunity to bring about change) and a visionary position. We explore these three features in the views of key informants as important positions in the field of abolition, and analyse each for the 'hermeneutic resources' - forms of collective interpretive resources - they provide. Abolition of mental health laws is often seen as not feasible in the context of psychiatry. However, abolition theories and practices are hermeneutic resources that need to be better understood because they offer social justice and community-led solutions beyond mental health laws and systems.

Compulsory Community Treatment (CCT) is any intervention that mandates community psychiatric care. Despite Australia's high use of CCT compared to other countries, there is no standardised national reporting framework, limiting transparency and comparability across jurisdictions. To determine rates of CCT orders per 100 000 population, individuals subject to CCT per 100 000 population and the proportion of all community mental healthcare contacts that were involuntary between 2016-2017 and 2023-2024. We also sought to identify and document differences in reporting practices across CCT reporting bodies. Publicly available data were extracted from annual reports of state and territory Mental Health Review Tribunals or Civil and Administrative Tribunals, Offices of the Chief Psychiatrist and the Australian Institute of Health and Welfare. Rates of CCT orders per 100 000 population, individuals subject to CCT per 100 000 population and the proportion of all community mental healthcare contacts that were involuntary were calculated and compared across jurisdictions. Marked differences were identified in CCT terminology, reporting scope and data completeness across jurisdictions and reporting bodies. Only three jurisdictions reported the number of individuals subject to CCT and none reported incidence data. Rates of CCT increased in most jurisdictions, except Western Australia, which showed a decline and the lowest rate of all jurisdictions. The proportion of involuntary community contacts ranged from 3 to 26% nationally. Australia's fragmented CCT reporting landscape impedes accurate national monitoring. A standardised national CCT data-set that incorporates prevalence and incidence indicators is urgently needed to enable transparent, comparable reporting.

SummaryBackgroundCompulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.MethodsFor this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.FindingsOf 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53–1·08; I2=94·74), use of community services (0·83, 0·46–1·21; I2=87·26), and treatment adherence (2·12, 1·69–2·55; I2=0), and a medium effect on inpatient bed-days (0·66, 0·46–0·85; I2=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19–0·58; I2=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.InterpretationWe found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.FundingNational Institute for Health Research.

This article explores how the European Court of Human Rights has applied the norms of the UN Convention on the Rights of Persons with Disabilities (CRPD) in the area of mental health law. The European Court was initially receptive to the CRPD, including the UN Committee on the Rights of Persons with Disabilities' call for a repeal of legislation permitting involuntary psychiatric hospitalisation, but later distanced itself from it. The CRPD has nevertheless influenced how the European Court approached (a) involuntary hospitalisation, (b) separating detention from treatment, (c) restraints and other forms of ill-treatment in institutions, and (d) disability-neutral detention based on disability. Despite the two treaty bodies' different jurisprudential methodology and their different assumptions about the role of medical and legal professionals, the CRPD can continue to influence the European Court in areas such as less restrictive alternatives to coercive treatment, the relevance of capacity, and the importance of personal integrity for mental health treatment.