Reducing coercion in mental healthcare

Prevalence of involuntary treatment among community-living older persons with dementia: A systematic review

OBJECTIVE

This systematic review and meta-analysis aimed to ascertain the prevalence of involuntary treatment among community-living older persons with dementia and explore associated factors.

METHODS

We comprehensively searched seven electronic databases (PubMed, Embase, Cochrane Library, Web of Science, CINAHL, PsycINFO, and Scopus) from their inception to October 17, 2023, with an update conducted on April 1, 2024. Meta-analysis synthesized prevalence estimates of involuntary treatment and its three subcategories, with 95% confidence intervals.

RESULTS

This study included 11 research papers involving 12,136 community-dwelling individuals with cognitive impairment and dementia from 19 countries. The pooled prevalence of involuntary treatment among community-dwelling older persons with dementia was 45.2% (95% CI: 33.7-60.5%). Subcategories included physical restraints (9.8%, 95% CI: 5.1-18.8%), psychotropic medication (19.1%, 95% CI: 13.6-26.9%), and non-consensual care (34.3%, 27.6-42.7%). Factors influencing involuntary treatment were categorized as caregiver-related and care recipient-related.

CONCLUSION

This study underscores the prevalent use of involuntary treatment among community-dwelling older persons with dementia, emphasizing its association with specific caregiver and care recipient factors. Addressing these findings underscores the importance of proactive measures and targeted interventions to improve the quality of care for this vulnerable population.

Ethical challenges for nurses delivering coercive interventions in community mental health settings: A scoping review

The number of Australians subject to coercive interventions in community mental health services continues to increase. This is in the context of a growing awareness of the harms from coercion, increasing concerns about potential breaches of human rights and an ongoing uncertainty regarding the clinical benefits of community treatment orders, the primary instrument of legislated coercion in community mental health services. Nurses in community mental health services are on the frontline with regard to coercion. They police the requirements of the community treatment order, administer medication to people in community settings without their consent and facilitate re-hospitalisation if indicated. Coercive practice contradicts the person-centred, recovery-oriented and trauma-informed care principles that inform contemporary mental health nursing. This contradiction may generate ethical challenges for nurses and result in ethical distress. The aim of this scoping review was to map the research literature on how nurses in community mental health settings recognise and manage the harm associated with the administration of coercive interventions and consider the ethical challenges that may arise within this practice. The search strategy yielded 562 studies with author consensus determining a total of three articles as meeting the inclusion criteria. The resulting literature identified three themes: (1) maintaining the therapeutic relationship, (2) promoting autonomy and (3) using subtle forms of control. This review demonstrated that there is minimal research that has considered the ethical challenges related to the use of coercion by nurses in community mental health settings.

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

In their own words: Mental health nurses' experiences of trauma-informed care in acute mental health settings or hospitals

Trauma-informed care has emerged as a prominent strategy to eliminate coercive practices and improve experiences of care in mental health settings, with advocacy from international bodies for mental health reform. Despite this, there remains a significant gap in research understanding the integration of trauma-informed care in mental health nursing practice, particularly when applied to the acute mental health or hospital-based setting. The study aimed to explore the experiences of mental health nurses employed in acute hospital-based settings from a trauma-informed care perspective. The study design was qualitative, using a phenomenological approach to research. A total of 29 nurses employed in acute mental health or hospital-based environments participated. Three over-arching themes were uncovered: 'Embodied Awareness': highlighting mental health nursing emotional capabilities are deeply rooted in bodily awareness. 'Navigating Safety': signifying spatial elements of fear and how some mental health nurses' resort to coercive or restrictive practices for self-preservation. 'Caring Amidst Uncertainty': revealing the relational influences of security guards in mental health nursing. The study reveals a significant gap in trauma-informed care implementation when applied to the context of mental health nursing practice in this setting. Limited evidence on trauma-informed care for mental health nurses, coupled with inadequate workforce preparation and challenging work environments, hinder the effective integration of it. To genuinely embed TIC in acute mental health settings, the study emphasises the need for a thorough exploration of what this entails for mental health nurses.

Expert opinions on improving coercion data collection across Europe: a concept mapping study

Introduction

Coercion is frequently used in mental health practice. Since it overrides some patients' fundamental human rights, adequate use of coercion requires legal and ethical justifications. Having internationally standardised datasets to benchmark and monitor coercion reduction programs is desirable. However, only a few countries have specific, open, publicly accessible registries for this issue.

