[After the reform is before the reform : Results of the amendment processes of mental health law in German federal states]

[Involuntary Psychiatric Hospital Admissions According to Public Law - A Retrospective Analysis]

OBJECTIVE

We provide an empirical survey of the current practice on involuntary psychiatric hospital admission.

METHODS

Bases on clinical case records, we performed a retrospective analysis of 346 cases with an involuntary hospital admission according to public law in 2020 (21.0% of all inpatient admissions in this period).

RESULTS

Announcement of suicide was the most frequent cause for involuntary hospital admission (45.1%). Most common diagnoses were substance-related disorders (30.1%), stress-related disorders (19.9%), and schizophrenic psychoses (18.8%). Only 12.7% of the involuntary admissions resulted in a further involuntary hospitalization, whereas 44.5% of all episodes were followed by a discharge within 24 hours.

CONCLUSION

In many cases, involuntary hospital admissions are reactions to suicidal crises. It will be interesting to see, if the introduction of alternative low-threshold services can help to reduce the frequency of such admissions.

[Coercive Medication: Who, how, how Long? A Retrospective Chart Analysis in 6 Hospital Sites in Baden-Wuerttemberg]

BACKGROUND

Evaluation of the practice of coercive treatment in Germany after the Constiutional Court's decision in 2011.

METHODS

The documented emergency treatments (N=86) and judicially approved compulsory treatments (N=62) in 2015 and 2016 at 6 hospital locations in Baden-Württemberg were retrospectively analysed.

RESULTS

Patients had an average of 8 previous psychiatric hospitalisations with a cumulative duration of 645 days on average and 87% had a psychotic disorder. 34% received subsequent compulsory treatment within one year. The median duration of compulsory treatment was 15 days. 92% of the patients were taking an antipsychotic at discharge, 45% received further treatment in a day hospital or a psychiatric outpatient clinic.

CONCLUSION

Coercive treatment affects a relatively small, chronically severely ill group of patients and is frequently recurrent among them. For considerable part, no consecutive treatment setting can be established after discharge.

[Monitoring of coercive measures and compulsory treatment in Germany]

Epidemiological registers on the burden of disease and adverse events (deaths, serious side effects, etc.) play an important role in the management, evaluation, and improvement of healthcare treatment for the population. This also applies to coercive measures in the psychiatric healthcare system. Such registers only became feasible on a broad basis due to the availability of electronic medical records and steadily increasing computing capacities; however, in most German states, registers have not been implemented. Data protection problems must be taken into account in the collation of person-related data but can be solved by appropriate pseudonymization procedures taking the prerequisites of data parsimony into account. Extensive data are now available from the Baden-Wuerttemberg register for coercive measures, which has been in existence since 2015 and which enabled, for instance, evaluating the consequences of the changes to the law following the 2018 ruling of the Federal Constitutional Court on mechanical restraint and the consequences of the coronavirus pandemic. In the meantime, there are also state-wide data collections in some other German states; however, unlike in Baden-Wuerttemberg, these registers do not include measures under guardianship law. A nationwide register for coercive measures, compulsory treatment and involuntary detention has justifiably repeatedly been demanded for a long time. A major obstacle is the historically developed separation between the responsibility of the German states for the detention regulated by public law and the Federal State for the scope of application of the guardianship law.

[Documentation, Application and Efforts to Reduce Involuntary Admissions and Coercive Measures - Results from a Nationwide Study on Acute Psychiatric Hospitals in Germany]

OBJECTIVE

This nationwide full census survey investigated the documentation status regarding involuntary admissions and coercive measures in psychiatric hospitals in Germany.

METHODS

As part of the ZIPHER study, a questionnaire survey on the documentation, application and reduction of coercion was conducted (N = 147, response rate = 34.4 %).

RESULTS

The majority of participating hospitals reported a comprehensive documentation of the use of coercion. However, substantial regional differences could be found in this regard as well as for the use of guidelines. The involuntary admission quote was M = 13.4 % (± 10.9). Of those, 33.9 % (± 22.2) were affected by mechanical restraint, 8.9 % (± 17.2) by seclusion, and 11.8 % (± 18.0) by compulsory medication.

CONCLUSION

The regional differences plead for a unification of legal bases and applied practice as well as for a merge of respective data on a nationwide level of the relevant stakeholders.

