ArticleLiterature Review

Involuntary treatment in Europe: Different countries, different practices

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Abstract

Involuntary treatment is burdened by the lack of evidence. One of the challenges is the difference in practice across borders in Europe. While reviewing the current literature, a proposal of monitoring guidelines is discussed. The field is characterized by a small number of dedicated researchers. A study of violence in first-episode psychosis shows that differences in criteria for involuntary admission lead to different prognosis for the patients. The most recent contributions from the cross-national EUNOMIA study point to great variation across countries, regarding frequencies of involuntary admission as well as outcome. The EUNOMIA study provides suggestions for good quality in involuntary admission. A Cochrane review has examined the evidence of involuntary community treatment compared with standard treatment. The effectiveness of involuntary community treatment is limited. The review concludes that the benefits for a small number of patients are outweighed by the high numbers needed to treat in terms of avoided re-admission. Despite pioneering work, involuntary treatment is still caught up in tradition. There is a lack of standard and proof of effectiveness. A proposal of monitoring guidelines for involuntary measures is a first step to improve the situation.

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... The situation does not improve on analysis of the European context. The difficulties arise from the differences in calculation: the data are often calculated in percentage rates; in some countries short emergency admissions are also counted as involuntary, whereas in other countries they are not (De Stefano & Ducci, 2008;Jacobsen, 2012;Salize, Dreßing, & Peitz, 2002). Moreover, each country has different legislation regulating involuntary admissions based on their cultural and historical background. ...
... Thus data at European level vary considerably: the relevant literature is scarce (Jacobsen, 2012), and the data in our possession in reference to the year 2005 show variations ranging from a mere 6 annual compulsory admissions per 100,000 in Portugal to 218 in Finland (De Stefano & Ducci, 2008). The data revealed in the literature for the years 2008 and 2009 indicate that in Belgium there were 47 compulsory admission per 100.000 and 80/100.000 in Holland (Schoevaerts, Bruffaerts, Mulder, & Vandenberghe, 2013). ...
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Patient satisfaction is considered an important indicator of the quality of care in psychiatric services. Its importance has been widely studied, but the literature identifies methodological problems deriving from samples with low response rates and exclusion criteria which would seem to imply a kind of exclusion in the evaluations of less compliant patients. The aim of this study is to test a methodology to assess patient satisfaction with the quality of care received at an acute psychiatric ward in terms of its application in daily routine. In this cross sectional survey inpatients were given the Rome Opinion Questionnaire (ROQ). Our patients, involuntary patients included, with a 92.3% participation rate (47 patients out of 51), returned a mean general satisfaction score of 7.7/9. This response rate is higher than that reported in most previously published studies, which shows that a good level of both voluntary and involuntary patient participation may be achieved when an appropriate methodological approach is adopted. Not acknowledging patient satisfaction reduces the possibility of more effective caring actions. Measuring patient satisfaction, through use of short questionnaires, should become a routine in daily practice.
... Whether CPT reduces health service use, and/or improves outcomes, remains an unresolved question and there is a lack of standards and proof of effectiveness (Jacobsen, 2012). The few studies available have shown contradictory results (Høyer, 2008;Kallert et al., 2011;Okai et al., 2007;Prinsen & van Delden, 2009;Sibitz et al., 2011), with observational studies showing positive effects (Bursten, 1986;Durst, Teitelbaum, Bar-El, Shlafman, & Ginath, 1999;Fernandez & Nygard, compared with patients treated on standard voluntary care (Kisely & Campbell, 2015). ...
... If compulsion is to be justified, much clearer evidence should be required as to how it is currently used, and the circumstances in which it is necessary, rather than merely convenient (Bartlett, 2011). A proposal of monitoring guidelines for involuntary measures has been proposed to improve the situation (Jacobsen, 2012), since such a standard is absent, the imposition of treatment becomes a matter of luck as to who is the responsible clinician, and human rights become a lottery (Bartlett, 2011). ...
Article
Instruments designed to evaluate the necessity of compulsory psychiatric treatment (CPT) are scarce to non-existent. We developed a 25-item Checklist (scoring 0 to 50) with four clusters (Legal, Danger, Historic and Cognitive), based on variables identified as relevant to compulsory treatment. The Compulsory Treatment Checklist (CTC) was filled with information on case (n = 324) and control (n = 251) subjects, evaluated under the Portuguese Mental Health Act (Law 36/98), in three hospitals. For internal validation, we used Confir-matory Factor Analysis (CFA), testing unidimensional and bifactor models. Multilevel logistic regression model (MLL) was used to predict the odds ratio (OR) for compulsory treatment based on the total scale score. Receiver Operating Characteristic analysis (ROC) was performed to predict compulsory treatment. CFA revealed the best fit indexes for the bifactor model, with all items loading on one General factor and the residual loading in the a priori predicted four specific factors. Reliability indexes were high for the General factor (88.4%), and low for specific factors (b 5%), which demonstrate that CTC should not be performed in the subscales to access compulsory treatment. MLL reveals that for each item scored in the scale, it increases the OR by 1.26 for compulsory treatment (95%CI 1.21–1.31, p b 0.001). Based on the total score, accuracy was 90%, and the best cutoff point of 23.5 detects compulsory treatment with a sensitivity of 75% and specificity of 93.6%. The CTC presents robust internal structure with a strong unidimensional characteristic, and a cutoff point for compulsory treatment of 23.5. The improved 20-item version of the CTC could represent an important instrument to improve clinical decision regarding CPT, and ultimately to improve mental health care of patients with severe psychiatric disorders.