Methods

This study aims to assemble expert opinions regarding strategies that might be feasible for promoting, developing, and implementing an integrated and differentiated coercion data collection system in Europe at national and international levels. A concept mapping methodology was followed, involving 59 experts from 27 countries in generating, sorting and rating strategies regarding relevance and feasibility. The experts were all researchers and/or practitioner members of an EU-COST-Action focused on coercion reduction Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services (FOSTREN).

Results

A hierarchical cluster analysis revealed a conceptual map of 41 strategies organized in seven clusters. These clusters fit into two higher-order domains: "Advancing Global Health Research: Collaboration, Accessibility, and Technological Innovations/Advancing International Research" and "Strategies for Comprehensive Healthcare Data Integration, Standardization, and Collaboration." Regarding the action with the higher priority, relevance was generally rated higher than feasibility. No differences could be found regarding the two domains regarding the relevance rating or feasibility of the respective strategies in those domains. The following strategies were rated as most relevant: "Collection of reliable data", "Implementation of nationwide register, including data on coercive measures", and "Equal understanding of different coercive measures". In analysing the differences in strategies between countries and their health prosperity, the overall rating did not differ substantially between the groups.

Conclusion

The strategy rated as most relevant was the collection of reliable data in the nationwide health register, ensuring that countries share a standard understanding/definition of different coercive measures. Respondents did not consider the feasibility of establishing a shared European database for coercive measures to be high, nor did they envision the unification of mental health legislation in the future. There is some consensus on the most suitable strategies that can be adopted to enable international benchmarking of coercion in mental health settings.

Implementation of the World Health Organization's QualityRights initiative in Ghana: an overview

BACKGROUND

Globally, human rights violations experienced by persons with psychosocial, intellectual or cognitive disabilities continue to be a concern. The World Health Organization's (WHO) QualityRights initiative presents practical remedies to address these abuses. This paper presents an overview of the implementation of the initiative in Ghana.

AIMS

The main objective of the QualityRights initiative in Ghana was to train and change attitudes among a wide range of stakeholders to promote recovery and respect for human rights for people with psychosocial, intellectual and cognitive disabilities.

METHOD

Reports of in-person and online training, minutes of meetings and correspondence among stakeholders of the QualityRights initiative in Ghana, including activities of international collaborators, were analysed to shed light on the implementation of the project in Ghana.

RESULTS

In-person and online e-training on mental health were conducted. At the time of writing, 40 443 people had registered for the training, 25 416 had started the training and 20 865 people had completed the training and obtained a certificate. The team conducted 27 in-person training sessions with 910 people. The successful implementation of the project is underpinned by a committed partnership among stakeholders, strong leadership from the coordinating agency, the acceptance of the initiative and the outcome. A few challenges, both in implementation and acceptance, are discussed.

CONCLUSIONS

The exposure of the WHO QualityRights initiative to a substantial number of key stakeholders involved in mental healthcare in Ghana is critical to reducing human rights abuses for people with psychosocial, intellectual and cognitive disabilities.

Risk assessment for aggressive behaviour in schizophrenia

BACKGROUND

Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings.

OBJECTIVES

To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach.

MAIN RESULTS

We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs.

AUTHORS' CONCLUSIONS

Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.

Abolition of coercion in mental health services - A European survey of feasibility

BACKGROUND

In 2019, the Council of Europe agreed to urge member states to take steps toward total abolition of psychiatric coercive measures.

AIMS

To test if this aspiration is perceived as realistic and what the alternative would be in the event of a total abolition, we surveyed members of the European FOSTREN network of mental health practitioners and researchers, which is specifically dedicated to exchanging knowledge on reducing psychiatric coercion to its minimum.

METHODS

Web-based survey. Categorical responses were analyzed using frequencies, and free text responses were analyzed through thematic analysis.

RESULTS

In total, out of 167 invitations to FOSTREN network members, 76 responded to the survey (Response Rate 45.5%). A minority (31%) of participating experts dedicated to the reduction of psychiatric coercive measures believed a total abolition to be an achievable goal. A commonly held belief was that total abolition is not achievable because mental health disorders are difficult to treat and may cause violence, necessitating coercion, and there is a need to protect the involved persons from harm. Those responding that complete abolition is achievable argued that the consequences of coercion outweigh any gains and indicated that use of advance directives are sufficient as alternatives to coercion.