[Effects of the Decision of the German Constitutional Court on mechanical restraint in 2018 : Coercive measures in the psychiatric hospitals in Baden-Wuerttemberg in 2019 compared to the years 2015-2017]

On 23 July 2018 the German Constitutional Court decided that mechanical restraint in psychiatric patients with 5 or 7‑point mechanical restraint lasting longer than 30 min requires a judicial authorization. On the same day, the German Association for Psychiatry and Psychotherapy (DGPPN) published guidelines on the prevention of coercion and violence. Together, this can be considered as the strongest intervention to reduce coercion on a national level worldwide. The registry for coercive measures in the Federal State of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2015 to 2017 compared to 2019 among a total of 438,003 admissions. The percentage of patients subjected to any kind of freedom-restricting coercion (restraint or seclusion) decreased from 6.7% (average 2015-2017) to 5.8% in 2019 (p < 0.001). Effects were strongest in patients with organic (F0) and schizophrenic disorders (F2). The percentage of patients subjected to mechanical restraint decreased from 4.8% to 3.6% in 2019, and the percentage of mechanical restraints less than 30 min increased from 1.8% to 10.5%. Vice versa, the percentage of patients subjected to seclusion increased from 2.9% to 3.3%. The median cumulated duration of restraint and seclusion per affected case decreased from 12.7h to 10.9 h (median). The intervention was probably responsible for a reduction of the percentage of cases subjected to coercive measures by about 13% and a reduction of the duration of these measures per affected case by about 14%.

Opportunities, risks and challenges in global mental health and population neuroscience: a case of Sino-German cooperation

Large scale prospective cohorts have now been established across several countries, and continents, and among the aims include an assessment of the developmental trajectory of mental disorders. This level of international cooperation helps transfer research findings to new social contexts as well as enabling an assessment of which findings can be replicated, and which interventions are most effective, in different social and cultural settings. However, data sharing across different regional and national health care systems requires a careful consideration of different standards in ethical research, data protection and patient care, including respect for patients' rights, in cooperating jurisdictions. In our review, we discuss ethical, legal and practical challenges associated with such cooperation with a focus on research participants, specifically patient recruitment, by considering the instance of China and Germany. Our broader aim is to promote international cooperation by identifying key challenges that arise in international cooperation, and to facilitate an exchange in relation to legal and practical approaches.

[Cologne Questionnaire on Attitudes Towards Coercive Measures (KEZ)]

OBJECTIVE

To develop a psychometric instrument for the assessment of the attitude of psychiatric staff towards the use of coercion.

METHODS

Based on a literature search, interviews (37 open questions) were carried out by representatives each of doctors and nurses. A first version was developed, all doctors and nurses in a psychiatric clinic were asked to answer the questionnaire anonymously.

RESULTS

226 employees took part (response rate 32.3 %). A test-theoretical analysis led to a 39 item set with a high consistency of the overall scale (Cronbach's α =0 .904) and three factors: 1) Acceptance of coercive measures without questioning (Cronbach's α = 0.797); 2) Meaningfulness and legitimation of coercive measures (Cronbach's α = 0.812); and 3) Security and order through coercive measures (Cronbach's α = 0.791).

CONCLUSIONS

With the KEZ an instrument is available that holistically presents the various aspects of the attitudes of psychiatric staff to the use of coercion.

[Structural Features and Use of Coercive Measures in Forensic Psychiatry Throughout Germany]

OBJECTIVE

Nationwide assessment of structural data and the frequency of use of coercive measures in forensic psychiatric hospitals in Germany.

METHODS

Quantitative survey using a postal questionnaire on structural data and on the use of coercive measures in forensic psychiatric hospitals as part of the "ZIPHER" study.

RESULTS

About one fourth of all forensic patients are affected by coercive measures, with seclusion (21.2 %) being way more often than mechanical restraint (3.2 %). This ratio contrasts with general psychiatric hospitals, where restraints are more common than seclusions.

CONCLUSION

The results of the study reveal nationwide peculiarities in the use of coercive measures in forensic psychiatric hospitals. At the same time, it demonstrated the lack of general structural and process data of forensic hospitals in Germany.