... The IA rate declined rapidly under the influence of the new regulation; however, it rose gradually due to a lack of supporting measures following the law, such as detailed operational procedures on IA and sufficient community-based services. The mechanism had characteristics that were similar to those of the deinstitutionalization and reinstitutionalization of psychiatric services in some Western countries 17 . ...
... As found in this study, the medical factors influencing IA were quite similar to those found in previous studies, such as poor insight 7,18 , history of hospitalization 19,20 , aggressive or self-harm behaviour 6,7,17,21 , and diagnoses of schizophrenia or other psychotic illness 4,9,15 . As stipulated in the dangerousness admission criteria of the new law, there was a significant association between patients' aggressive or self-harm behaviour and IA. ...
Article
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Involuntary admission (IA) is limited to particular situations in mental health laws to protect patients from unnecessary coercion. China’s first national mental health law has been in effect since 2013; however, the status of IA has not been sufficiently explored. To explore the changing patterns of IA since the clinical application of the IA criteria specified in the new law, an investigation of IA status was undertaken in 14 periods (each period lasting for one month from 05/2013 to 05/2017) in the tertiary specialized psychiatric hospital in Shanghai. The socio-demographic and clinical characteristics of 3733 patients were collected. The differences among IA rates in different periods were compared, and the characteristics of patients who were and were not involuntarily admitted were analysed. Multiple logistic regression analysis was used to clarify the independent variables of IA. The IA rate dramatically decreased after the implementation of the new law, while the overall trend gradually increased. The implementation of the IA risk criteria is effective, but IA is still common in China. The medical factors influencing IA following the implementation of the new law are similar to those in previous studies at home and abroad. Non-medical factors might be the main causes of the high IA rates in Chinese psychiatric institutions.
... Involuntary treatment denotes medical treatment given without informed consent from the patient. Literature suggests that the use of involuntary methods varies across Europe and to obtain clinical data about it is difficult (12). The association of a more frequent involuntary aspect in psychiatric treatments and a higher perceived stigma of psychiatric diseases (13) might help to explain the difference in regarding the possibility of assisted dying in mental and somatic disorders in the public. ...
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With about 65,000 deaths per year in Switzerland, about 1,000 assisted suicides of Swiss citizens are carried out with the help of assisted dying organizations per year. Assisted suicide, which is carried out without selfish motives on the side of the helping person, only remains unpunished if there is a free will decision by the person willing to die who has the capacity of judgement and to act independently. While this is usually accepted as an option for somatically terminally ill patients in society at large, this procedure is controversial for psychiatrically ill patients. In Switzerland the topic of assisted dying is highly debated between medical professionals. In 2018, the Swiss Academy of Medical Sciences (SAMS) put revised guidelines into force, which are in discrepancy to the current rules of the Swiss Medical Association (FMH). This article gives an overview of the past and current development of the Code of Professional Conduct and medical-ethical guidelines as well as current Swiss criminal and medical law on this topic. Practical implications for the assessment of assessing persons with mental illness in this circumstances are discussed. It is to be concluded, that persons with a mental illness seem to face extra obstacles in relation with somatically ill persons as the assessment of the prerequisites comprises additional requirements. Among other issues there is an urgent need for the elaboration of contents to be assessed and standards of procedures. The procedures and guidelines to be elaborated should be scientifically accompanied in order to gain a more reliable basis for decision-making. Multidisciplinary assessments would help to avoid biases and blind spots of a mono-disciplinary assessments. In addition, even in the case of mentally ill people, their right to self-determined suicide should not be restricted by excessive hurdles in the assessment process. Lastly, reliable funding should be secured, as it is otherwise to be expected that the complex assessment of prerequisites through multi-professional-teams or just one assessor cannot be sustained. The exercise of fundamental rights must be possible for all persons to the same extent, regardless of their financial resources.
... La fréquence et les types des mesures de contrainte varient largement entre différents pays et sont sensiblement liées au degré de formation des psychiatres, à l'organisation des services et à leurs cultures [6,7]. Malgré la ratification de la CIDPH par une majorité des pays du monde, les politiques de mise en application de la convention varient encore beaucoup et la qualité générale de son implémentation reste insatisfaisante [8]. ...
Article
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In December 2006, the United Nations General Assembly adopted the United Nations International Convention on the Rights of Persons with Disabilities (CRPD). Twelve years later, it has already been ratified by 177 countries. The purpose of this convention is to eliminate discrimination against people with disabilities. The CRPD is a human rights convention aimed at promoting social inclusion, full access to human rights, fundamental freedoms and promotion of dignity for people with disabilities. According to Article 1 of the Convention, disabilities contain long-term physical, mental, intellectual and or sensory disabilities. These may pose obstacles to the full and effective participation of the persons concerned in society on an equal basis with others. In light of this first article, it is expected that medicine will help remove some of these barriers particularly by helping people express their needs, priorities, personal values and preferences regarding decisions related to their care or broader aspects of their lives. The CRPD is interested in the social inclusion of people with disabilities in all areas of life. This review article will focus more specifically on the position of the CRPD regarding coercive measures. This challenge is particularly important in psychiatry.
... Moreover closed doors are often used to replace the staffepatient contact, which again might lead to increased involuntary treatment and safety measures like seclusion and mechanical restraint. This is problematic as these are considered as a last resort measure requiring individual ethical assessment, and legal practices in different European countries have recently been questioned (Jacobsen, 2012;Muller et al., 2012). Closed door treatment, seclusion, and forced medication lead to increased stigmatization (Jorm and Griffiths, 2008), are perceived as degrading by the patients (Rusch et al., 2014), may lead to traumatization (Steinert et al., 2013), are detrimental for the patientetherapist-relationship (Theodoridou et al., 2012) and the therapeutic climate (Blaesi et al., 2013), and endanger therapy adherence that is essential for successful long-term treatment (Deutschenbaur et al., 2014). ...
