Socio-economic impact on involuntary admissions and coercive measures in psychiatric hospitals in Germany

Is this an underestimated problem? Using coercion before psychiatric hospitalization

BACKGROUND

The Mental Health Act (1994) specifies rules of use for direct coercion in Poland. Coercion in psychiatric wards may improve the safety of patients and surroundings but influences compliance and satisfaction with treatment. Legal (formal) coercion regulated by law isn't the one and only form of coercion used on people with mental disorders. Pressure, threats and orders from relatives and medical staff in relation to procedures of referral and admission to a psychiatric hospital can be described as informal coercion. In Poland there aren't many studies on the use of coercion before psychiatric hospitalization, which justifies the need to conduct this research.

OBJECTIVES

Assessment of the extent of coercive measures used prior to admission and the relationships between the use of direct coercion and selected demographic-clinical factors.

MATERIAL AND METHODS

This study was conducted as part of statutory research at the 4th Clinic of the Institute of Psychiatry and Neurology at the Bielanski Hospital in Warsaw from 1.06.13. to 31.05.14. on all the patients admitted to the psychiatric ward in that period. We gathered data on the extent of coercion in the process of hospital referral, and demographic and clinical data was collected. The following tools were used: a specially prepared questionnaire on the extent of the coercion used prior to admission at the hospital, questionnaire on demographic and clinical data, the Brief Psychiatric Rating Scale (BPRS).

RESULTS

Coercion prior to admission to the hospital was applied to 53 % of patients, 45 % received informal coercion, and 8 % were physically coerced. Man were more likely to be coerced than women, for people diagnosed with F10-F19 and F20-F29, physical coercion was used more frequently than in patients with other disorders. Patients undergoing informal coercion on the way to the hospital were significantly older than those who weren't exposed on coercion or experienced physical coercion. Higher severity of almost all BPRS subscales (without anxiety and depression subscale) be found in patients who were coerced on their way to hospital than in patients who were not coerced. In the analysis of the logistic regression use of coercion prior to admission to the hospital was positively associated with admission without consent, severity of negative symptoms as well as negatively associated with severity of depression symptoms.

CONCLUSIONS

The high probability of experience coercion before admission to the psychiatric hospital suggests more attention should be paid to procedures connected with referral and transport before psychiatric hospitalization.

Predictors of the use of restraint in inpatient psychiatric care among patients admitted via the emergency department

BACKGROUND

Coercive measures are associated with negative consequences for both patients and hospital staff. The aim of the study was to identify predictors for the use of restraints in the emergency department and in subsequent inpatient care.

METHOD

Retrospective routine clinical data of all patients admitted to the psychiatric departments of Vivantes Klinikum Am Urban in Berlin via the emergency department in 2019 was examined case-wise (n = 2584) as well as patient-wise (n = 2118).

RESULTS

Of all cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. Of the 2584 cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. These 195 cases experienced a total of 358 restraints and were distributed across 159 individuals. Multivariate regression analyses on patient-level show that age (p < .001), judicial placement (p < .001), and police referral in the presence of others (p < .001) had a statistically significant effect on the use of restraint.

DISCUSSION

The results indicate that certain patient characteristics increase the risk of restraints. A majority of the findings of this study underline previous research findings. However, ICD-10 diagnosis and gender do not prove to be significant variables, contrary to expectations based on previous.

[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.

Impact of Compulsory Admission on Treatment and Outcome: A Propensity Score Matched Analysis

Background

Despite multiple ethical issues and little evidence of their efficacy, compulsory admission and treatment are still common psychiatric practice. Therefore, we aimed to assess potential differences in treatment and outcome between voluntarily and compulsorily admitted patients.

Methods

We extracted clinical data from inpatients treated in an academic hospital in Zurich, Switzerland between January 1, 2013 and December 31, 2019. Observation time started upon the first admission and ended after a one-year follow-up after the last discharge. Several sociodemographic and clinical characteristics, including Health of the Nation Outcome Scales (HoNOS) scores, were retrospectively obtained. We then identified risk factors of compulsory admission using logistic regression in order to perform a widely balanced propensity score matching. Altogether, we compared 4,570 compulsorily and 4,570 voluntarily admitted propensity score-matched patients. Multiple differences between these groups concerning received treatment, coercive measures, clinical parameters, and service use outcomes were detected.

Results

Upon discharge, compulsorily admitted patients reached a similar HoNOS sum score in a significantly shorter duration of treatment. They were more often admitted for crisis interventions, were prescribed less pharmacologic treatment, and received fewer therapies. During the follow-up, voluntarily admitted patients were readmitted more often, while the time to readmission did not differ.

Conclusions

Under narrowly set circumstances, compulsory admissions might be helpful to avert and relieve exacerbations of severe psychiatric disorders.

Sociodemographic, Circumstantial, and Psychopathological Predictors of Involuntary Admission of Patients with Acute Psychosis

Studies have consistently determined that patients with acute psychosis are more likely to be involuntarily admitted, although few studies examine specific risk factors of involuntary admission (IA) among this patient group. Data from all patients presenting in the psychiatric emergency department (PED) over a period of one year were extracted. Acute psychosis was identified using specific diagnostic criteria. Predictors of IA were determined using logistic regression analysis. Out of 2533 emergency consultations, 597 patients presented with symptoms of acute psychosis, of whom 118 were involuntarily admitted (19.8%). Involuntarily admitted patients were more likely to arrive via police escort (odds ratio (OR) 10.94) or ambulance (OR 2.95), live in a psychiatric residency/nursing home (OR 2.76), report non-adherence to medication (OR 2.39), and were less likely to suffer from (comorbid) substance abuse (OR 0.53). Use of mechanical restraint was significantly associated with IA (OR 13.31). Among psychopathological aspects, aggressiveness was related to the highest risk of IA (OR 6.18), followed by suicidal intent (OR 5.54), disorientation (OR 4.66), tangential thinking (OR 3.95), and suspiciousness (OR 2.80). Patients stating fears were less likely to be involuntarily admitted (OR 0.25). By understanding the surrounding influencing factors, patient care can be improved with the aim of reducing the use of coercion.