CONCLUSION

Of a European group of experts specifically dedicated to the reduction of psychiatric coercion who participated in this questionnaire study, a minority believed a total abolition be an achievable goal. The study adds to the empirical evidence of the feasibility of the aspiration to totally abolish involuntary measures in the mental health services from the perspective of experts.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey

PURPOSE

To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings.

METHODS

We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention.

RESULTS

A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores.

CONCLUSIONS

The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

Humanised care in acute psychiatric hospitalisation units: Definition, values and strategic initiatives from the perspective of persons with mental health problems, primary carers and professionals

INTRODUCTION

Humanised care refers to the holistic approach to the person, considering their bio-psycho-social and behavioural dimensions. It becomes more complex when the person has mental health problems that may affect his or her will, cognition and relationship to the world. The literature on the humanisation of mental health is scarce and only offers the view of professionals.

AIM

To analyse the concept, values and strategic initiatives of humanised care in acute psychiatric units from the perspective of persons with mental health problems, carers and professionals.

METHOD

Qualitative grounded-theory approach. Data were collected through focus groups and in-depth interviews among persons with mental health problems, carers and professionals.

RESULTS

Thirteen focus groups and three in-depth staff interviews were performed, with a total of 61 participants. Humanised care is defined as quality care of an individualised, ethical and safe nature, empowering persons/carers to involve them in their health process, helping them resist the stigma of mental illness through a therapeutic relationship, bond and communication. Formal training, teamwork and effective communication are required. Six values and strategic initiatives were identified.

DISCUSSION

Each value and strategic initiatives acquires full meaning when connected with the rest. Without this interconnection, humanised care would be impossible.

[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.

Using latent class analysis to investigate enduring effects of intersectional social disadvantage on long-term vocational and financial outcomes in the 20-year prospective Chicago Longitudinal Study

BACKGROUND

Class and social disadvantage have long been identified as significant factors in the etiology and epidemiology of psychosis. Few studies have explicitly examined the impact of intersecting social disadvantage on long-term employment and financial independence.

METHODS

We applied latent class analysis (LCA) to 20-year longitudinal data from participants with affective and non-affective psychosis (n = 256) within the Chicago Longitudinal Research. LCA groups were modeled using multiple indicators of pre-morbid disadvantage (parental social class, educational attainment, race, gender, and work and social functioning prior to psychosis onset). The comparative longitudinal work and financial functioning of LCA groups were then examined.

RESULTS

We identified three distinct latent classes: one comprised entirely of White participants, with the highest parental class and highest levels of educational attainment; a second predominantly working-class group, with equal numbers of Black and White participants; and a third with the lowest parental social class, lowest levels of education and a mix of Black and White participants. The latter, our highest social disadvantage group experienced significantly poorer employment and financial outcomes at all time-points, controlling for diagnosis, symptoms, and hospitalizations prior to baseline. Contrary to our hypotheses, on most measures, the two less disadvantaged groups did not significantly differ from each other.

CONCLUSIONS

Our analyses add to a growing literature on the impact of multiple forms of social disadvantage on long-term functional trajectories, underscoring the importance of proactive attention to sociostructural disadvantage early in treatment, and the development and evaluation of interventions designed to mitigate ongoing social stratification.

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.

Compulsory treatment in Portuguese-speaking countries: An analysis and comparison of the legal framework

BACKGROUND

Compulsory treatment involves the hospital admission of individuals with mental disorders in appropriate facilities through judicial decisions. However, limited information is available regarding the similarities and differences in compulsory treatment legislation in Portuguese-speaking countries.

AIMS

To analyse the commonalities and differences in compulsory treatment legislation in Portuguese-speaking countries, where Portuguese is the primary official language, including Angola, Brazil, Cape Verde, East Timor, Guinea-Bissau, Mozambique, Portugal, and São Tomé and Príncipe.

METHODS

A comparative analysis of the specific legislation on compulsory treatment in Portuguese-speaking countries was conducted. National development plans were analysed in countries lacking legislation. A purposive sampling of mental health professionals was contacted to gather information on the countries under study.

RESULTS

Among the eight Portuguese-speaking countries examined, specific legislation regarding compulsory treatment was found only in Brazil, Cape Verde, and Portugal. These countries, with the lowest poverty rates, exhibited a notable degree of homogeneity in the criteria supporting compulsory treatment, ensuring the protection of individual rights. In contrast, in Angola, East Timor, Guinea-Bissau, Mozambique, and São Tomé and Príncipe, compulsory treatment primarily relies on mental health development plans, resulting in significant variations in the presented criteria.