... However, when comparing mean BMI at admission with the percentage of involuntary treatment across all studies the picture is less clear. Due to the controversial nature of forced intervention, cultural, organisational and procedural/legal differences between institutions and countries must also be considered, as decisions regarding treatment may be based more on tradition and local regulations and procedures and less on symptom severity or evidence of treatment efficacy [24,25]. A study examining compulsory admission regulations and procedures across countries in the European Union reported that the differences in regulations and procedures across countries were the most significant source of variance [26]. ...
Article
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Involuntary treatment of anorexia nervosa is controversial and costly. A better understanding of the conditions that determine involuntary treatment, as well as the effect of such treatment is needed in order to adequately assess the legitimacy of this model of care. The aim of the present study was to investigate the frequency and duration of involuntary treatment, the characteristics of this group of patients, the kind of involuntary actions that are applied and the effect of such actions. Relevant databases were systematically searched for studies investigating the involuntary treatment of individuals diagnosed with anorexia nervosa. The studies included in the review contained people treated in an inpatient setting for severe or severe and enduring anorexia nervosa. People that were treated involuntarily were characterised by a more severe psychiatric load. The levels of eating disorder pathology between involuntary and voluntary groups were similar and the outcome of involuntary treatment was comparable in terms of symptom reduction to that of voluntary treatment. Despite inconsistent findings, the comparable levels of eating disorder pathology observed between involuntary and voluntary patient-groups together with findings of higher co-morbidity, more preadmissions, longer duration of illness and more incidences of self-harm for involuntary patients suggest that involuntary treatment is not a reaction to the severity of eating disorder symptoms alone, but is most likely a response to the complexity of the patient's situation as a whole.
... Locked wards could also potentially affect the way that nursing staff deal with acute mental health patients, with one study suggesting that individual personality traits and burnout of nursing staff was predictive of incidents in locked psychiatric wards, and that these incidents were exacerbated by the restrictive approach of locked ward environments, ultimately leading to increased aggressive incidents and use of further coercive measures to control patients. 104 The fact that locked door policies are often used as a replacement for staff-patient contact has been suggested to result in increased unnecessary involuntary treatment and safety measures such as seclusion and restraint, and are being increasingly questioned by legal practitioners, particularly in Europe, 105 as these therapies and approaches should ordinarily be viewed as 'last resort' measures which require individual ethical assessment and consideration, and policies that unnecessarily increase these measures may be in breach of human rights principles. ...
Article
Although there has been a consistent trend away from institutionalised mental health care over the past decades, this has occurred at the same time as increased coercive care measures are employed in mental health inpatient facilities, as these facilities become weighted to more serious cases. Locked wards, which regulate the ability of both voluntary and involuntary patients to leave psychiatric units, are increasingly common in acute mental health inpatient settings. This article focuses on the controversy surrounding a recent initiative to extend locked door policies across all public acute inpatient facilities in Queensland, explores the legal, ethical and clinical issues around the implementation of locked door policies in acute mental health inpatient facilities, and examines the tensions in balancing individual rights and public and personal protections in the treatment of acute mental health disorders.
... There is no conclusive data on the effectiveness of involuntary treatment with regard to treatment outcomes [20][21][22][23]. Quantitative as well as qualitative studies on patients' attitudes to involuntary treatment report mixed findings. ...
Article
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Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists. In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach. The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment. Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents' judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation.
... Häu gkeit und Art der angewendeten Zwangsmaßnahmen unterschieden sich jedoch nicht nur auf nationaler Ebene, sondern auch zwischen den untersuchten Institutionen innerhalb einer Region, wie am Beispiel der Region Zürich gezeigt wurde [2]. Diese Unterschiede ließen sich am ehesten durch lokale Traditionen erklären, die anstelle (meist fehlender) überregionaler Richtlinien die Anwendung von Zwangsmaßnahmen prägen [1,3]. ...
Article
Häufig sind Ärzte mit Patienten konfrontiert, die diagnostische oder therapeutische Vorschläge des Behandlers ablehnen. Insbesondere in der Psychiatrie kann es dabei zu ethisch und/oder rechtlich problematischen Situationen kommen, wenn ein psychisch kranker Patient eine eindeutig indizierte Maßnahme ablehnt und dadurch sich oder seine Umwelt gefährdet. Das beteiligte medizinische Personal muss in einer derartigen Situation zwischen Patientenautonomie einerseits und Patientenwohl andererseits abwägen.
... mechanical restraint, seclusion and forced medication) used during these hospitalizations. It also provides suggestions for good quality in involuntary admission [9,10]. Involuntary coerced admissions appear to be associated with poorer clinical outcomes than with voluntary admissions. ...
Article
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Introduction: Involuntary admissions to acute psychiatric units are one of the most ethically challenging practices in Psychiatry. However, published literature falls back in examining this area that touches patient's rights and freedom.
... Legal arrangements for involuntary psychiatric admission vary considerably across European countries so it is, perhaps, unsurprising that rates of involuntary admission also vary across Europe (Fiorillo et al., 2011;Jacobsen, 2012). Variations within countries are, however, more difficult to explain and there is a need for research that elucidates the roles of both patient level factors and centre level factors in explaining such variations (Lay et al., 2011). ...