[Open doors in psychiatric hospitals : An overview of empirical findings]

BACKGROUND

Currently, it is a topic of debate whether psychiatric hospitals can and should be managed with a full open door policy. The revised legislation of public law for involuntary commitment explicitly allows or even encourages such practice in several German federal states. In parts of Austria, open doors are required for legal reasons. A systematic literature search was conducted for articles providing empirical data related to this issue.

METHOD

Literature search in PubMed augmented by a manual search in references of retrieved papers and reviews with similar objectives.

RESULTS

A total of 26 articles reporting empirical data could be identified. Most of these articles came from Germany or Switzerland. The majority were published within the past 5 years. The definition of "open doors" ranged from an only vaguely defined open door policy up to explicit set time periods with open doors. Some studies reported a decrease in coercive interventions. No study reported any associated adverse events resulting from open doors in psychiatric wards.

DISCUSSION

Generally, all studies had methodological weaknesses. Prospective randomized controlled studies or quasi-experimental studies are missing in the context of European healthcare systems. The risk of bias was considerable in most studies. A final conclusion regarding the possible extent of psychiatry with open doors and the associated risks is currently not possible. There is an urgent need for future high-quality prospective studies.

Refusing Medication Therapy in Involuntary Inpatient Treatment-A Multiperspective Qualitative Study

Objective: Between June 2012 and February 2013, two decisions by the German Federal Constitutional Court restricted the so-far common practice to use involuntary medication in inpatients who were involuntarily hospitalized. Up to then, involuntary medication was justified by a judge's decision on involuntary hospitalization. It could be applied according to clinical judgment even against the declared will of a patient. Since then, all domestic laws related to involuntary treatment had to be revised. For several months, involuntary medication was allowed only in an emergency. We were interested in the impact of the changed legal framework on the experiences of inpatients, their relatives, and clinical professionals during that time. Methods: Thirty-two interviews were analyzed qualitatively using a grounded theory methodology framework. Results: As a consequence of the restrictions to involuntary medication, special efforts by nursing and medical staff were required concerning de-escalation, ward management, and the promotion of treatment commitment in inpatients who refused medication. Family caregivers were also under strong pressure. They wanted to help and to protect their relatives, but some also welcomed the use of coercion if the patient refused treatment. Most of the interviewed patients had not even noticed that their rights to refuse medication had been strengthened. They complained primarily about the involuntary hospital stay and the associated limitations of their everyday lives. While patients and family members evaluated the refusal of medication from a biographical perspective, the mental health care professionals' focus was on the patients' symptoms, and they understood the situation from a professional perspective. It was obvious that, in any of the four perspectives, the problem of feeling restricted was crucial and that all groups strived to gain back their scope of action. Conclusion: The temporary ban on involuntary medication questioned the hitherto common routines in inpatient treatment, in particular when patients refused to take medication. Each of the different groups did not feel good about the situation, for different reasons, however. As a consequence, it might be indispensable to increase awareness of the different perspectives and to focus the efforts on the establishment of nonviolent treatment structures and practices.

International variations in mental-health law regulating involuntary commitment of psychiatric patients as measured by the Mental Health Legislation Attitudes Scale

Previous research illustrated that the laws regulating involuntary placement and treatment of people with mental-health problems are diverse across countries. International studies comparing satisfaction levels between countries are rare. We compared the opinions of professionals and family members about the operation of the national mental-health law regulating forcibly admission and treatment of psychiatric patients in 11 countries: Ireland, Iceland, England and Wales, Romania, Slovenia, Denmark, Germany, Sweden, Norway and India. An online survey design was adopted using a Mental Health Legislation Attitudes Scale (MHLAS). This brief nine-item questionnaire was distributed via email to psychiatrists, general practitioners, acute and community mental-health nurses, tribunal members, police officers and family members in each collaborating country. The levels of agreement/disagreement were measured on a Likert scale. Data were analysed both per question and with regard to a total MHLAS 'approval' score computed as a sum of the nine questions. We found that respondents in England and Wales and Denmark expressed the highest approval for their national legislation (76% and 74%, respectively), with those in India and Ireland expressing the lowest approval (65% and 64%, respectively). Almost all countries had a more positive attitude in comparison to Ireland on the admission criteria for involuntary placement and the way people are transferred to psychiatric hospitals. There are significant variations across Europe and beyond in terms of approval for how the national mental-health law framework operates in each country.