CONCLUSIONS

The significant disparities in compulsory treatment policies among Portuguese-speaking countries, with only Brazil, Cape Verde, and Portugal having specific legislation, underscore the need for a collective effort to establish more consistent procedures and safeguard individual rights.

Risk factors for coercion length at psychiatric hospitals in Israel: Relationship with staff

Background

Coercive interventions continue to be applied frequently in psychiatric care when patients are at imminent risk of harming themselves and/or others.

Aim

The purpose of this study was to demonstrate the relationship between the length of coercion and a variety of factors, including the sociodemographic background of patients, their diagnoses and the characteristics of hospital staff.

Methods

This is a one-year cross-sectional retrospective study, including records of 298 patients who underwent restraint and/or seclusion interventions in male acute, closed wards in two psychiatric hospitals in Israel.

Results

A higher proportion of academic nurses to nonacademic nurses on duty leads to a shorter coercion time (P < 0.000). The number of male staff on duty, without any relation to their level of education, also leads to the shortening of the coercion time.

Conclusion

The presence of registered, academic female nurses, male staff on duty and the administration of medication before coercive measures can reduce the length of restriction.

Ambulance personnel use of coercion and use of safety belts in Norway

BACKGROUND

Providing health care in a moving vehicle requires different considerations regarding safety than in other settings. Use of seatbelts are mandatory, and during ambulance transport patients are fastened to the stretcher with safety straps. However, patients who wriggle out of, or unfasten, their safety straps pose a threat to him/herself and escorting personnel in the ambulance compartment in case of an accident. To prevent harm, ambulance personnel sometimes restrain the patient or unfasten their own seatbelts to keep the patient safe on the stretcher. The prevalence of coercive measures, and the relationship between the use of mechanical restraints comparable to coercion and seatbelt use, are scarcely investigated. Use of coercion normally requires a specific statutory basis. However, coercive measures needed to ensure safety in a moving vehicle while providing healthcare is hardly discussed in the literature. The aim of this study is to explore the use of coercion in ambulance services, the use of safety belts among escorts in situations where they need to keep the patient calm during transportation, and to analyse the relationship between safety belt non-compliance and coercion in these situations.

METHODS

This is a retrospective, cross-sectional study using a self-administered, online survey aiming to investigate the use of coercion and use of seatbelts during ambulance transport. Approximately 3,400 ambulance personnel from all 18 Health Trusts in Norway were invited to participate between Oct 2021 and Nov 2022. Descriptive analyses were used to describe the sample and the prevalence of findings, while multiple linear regressions were used to investigate associations.

RESULTS

Altogether, 681 (20%) ambulance personnel completed the survey where 488 (72.4%) stated that they had used coercion during the last six months and 375 (55.7%) had experienced ambulance personnel or escorting personnel working with unfastened seatbelts during transport. The majority of respondents experienced coercion as being unpleasant and more negative feelings were associated with less use of seatbelts.

CONCLUSIONS

Coercion seems to be used by ambulance personnel frequently. For the study participants, keeping the patient securely fastened was prioritized above escorting personnel's traffic safety, despite feeling uncomfortable doing so. Because coercive measures have negative consequences for patients, is associated with negative feelings for health personnel, and is not discussed ethically and legally in relation to the prehospital context, there is an urgent need for more research on the topic, and for legal preparatory work to address the unique perspectives of the prehospital context in which traffic safety also is an important factor.

Outcome of Involuntary Mental Health Assessment in a Psychiatric Department in Greece

Despite their controversiality, involuntary admissions in psychiatric departments remain a central issue in mental health care. The present study aims to identify demographic and clinical factors possibly associated with emergency involuntary psychiatric assessment and its outcome in Greece. This study was carried out in the psychiatric department of the University General Hospital of Alexandroupolis (UGHA) from 1 March 2018 to 28 February 2019. The sample included 191 individuals who had been psychiatrically assessed without their consent following a prosecutorial order. The majority of the involuntary assessments resulted in hospitalization (71%), with 51% of them resulting in involuntary hospitalization. Almost all patients diagnosed with "F20-29 schizophrenia, schizotypal and delusional disorders" were subsequently admitted to the psychiatric department of the UGHA (77 of 81, 66 of them involuntarily). Higher admission rates were recorded among those who had been referred from the Prosecutor's Office of regions that are located far from the psychiatric department of UGHA (Fisher's exact test, p-value = 0.045). In multivariate logistic regression, prior contact with psychiatric services and having an "F20-29 schizophrenia, schizotypal and delusional disorders" diagnosis was statistically significant with admission to the hospital as an outcome variable. Our study suggests an increased risk of involuntary admission among patients with psychosis, patients who had visited a psychiatric service prior to their assessment as well as those living further away from the main psychiatric services of the hospital. Better organization of community psychiatric services in remote places from hospital central services may lead to fewer prosecutorial referrals and coercive measures.