Article
Involuntary psychiatric admission is an established practice for patients who are acutely or severely mentally ill but the factors contributing to involuntary (as opposed to voluntary) admission are not fully clear. Nor is it clear why rates of involuntary admission often vary between hospitals within the same jurisdiction. We studied all admissions, voluntary and involuntary, in three inpatient psychiatry units in Dublin, Ireland, which cover a population of 552,019 people, over a one-year period (1 July 2014 until 30 June 2015, inclusive), as part of the Dublin Involuntary Admission Study (DIAS). During the study period, there was a total of 1136 admissions to these three units, of which 17% were involuntary for all or part of their admission. The overall admission rate (205.8 admissions per 100,000 population per year) was lower than the national rate (387.9) but this varied substantially across the three units studied. On multi-variable analysis, involuntary admission status was associated with male gender, being unmarried, and a diagnosis of schizophrenia, and was not significantly associated with age, occupation or which inpatient unit the person was admitted to. We conclude that variations in involuntary admission rates between different psychiatry admission units in Dublin are significantly explained by patient-level variables (such as gender, marital status and diagnosis) rather than centre-level variables, but that much of the variation in admission status between patients remains unexplained. Future, multi-level research could usefully focus on other patient-level factors of possible relevance (e.g. symptom severity), centre-level factors (e.g. local mental health service resourcing) and community-level factors (e.g. socio-economic circumstances in different areas) in order to further elucidate unexplained variance in admission status between patients.
... Nevertheless,Tyrer et al. (2012) found that the duration of seclusion initiated in the morning was longer than the seclusion initiated in the afternoon and evening, but the results were not statistically significant, probably because of the small sample size. Other studies found differences between units(Jacob et al., 2016;Janssen et al., 2013) and found the so-called "centre effect" by which the use of coercive measures is determined by the tradition of each unit or region more than by the users' characteristics or organizational factors and regulations(Jacobsen, 2012;Raboch et al., 2010). These data suggest that there are organizational factors that influence the duration of these coercive measures and that stricter supervision and regulations could avoid prolonged episodes of mechanical restraint and improve user safety. ...
Article
Abstract Introduction Factors associated with prolonged episodes of mechanical restraint and other coercive interventions are not clearly established and have been not studied in Andalusia (Spain). Aim To study factors associated with prolonged episodes of mechanical restraint. Method We analysed retrospectively episodes of mechanical restraint (N=6267, prolonged episode >9.5 hours) in all public mental health hospitalisation units (N=20, 535 beds) that offer health coverage for the autonomous community of Andalusia. The data came from clinical records. A multivariable mixed logistic regression was used. Results In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. Discussion The results provide evidence that prolonged episodes largely depend on the unit where they occur and that stricter control and regulation are necessary to prevent prolonged episodes. Implications for practice Interventions at the level of the unit are necessary. Stricter control in the shifts during which there is more risk of prolonged restraint may be necessary, especially in the first days following admission.
... Sometimes involuntary treatment is the only option for providing treatment to highly vulnerable and distressed patients [13,14]. Despite the important place it holds in psychiatric practice, there has been relatively limited experimental research to inform practices, which appear to be largely based on traditions rather than on evidence [15]. ...
Article
Abstract Background Observational research has found that involuntary treatment provides limited benefits in terms of long-term clinical outcomes. Our aim was to review literature on existing interventions in order to identify helpful approaches to improve outcomes of involuntary treatment. Methods This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement guidelines. Seven databases (AMED, PsycINFO, Embase Classic, Embase 1974–2017, CINAHL, MEDLINE, and BNI) were searched and the results were analysed in a narrative synthesis. Results Nineteen papers describing fourteen different interventions were included. Using narrative synthesis the interventions were summarised into three categories: a) structured patient-centred care planning; b) specialist therapeutic interventions; c) systemic changes to hospital practice. The methodologies used and outcomes assessed were heterogeneous. Most studies were of low quality, although five interventions were tested in randomised controlled trials (RCTs). Preliminary evidence supports structured patient-centred care planning interventions have an effect on long-term outcomes (such as readmission), and that specialist therapeutic interventions and systemic changes to hospital practice have an effect on reducing the use of coercive measures on wards. Conclusions This review shows that it is possible to conduct rigorous intervention-testing studies in involuntary patients, including RCTs. Yet, the overall evidence is limited. Structured patient-centred care planning interventions show promise for the improvement of long-term outcomes and should be further evaluated.
... A previous study suggests that coercive measures are used in between 21% and 59% of individuals admitted to psychiatric hospitals across various European countries (4). Types of coercive intervention used varies between countries depending on the national psychiatric legislations (5)(6)(7)(8)(9). Coercive measures are associated with longer duration of inpatient treatment and forced medication seems to have a significant impact on patient disapproval of treatment (10). ...
Article
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Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ 2 (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ 2 (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ 2 (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = −2.142, p = 0.032] with an effect size of Cohen's d = −0.282 (95% CI: −0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.
... Stigma and lack of knowledge also relate to key aspects of the health care systems of each of three countries where, in spite some form of universal health care among them, mental health is not as well funded or supported as other health conditions (Corrigan, Druss, and Perlick 2014). Moreover, in most Western countries, the law allows for court-mandated involuntary commitment or compulsory treatment for a person whose mental health condition poses a likelihood of serious harm to herself or others (Raboch et al. 2010;Jacobsen 2012;Steinert et al. 2010;Udwadia and Illes, in press). ...
Article
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Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.
... This tight regulation requires the patients to be exacerbated or relapsed enough to express the danger of self-harm and other-harm. In contrast, Western countries require a condition of either self-harm or other-harm for involuntary admission [41]. Thus, the decrease of re-admission may be a negative signal that patients with recurrence or worsening of psychosis cannot be readmitted when required, especially within a short period after discharge. ...
Article
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Background High rates of involuntary hospitalization and long lengths of stay have been problematic in Korea. To address these problems, the Mental Health and Welfare Law was revised in 2016, mainly to protect patient rights by managing involuntary admissions. The aim of this study was to evaluate the impact of the revised Mental Health and Welfare Law on deinstitutionalization by using routinely collected data from hospital admissions and continuity of mental health service use after hospital discharge as proxy measures of deinstitutionalization. Methods We used monthly-aggregated claims-based data with a principal or secondary diagnosis of schizophrenia from 2012 to 2019, collected by the National Health Insurance Service. Outcome variables included rates of first admission; discharges; re-admissions within 7, 30, and 90 days; outpatient visits after discharge within 7 and 30 days; and continuity of visits, at least once a month for 6 months after discharge. Using interrupted time series analysis, we estimated the change in levels and trends of the rates after revision, controlling for baseline level and trend. Results There was no significant change in first admission and discharge rates after the revision. Immediately after the revision, however, the rates of re-admission within 7 and 30 days dropped significantly, by 2.24% and 1.99%, respectively. The slopes of the re-admission rate decreased significantly, by 0.10% and 0.14%, respectively. The slopes of the re-admission rate within 90 days decreased (0.001%). The rates of outpatient visits within 7 and 30 days increased by 1.98% and 2.72%, respectively. The rate of continuous care showed an immediate 4.0% increase. Conclusions The revision had slight but significant effects on deinstitutionalization, especially decreasing short-term re-admission and increasing immediate outpatient service utilization.
... It is associated with long-term deleterious psychological impact (Murphy et al., 2017), possible traumatic effects (Berry et al., 2013), and with a reduction in adherence to mental health care (Jaeger et al., 2013). Nevertheless, evidence is relatively scarce on involuntary psychiatric treatment risk factors and there is no conclusive data on the effects of involuntary treatment on health outcomes (Jacobsen, 2012;Katsakou & Priebe, 2006;Zhang et al., 2015). Coercive psychiatric treatment also has the potential of retraumatizing asylum seekers and refugees . ...
Article
Background Immigrants in Europe appear to be at higher risk of psychiatric coercive interventions. Involuntary psychiatric hospitalization poses significant ethical and clinical challenges. Nonetheless, reasons for migration and other risk factors for involuntary treatment were rarely addressed in previous studies. The aims of this study are to clarify whether immigrant patients with acute mental disorders are at higher risk to be involuntarily admitted to hospital and to explore clinical and migratory factors associated with involuntary treatment. Methods In this cross-sectional matched sample study, we compared the rates of involuntary treatment in a sample of first-generation immigrants admitted in a Psychiatric Intensive Care Unit of a large metropolitan academic hospital to their age-, gender-, and psychiatric diagnosis-matched native counterparts. Clinical, sociodemographic, and migratory variables were collected. The Brief Psychiatric Rating Scale-expanded (BPRS-E) and the Clinical Global Impression-Severity (CGI-S) scale were administered. McNemar test was used for paired categorical variables and a binary logistic regression analysis was performed. Results A total of 234 patients were included in the analysis. Involuntary treatment rates were significantly higher in immigrants as compared to their matched natives (32% vs. 24% respectively; p < .001). Among immigrants, involuntary hospitalization was found to be more frequent in those patients whose length of stay in Italy was less than 2 years (OR = 4.2, 95% CI [1.4–12.7]). Conclusion Recently arrived immigrants appear to be at higher risk of involuntary admission. Since coercive interventions can be traumatic and negatively affect outcomes, strategies to prevent this phenomenon are needed.
... Therefore, defining criteria for patients to be involuntary admitted is paramount to prevent abuse. Research found that the main criterion for compulsory admission to mental health care across European Union Member States is a confirmed mental disorder [1,3,37,[42][43][44][45]. However, mental disorder is a necessary for most countries but not sufficient condition to be admitted. ...
Article
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Background.: Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care. Methods.: The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions. Results.: We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures. Conclusions.: We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.
... This variability could be explained by the possible influence that the culture and functioning of each ward exerts, probably as a result of the lack of unified standards and performance criteria. Indeed, other authors have suggested the existence of the "centre effect," by which the use of a coercive measure is determined based on the tradition of each country, region or even ward more than by the symptoms of the patient, organizational variables or legislation (Jacobsen, 2012;Raboch et al., 2010). ...
Article
Introduction: Mechanical restraint (MR) is used in many countries, including Spain, where non-harmonized policies between autonomous communities exist. There is a lack of research about interventions at regional levels to reduce their use. Aim: To analyse data on key outcomes during the implementation of a multicomponent intervention in Andalusia (Spain) to reduce the use of MR. Method: Episodes in a period of 30 months in all wards (N = 20) were analysed. The intervention consisted of five strategies: (a) leadership, (b) analysis of the situation, (c) awareness training for the heads of the wards, (d) unified record of MR and (e) staff training. We analysed the monthly trend of restraint hours and restraint episodes/ 1,000 bed days using segmented regression. Results: There were 206.32 restraint hours and 12.96 restraint episodes/1,000 bed days during the study period. A significant decreasing trend was observed in restraint hours (−1.79%, p < .001), but not in the number of restraint episodes (−0.45%; p = .149). Discussion: The results coincide with other international studies; however, studies with better designs are required to evaluate the effectiveness of the intervention. Implications for Practice: Interventions at a regional level aimed at preventing MR are feasible in the Spanish context.