A qualitative integrative analysis of service users' and service providers' perspectives on ways to reduce coercion in mental health care

PURPOSE

The movement to develop and implement non-coercive alternatives in the provision of mental health care is gaining momentum globally. To strengthen the basis of potential interventions that will be contextually relevant, and to complement the body of literature which is largely from high-income settings, the current study sought to explore the suggestions of service users and providers in Nigeria on how to reduce the use of coercive measures in mental health settings.

METHODS

Semi-structured interviews with 30 mental health professionals and four focus group discussions among 30 service users from two psychiatric hospitals in Nigeria were conducted. The data were analyzed thematically with the aid of MAXQDA.

RESULTS

The suggestions proposed by service users and mental health professionals were within the broad themes of communication, policies and legislation, and increased resources. Service users felt that improved communication, home consultations, non-legal advocates and clear rules and legislation would reduce the use of coercion, while service providers suggested increased public mental health literacy, better interpersonal relationships with patients, increased resources for mental health care, more research on the topic and regulation of coercive measures.

CONCLUSION

Many of the suggestions from this study reinforce strategies already in place to decrease coercion in other settings. However, additional recommendations that are relevant to the study setting, such as enhancing public mental health literacy, mental health legislation reform and increasing access to mental health services, deserve further consideration.

Psychometric properties of the Italian version of the staff attitude to coercion scale: an exploratory factor analysis

Aims

The current study aimed to validate the Italian version of the Staff Attitude to Coercion Scale (SACS), which assesses mental health care staff's attitudes to the use of coercion in treatment.

Methods

The original English version of the SACS was translated into Italian, according to the back-translation procedure. Subsequently, it was empirically validated by performing an exploratory factor analysis on a sample of 217 mental health professionals (Mean = 43.40 years, SD = 11.06) recruited form Italian general hospital (acute) psychiatric wards (GHPWs), with at least 1 year of work experience (i.e., inclusion criteria).

Results

Results confirmed the three-factor solution of the original version for the Italian version of the SACS, though three items loaded on different factors, compared to the original. The three extracted factors, explained 41% of total variance, and were labeled similarly to the original scale and according to their respective item content, i.e., Factor 1 "Coercion as offending" (items: 3, 13, 14, and 15), Factor 2 "Coercion as care and security" (items: 1, 2, 4, 5, 7, 8, and 9), and Factor 3 "Coercion as treatment" (items: 6, 10, 11, and 12). The internal consistency of the three-factor model of the Italian version of the SACS was assessed through Cronbach's α and yielded acceptable indexes, ranging from 0.64 to 0.77.

Conclusion

The present findings suggest that the Italian version of the SACS is a valid and reliable tool that can be used to assess healthcare professionals' attitudes toward coercion.

[PLAID-Care: Research into the reduced use of coercion in France]

The use of coercion is a common practice in psychiatry despite its deleterious effects and insufficient evidence of benefits. It is so deeply rooted that the mention of establishments that make little use of it arouses a form of incredulity. However, the history of psychiatry and the international literature provide numerous examples of a psychiatry that is hardly coercive and numerous experiences of a reduction in the use of seclusion and/or restraint in psychiatric facilities. Today, in France, there are also less coercive establishments, which, for example, do not use mechanical restraint, have all their units open, or have reduced their use of seclusion and restraint. With regard to the stated policy objectives of reducing the use of coercion, it is surprising that most of these facilities receive little attention. PLAID-Care research aims to contribute to the visibility and analysis of these institutions and the factors involved in the reduced use of coercion. While these factors have already been identified in the international literature, the research is based on the multiplication of disciplinary perspectives (nursing, sociology, anthropology, geography) and the mobilization of a multi-level analytical framework that allows us to embrace their multiplicity and better understand their articulation. The originality of the research also lies in its historical dimension, which allows us to understand, on the scale of an institution, how a policy and practices aiming at the least recourse emerge and are consolidated. The project timeline is divided in three tasks: firstly, an inventory of "low-coercion" facilities in France; secondly, we will select and research four traditionally "low-coercion" facilities in France; thirdly we will focus on recently emerged "low-coercion" practices. PLAID-Care aims to revitalize French research on this theme which to date has been relatively lagging behind the numerous international studies. It will bring together and articulate the knowledge, tools and forms of organization and collaboration that contribute to making a policy of lesser use of coercion operational.

Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors

BACKGROUND

A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN.

METHODS

In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics.

RESULTS

IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these.

CONCLUSIONS

High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.

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.

Change of home visit frequency by public health nurses predicts emergency escorts for psychiatric patients living in the community: A retrospective medical record review

Background

Improper or insufficient treatment of mental health illness harms individuals, families, and society. When psychiatric treatment shifts from a hospital-based to a community-based health care system, risk management is essential to the provision of effective care.

Objective

We examine whether an upgrade in home visit frequency of psychiatric patients as identified by public health nurses can predict the subsequent need for emergency escort services for medical treatment.

Design

A 2-year retrospective medical record review.

Settings

A district of New Taipei City in Taiwan.

Participants

A total of 425 patients with a diagnosed mental health illness cared for through home visits by public health nurses from January 2018 to December 2019.

Methods

We accessed the Ministry of Health and Welfare's psychiatric care management information system to identify a set of medical records, and analyzed these records using chi-square and regression analyses.

Results

The analyses indicated that the groups experiencing the greatest need for emergency escort services were: male, 35-49 years old, with a senior high school level of education, without a disability identification card, with a schizophrenia diagnosis, and had been reported by the nurse as having progressed to a serious level. Nurses' increased frequency of home visits (an indicator that the patient's overall condition was worsening) and nurses' reports of increased severity of problems were significant predictors of the need for emergency escort services.

Conclusions

The nurses' adjustment of visit frequency based on the results of the visit assessment predicts the need for emergency escort services for mental patients. The findings support not only the professional roles and functions of public health nurses, but also the importance of strengthening psychiatric health community support services.

National Strategies to Reduce the Use of Coercive Measures in Psychiatry in Denmark - A Review of Two Decades of Initiatives

Coercive measures are a major infringement of the autonomy of psychiatric patients and no medical justification exists for applying mechanical restraint (MR) to these patients currently. Knowledge regarding how preventive strategies affect the use of MR is limited. This paper aimed to understand the link between the initiatives taken by national authorities and the practical implications to MR reduction. Policy texts and the number of coercive measures used in two decades were reviewed. Trends were discussed with five experts with real-life experience and suggestions were obtained regarding how to end the use of mechanical restraint in mental health care settings.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff.

ABSTRACT

INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required.

AIM

We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities.

METHOD

After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study.

RESULTS

After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits.

DISCUSSION

Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration.

IMPLICATIONS FOR PRACTICE

When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review

PURPOSE

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings.

METHODS

A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored.

RESULTS

Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1).

CONCLUSIONS

Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Helpful encounters with mental health nurses in Australia: A survey of service users and their supporters

WHAT IS KNOWN ABOUT THE SUBJECT?: Most nurses who work in mental health in Australia have completed a comprehensive nursing programme at a university. This training has been widely criticized and has not produced "job-ready" graduates. Public inquiries into mental health services have highlighted the need for transformation of mental health services and concern about future nursing shortages. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This survey highlights what service users and supporters perceive are useful nursing skills and capabilities. The characteristics of helpful encounters with nurses are also described. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Helpful nursing practice is aligned with traditional nursing values and theory, rather than the performance of specific tasks. Improving the retention of nurses to this specialty area of practice requires educational processes to enable nurses to enact values, develop their therapeutic potential and undertake facilitative and supportive practices which are helpful to service users.

ABSTRACT

INTRODUCTION: Successive inquiries into mental health services in Australia have identified the need for major reform of services and proposed a return to direct-entry nursing training.

AIM/QUESTION

To identify what service users, family and supporters have found helpful in their encounters with nurses in mental health settings.

METHOD

A survey of 95 service users and supporters rated the importance of the capabilities and competencies of nurses. They also shared examples of helpful encounters with nurses which were subject to thematic analysis.

RESULTS

The most highly rated competencies were around demonstrating caring, empathy and understanding, and responding effectively in crisis situations. Helpful encounters involved enacted values, highly skilful interpersonal and psychotherapeutic engagement and practices that were facilitative and supportive.