... However, according to Georgieva et al. [43], the effects of coercive measures on outcome are similar, with the exception of forced medication; . The procedural, legal and ethical differences, which that make multicenter comparisons difficult [71]; . The heterogeneity of considered outcomes [22]. ...
Article
Although coercive measures have always been part of the psychiatric armamentarium, the ethical dilemma between the use of a "therapeutic" coercion and the loss of patients' dignity is one of the major controversial issues in mental health research and practice. The aims of the present review are to explore the existing literature on predictors of use of coercive measures and to explore the relationship between coercive measures and patient outcome. A literature search was conducted using MEDLINE, PsychyINFO, Scopus, Web of Knowledge and the Cochrane Database. In all selected papers, references were cross-checked to identify other possible eligible papers. The use of coercive measures was predicted by patients' clinical and socio-demographic features, staff characteristics and ward-related factors. Coercive measures have only a limited impact on patients' clinical and social outcome. At the current level of knowledge, coercion is still a controversial issue in mental health practice. Only few studies with a solid methodology have been carried out. Large multicenter and rigorous studies, with long term follow-ups, are highly needed.
... Although many people with mental illness worldwide recognize the need for treatment and are voluntarily hospitalized, many others are still involuntarily hospitalized against their will (Jacobsen, 2012). Among the types of involuntary admissions defined by the Mental Health Act enacted in 1995 (Ministry of Health and Welfare, 1995), admission by legal guardians does not guarantee the rights to self-determination and procedural rights of people with mental illness. ...
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The Mental Health Promotion and Welfare Act, revised in 2016, tightened the involuntary admission regulations and processes, such as reporting involuntary admission within 3 days of admission, secondary diagnosis within 2 weeks, and admission suitability evaluation within 1 month, to improve the human rights of the mentally handicapped. The Admission Management Information System (AMIS) was also developed in 2017 to support these procedures and manage patients who were involuntarily admitted to the hospital. We analyzed 34,685 cases of involuntary admission registered in the AMIS between July 2017 and June 2018. The general characteristics, diagnosis, admission hospital, admission type, age, and admission duration were examined, and diagnoses and the length of stay per hospital were analyzed. Among the research subjects, 62.8% were male and 37.2% were female. A total of 70.8% had medical insurance and 28.5% had medical aid. A total of 67.8% of patients received secondary diagnosis by a psychiatrist who worked for a public or designated institution, 24.6% received secondary diagnosis by a psychiatrist who worked for the same institution as the primary psychiatrist, and 8.4% received primary diagnosis by a psychiatrist who admitted the patient. For diagnosis, F2 code was the most common at 38.1%, followed by F1 code at 29.1% and F3 code at 17.9%. For cases with only a primary diagnosis, F1 code diagnosis was the most common at 37.6%. For types of hospitalization, and admission by legal guardians was the most common at 93.2%, while administrative admission was at 6.7% and admission by legal guardians to a long-term care facility was at 0.1%. The average length of hospitalization duration was 74.4 days. A stay between 31 and 90 days was the most common (39.3%), and hospital stay of <14 days was at 16.6%. The number of involuntary admissions for every 100,000 people was 67 cases on average, and this number was the highest in the South Gyeongsang Province, at 105.8 cases. Length of stay by diagnosis was the longest for F7 code (118 days), followed by F1code (91 days). Patients older than 60 years constituted 31.7% of the total sample, and those younger than 20 years showed the highest proportion in patients with diagnoses from F4 to F9 code. Analyzing the involuntary admissions registered on the AMIS for 1 year revealed various information, such as the type of admission, sex, age, diagnosis, region, and admitted hospital. These results could be used to improve involuntary admission policies and mental health systems.
... This can be especially challenging in mental health care, where involuntary treatment and decisions made by guardians without the involvement of the person are still common in hospital and community settings ( Burns et al., 2013;Molodynski, Khazaal, & Callard, 2016;Seo, Kim, & Rhee, 2013). Coercion rates vary widely across countries and are sensitive, among other factors, to levels of psychiatric training and type of service organization (Eytan, Chatton, Safran, & Khazaal, 2013;Jacobsen, 2012) . ...
Article
Objectives: The Convention on the Rights of Persons with Disabilities (CRPD) was adopted at the United Nations Assembly in 2006. The main aim of the convention is to ensure equal rights for people with disabilities including the expression of people’s own “will and preferences” concerning health treatment. Article 12 demands the respect of a person’s “rights, will and preferences” (CRPD) and suggests supported decision making (SDM) when possible. The aim of this review was to gather information regarding the SDM implementation from a clinical perspective for people with mental health disorders. Methods: A systematic literature search was performed on electronic databases MEDLINE, PsycARTICLES, and PsycINFO using the keywords “supported decision making” and “UN convention on the rights of persons with disabilities” in March 2018. Results: Eleven articles were included in the final review, which focussed on three themes: (1) different models of SDM, (2) stakeholder views, and (3) challenges for implementation. A limited number of papers described clinical models that had good theoretical consistency with SDM. The main challenges of implementation related to critical situations when “will and preferences” are poorly understood or appear contradictory. Future studies should assess specific models of SDM implementation, including related outcomes and process measures.
... A previous study suggests that coercive measures are used in between 21% and 59% of individuals admitted to psychiatric hospitals across various European countries (4). Types of coercive intervention used varies between countries depending on the national psychiatric legislations (5)(6)(7)(8)(9). Coercive measures are associated with longer duration of inpatient treatment and forced medication seems to have a significant impact on patient disapproval of treatment (10). ...
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Civil commitment has evolved over the years to reflect the ideas of community, mental health professionals, and law. Individuals with an eating disorder or substance abuse problems can show a high degree of reluctance for treatment while displaying an inability to assess the outcome of their actions. When the safety of the individual clashes with their desire for maintaining the status quo or the individual is incapacitated due to the consequences of an eating disorder or substance use disorder, a discussion of involuntary treatment must be considered. The consequence of those behaviors directs the healthcare provider or family toward coercion. The perception of coercion in civil commitment is complex and not necessarily related to the degree of restriction of freedom. Civil commitment is a legitimate tool in emergent situations when an eating disorder or substance use disorder becomes life threatening. Compulsory treatment can be viewed as being in the best interest of the patient, family, and care provider. Civil commitment as a method to providing treatment is not without its critics or controversies, and a host of ethical concerns accompanies the use of this approach. Although controversial, there is a role for civil commitment in the treatment of eating disorders and substance use disorders.
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This paper deals with the clinical relationship in mental health as an encounter with the other. It is argued that the other, as a sensitive human being, lives a drama, rather than a diagnostic condition, and needs to be recognized in his individuality by a clinical environment that must provide him with security, trust, and dialogue in order to understand his experiences and conflicts. The professional is also a person that interacts with the people that come to his office. His attitude, both ethically and technically, must contribute to recognition and dialogue. For the development of a collaborative clinical practice, we consider three basic relational perspectives: Donald Davidson's principle of charity; the “world travelers” metaphor by Nancy Potter; and the idea of validating and “giving uptake” as proposed by Marsha Linehan and Nancy Potter, respectively. This collaborative clinical practice is compared to the common care model, which does not let room to talk about people's difficulties and where security, trust and collaboration are not values to be considered. It is pointed out that bioethics does not usually consider the central questions in current mental health care, profusely reflected by users’ movements, several professionals, and political and social instances. Changes in care services that promote dialogue and a collaborative clinical practice are required.
Chapter
Mental disorders, in particular when severe and in comorbidity with personality and/or substance-use disorders, are associated with a greater risk of aggressive behaviors, although a series of biographical and contextual factors play a fundamental role in explaining violent acts. Psychopathology, however, exposes those who suffer from mental disorders to the risk of being a victim of violence than to being author of violence. While contributing to a minimum extent to the overall violence in modern societies, aggression linked to psychopathology is associated with a disproportionate social alarm, which is fueled by the media and originates from the persistent negative stereotype about the intrinsic dangerousness of mental illness, which in turn feeds consistently stigmatizing attitudes. The process of progressive deinstitutionalization which took place in many countries has been associated sometimes with an increase in violent behaviors, although a consistent body of data from other countries seem to contradict this equation. However, aggression due to mental health problems contributes significantly to the family burden and the need to support families in the context of community-based systems of care. On a clinical level, both in hospital and extra-hospital contexts, the assessment of risk of violence and its prevention is an extremely difficult, at times impossible, task given the multiplicity and complexity of factors involved. Violent behavior is certainly among the major determinants of hospital admissions, especially involuntary admissions, of treatments without consent and/or coercive measures, all of which give rise to a series of human, ethical, and legal issues. The abolition, or at least the limitation, of involuntary hospitalizations and coercive measures represents an important challenge for current psychiatry, being a goal that many countries strive to pursue. On a forensic level, the management and treatment of people with mental disorders who commit crimes still represents a relevant challenge requiring new solutions, in the light of the unsatisfactory results of the treatment systems traditionally adopted by most countries, based on secure forensic psychiatric hospitals.
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Abstract A malpractice lawsuit is in the legal category of an action in tort, which is a demand for compensation for the damages that have occurred. For a physician to be found liable to a patient for malpractice, four essential elements must be proved to sustain an assertion of malpractice: duty, negligence, harm, and causation. The incidence of malpractice litigation in the field of psychiatry is increasing. The most common malpractice claim related to psychiatric practice is the failure to provide reasonable protection to patients from killing themselves. A psychiatrist should be able to evaluate suicide risk on the basis of all available information, including patient responses to direct and indirect questions, known risk factors, information on how the patient behaved under similar circumstances in the past, and collateral information. Reasonable care necessitates that a patient who is either thought of being or established to be suicidal must be the subject of some precautions. A failure either to soundly assess a patient's suicide risk or to employ an appropriate safety plan after the suicide potential becomes foreseeable is likely to make a physician liable if the patient is harmed because of a suicide event. It is imperative for a psychiatric office or facility to have a good documentation. Careful documentation of evaluations and treatment interventions with a description of changes related to the patient's clinical condition indicates clinically and legally appropriate psychiatric care.
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Psychosis is a challenging phenomenon for professionals. In the need-adapted approach (NAA), therapy meetings constitute a deliberate effort to meet the challenges by bringing all the main parties together within a common discussion. The aims of this study are to analyze and evaluate psychiatrists' experiences of the treatment processes in psychosis. A qualitative multiple case study approach has been used. Between August 2007 and January 2009, co-research interviews (CR-Is) and stimulated-recall interviews (STR-Is) with 10 psychiatrists from 3 different parts of Finland were videoed and transcribed verbatim. The material was analyzed using qualitative content analysis. The difficult emotions of the professionals and the critical views expressed had a prominent role. It was almost impossible to proceed with the treatment until the memories of coercive acts had been addressed. There were fewer harmful effects in outpatient than in inpatient care. If the client-centered principles of NAA were not followed, the CR-Is functioned primarily as critical evaluations of the treatment processes. The STR-Is helped the psychiatrists to find words for difficult experiences. For the sake of both practice and research, the experiences of staff in the treatment of psychosis should be taken into account. For better prediction of failure, routine measures to obtain feedback could be included in NAA.