DISCUSSION

The process and content of pre-registration nursing training needs to refocus on the nurse meeting the needs of service users and supporters, rather than the instrumental needs of services today.

IMPLICATIONS FOR PRACTICE

Educational reform may be necessary but insufficient to address anticipated nursing workforce shortages. Policymakers and health service directors need to align services with mental health nursing values and promote practices aligned with what service users and their supporters report as helpful.

Experiences and perceptions of coercive practices in mental health care among service users in Nigeria: a qualitative study

BACKGROUND

People with mental health problems are more vulnerable to a broad range of coercive practices and human rights abuses. There is a global campaign to eliminate, or at the very least decrease, the use of coercion in mental health care. The use of coercion in psychiatric hospitals in developing countries is poorly documented. The primary aim of this study was to explore service users' perceptions and experiences of coercion in psychiatric hospitals in Nigeria.

METHODS

Four focus group discussions were carried out among 30 service users on admission in two major psychiatric hospitals in Nigeria. The audio recordings were transcribed verbatim and then analyzed thematically with the aid of MAXQDA software.

RESULTS

The Focus group participants included 19 males and 11 females with a mean age of 34.67 ± 9.54. Schizophrenia was the most common diagnosis (40%, n = 12) and had a secondary school education (60%, n = 18). The focus group participants perceived coercion to be a necessary evil in severe cases but anti-therapeutic to their own recovery, an extension of stigma and a vicious cycle of abuse. The experience of involuntary admission revolved mainly around deception, maltreatment, and disdain. Participants in both study sites narrated experiences of being flogged for refusing medication. Mechanical restraint with chains was a common experience for reasons including refusing medications, to prevent absconding and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful.

CONCLUSION

The experiences of coercion by participants in this study confirm that human rights violations occur in large psychiatric hospitals and underscore the need for mental health services reform. The use of coercion in this context reflects agelong underinvestment in the mental health care system in the country and obsolete mental health legislation that does not protect the rights of people with mental health problems. The study findings highlight an urgent need to address issues of human rights violations in psychiatric hospitals in the country.

Harm Reduction, Humanistic Psychology, and the CRPD

Harm reduction, which was initially developed as a public health response to illicit drug use, has relevance to the prescription of psychotropic medication. Indeed, focusing on the agency of people who use drugs—licit or illicit—facilitates a more authentic engagement with treatment. In this paper, we show how the framework of harm reduction is congruent with the guiding principles of both humanistic psychology and the Convention on the Rights of Persons with Disabilities (CRPD). Moreover, applying a harm reduction model to psychotropic drug use raises awareness that there are risks to taking these medications, risks which are frequently glossed over because of the emphasis on medication adherence and compliance. We provide case examples of organizations that take a person-centered (vs. medication-centered) approach to people experiencing mental health crises. In their unique ways, these organizations embody the principles of harm reduction and the humanistic impulse that informs the CRPD.

Systematic review of involuntary hospitalisation and long-term compliance

INTRODUCTION

Involuntary hospitalisation denies autonomy and freedom of decision-making and is frequent in psychiatric clinical practice. However, there is still a lack of knowledge of long-term compliance after Involuntary commitment.

METHODS

We conducted a systematic review of published studies reporting people compliance after involuntary hospitalisation and people compliance after voluntary admission. Two investigators independently searched PubMed, PsycINFO, EMBASE and CINAHL up to December 17th, 2021 to identify eligible studies. The study is registered with PROSPERO number CRD42022299437.

RESULTS

Ten independent studies analysing the main indicators of compliance, engagement with services and medication adherence, were included. Three studies show that compliance is worse in people that have been involuntary hospitalised and in the others no association is found. Just two of the ten studies show an association with improved compliance. Outcomes are assessed from the first follow-up appointment after discharge up to 96 months.

CONCLUSIONS

Although evidences carried out so far are weak, the data do not show a trend of improvements and do not seem to exclude the possibility of worse compliance after compulsory hospitalisation. More appropriate methodologies and reliable assessment are needed in future research to provide scientific evidence on involuntary admission health effects.