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Involuntary admissions (IA) continue to be a controversial topic in psychiatry. There have been very few studies investigating the pattern of IA and contributing factors in Chinese psychiatric patients. This study examined the prevalence of IA and its relationships with demographic and clinical characteristics in a large psychiatric institution in Hunan province, China. A consecutively collected sample of 161 psychiatric inpatients was collected. The patients’ basic socio-demographic and clinical data including admission types were collected. The frequency of IA was 53.1% in the whole sample. In multiple logistic regression analysis, IA was independently associated with female sex, more recent aggression prior to admission and poorer social function and insight into illness. IA was common in clinical practice in China and its demographic and clinical correlates are similar to the findings reported from Western settings.
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Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.
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There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use or improves clinical outcome and social functioning. To examine the effectiveness of CCT for people with SMI. We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, 2012, and 2013). We obtained all references of identified studies and contacted authors where necessary. All relevant randomized controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another preexisting form of compulsory community treatment such as supervised discharge. We found 3 trials with a total of 752 people. Two trials compared a form of CCT called 'Outpatient Commitment' (OPC) versus standard voluntary care, whereas the third compared Community Treatment Orders with intermittent supervised discharge. CCT was no more likely to result in better service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care. However, people receiving CCT were less likely to be victims of crime than those on voluntary care. Further research is indicated into the effects of different types of CCT as these results are based on 3 relatively small trials. © The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions.
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Legislation and practice of involuntary hospital admission vary substantially among European countries, but differences in outcomes have not been studied. To explore patients' views following involuntary hospitalisation in different European countries. In a prospective study in 11 countries, 2326 consecutive involuntary patients admitted to psychiatric hospital departments were interviewed within 1 week of admission; 1809 were followed up 1 month and 1613 3 months later. Patients' views as to whether the admission was right were the outcome criterion. In the different countries, between 39 and 71% felt the admission was right after 1 month, and between 46 and 86% after 3 months. Females, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant. International differences in legislation and practice may be relevant to outcomes and inform improvements in policies, particularly in countries with poorer outcomes.
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The aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions. Combined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas. There are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries. Databases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.
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Education on the care of aggressive and disturbed patients is fragmentary. eLearning could ensure the quality of such education, but data on its impact on professional competence in psychiatry are lacking. The aim of this study was to explore the impact of ePsychNurse.Net, an eLearning course, on psychiatric nurses' professional competence in seclusion and restraint and on their job satisfaction and general self-efficacy. In a randomized controlled study, 12 wards were randomly assigned to ePsychNurse.Net (intervention) or education as usual (control). Baseline and 3-month follow-up data on nurses' knowledge of coercion-related legislation, physical restraint and seclusion, their attitudes towards physical restraint and seclusion, job satisfaction and general self-efficacy were analysed for 158 completers. Knowledge (primary outcome) of coercion-related legislation improved in the intervention group, while knowledge of physical restraint improved and knowledge of seclusion remained unchanged in both groups. General self-efficacy improved in the intervention group also attitude to seclusion in the control group. In between-group comparison, attitudes to seclusion (one of secondary outcomes) favoured the control group. Although the ePsychNurse.Net demonstrated only slight advantages over conventional learning, it may be worth further development with, e.g. flexible time schedule and individualized content.
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The use of coercive measures in psychiatry is still poorly understood. Most empirical research has been limited to compulsory admission and to risk factors on an individual patient level. This study addresses three coercive measures and the role of predictive factors at both patient and institutional levels. Using the central psychiatric register that covers all psychiatric hospitals in Canton Zurich (1.3 million people), Switzerland, we traced all inpatients in 2007 aged 18-70 (n = 9698). We used GEE models to analyse variation in rates between psychiatric hospitals. Overall, we found quotas of 24.8% involuntary admissions, 6.4% seclusion/restraint and 4.2% coerced medication. Results suggest that the kind and severity of mental illness are the most important risk factors for being subjected to any form of coercion. Variation across the six psychiatric hospitals was high, even after accounting for risk factors on the patient level suggesting that centre effects are an important source of variability. However, effects of the hospital characteristics 'size of the hospital', 'length of inpatient stay', and 'work load of the nursing staff' were only weak ('bed occupancy rate' was not statistically significant). The significant variation in use of coercive measures across psychiatric hospitals needs further study.
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Violence towards others is a recognised complication of first-episode psychosis. To estimate the rate of violence and the associations with violence in first-episode psychosis. A systematic review and meta-analysis of 9 studies. Pooled estimates of the proportion of patients with first-episode psychosis committing any violence, serious violence and severe violence were 34.5%, 16.6% and 0.6%, respectively. Violence of any severity was associated with involuntary treatment (OR=3.84), a forensic history (OR=3.28), hostile affect (OR=3.52), symptoms of mania (OR=2.86), illicit substance use (OR=2.33), lower levels of education (OR=1.99), younger age (OR=1.85), male sex (OR =1.61) and the duration of untreated psychosis (OR=1.56). Serious violence was associated with a forensic history (OR=4.42), the duration of untreated psychosis (OR=2.76) and total symptom scores (OR=2.05). Violence in the period after initiation of treatment for first-episode psychosis was associated with involuntary treatment (OR=5.71). A substantial proportion of patients in first-episode psychosis commit an act of violence before presenting for treatment, including a number who commit an act of more serious violence causing injury to another person. However, severe violence resulting in serious or permanent injury to the victim is uncommon in this population.
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Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients' rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.