Protection of Prisoners with Mental Health Disorders in Italy: Lights and Shadows after the Abolition of Judicial Psychiatric Hospitals

In Italy, a person suffering from a mental disorder who commits a crime will be given a custodial security order and serve the period of admission at a Residenza per la esecuzione delle misure di sicurezza (REMS) (Residence for the Execution of Security Measures, hereinafter "REMS"). These institutions have been established recently and though equipped with the necessary safety measures, the focus is on psychiatric therapy. Despite being present on a national scale, access is very limited in terms of capacity. Immediate remedial measures are needed, so much so that the European Court of Human Rights recently condemned Italy for this very reason. This article, through a review of the constitutive principles of these institutions, shows how they have very positive aspects such as the attention to necessary psychotherapy in order to protect the right to health and the real taking charge of the fragility of the subjects; however, it is seen how there are many negative aspects linked above all to the scarce availability of places in these structures. The article provides suggestions on a more comprehensive strategy for facilities for detainees with mental disorders.

The ReCoN intervention: a co-created comprehensive intervention for primary mental health care aiming to prevent involuntary admissions

BACKGROUND

Reducing involuntary psychiatric admissions is a global concern. In Norway, the rate of involuntary admissions was 199 per 100,000 people 16 years and older in 2020. Individuals' paths towards involuntary psychiatric admissions usually unfold when they live in the community and referrals to such admissions are often initiated by primary health care professionals. Interventions at the primary health care level can therefore have the potential to prevent such admissions. Interventions developed specifically for this care level are, however, lacking. To enhance the quality and development of services in a way that meets stakeholders' needs and facilitates implementation to practice, involving both persons with lived experience and service providers in developing such interventions is requested.

AIM

To develop a comprehensive intervention for primary mental health care aiming to prevent involuntary admissions of adults.

METHODS

This study had an action research approach with a participatory research design. Dialogue conferences with multiple stakeholders in five Norwegian municipalities, inductive thematic analysis of data material from the conferences, and a series of feedback meetings were conducted.

RESULTS

The co-creation process resulted in the development of the ReCoN (Reducing Coercion in Norway) intervention. This is a comprehensive intervention that includes six strategy areas: [1] Management, [2] Involving Persons with Lived Experience and Family Carers, [3] Competence Development, [4] Collaboration across Primary and Specialist Care Levels, [5] Collaboration within the Primary Care Level, and [6] Tailoring Individual Services. Each strategy area has two to four action areas with specified measures that constitute the practical actions or tasks that are believed to collectively impact the need for involuntary admissions.

CONCLUSIONS

The ReCoN intervention has the potential for application to both national and international mental health services. The co-creation process with the full range of stakeholders ensures face validity, acceptability, and relevance. The effectiveness of the ReCoN intervention is currently being tested in a cluster randomised controlled trial. Given positive effects, the ReCoN intervention may impact individuals with a severe mental illness at risk of involuntary admissions, as more people may experience empowerment and autonomy instead of coercion in their recovery process.

Current trends in restrictive interventions in psychiatry: a European perspective

This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.

The association between involuntary alcohol treatment and subsequent emergency department visits and hospitalizations: a Bayesian analysis of treated patients and matched controls

BACKGROUND AND AIMS

Many nations have provisions for involuntary treatment of alcohol dependence where the person is at serious risk of harm to themselves. To date, there has been little thorough evaluation of its effectiveness. This study aimed to determine if there were differences between involuntary and voluntary treatment for alcohol dependence on subsequent emergency and hospital care.

DESIGN

A retrospective cohort design using linked routinely collected administrative data on health-care utilization.

SETTING

Hospital and community-based alcohol treatment, New South Wales, Australia.

PARTICIPANTS

A total of 231 patients who were involuntarily treated for alcohol dependence and 231 matched controls who received treatment as usual within the period May 2012 to April 2018.

INTERVENTION AND COMPARATOR

Involuntary treatment comprised a 28-day mandated hospital admission which included supervised withdrawal, comprehensive assessment, rehabilitation and support followed by voluntary aftercare support for up to 6 months. Treatment as usual comprised three not mutually exclusive forms of intensive voluntary alcohol treatment: withdrawal management, rehabilitation and pharmacotherapies for alcohol dependence.

MEASUREMENTS

Outcome measures: changes in the number of emergency department (ED) visits and number of unplanned hospital admissions 12 months before and 12 months after completion of index treatment.

FINDINGS

Both groups showed a reduction in ED visits (incidence rate ratio (IRR) = 0.56, 95% credible intervals (CrI) = 0.39-0.78) and unplanned hospital admissions (IRR = 0.49, 95% CrI = 0.37-0.65). There was no statistically significant difference between the two groups (IRR = 0.77, 95% CrI = 0.58-1.03 for ED visits and IRR = 0.79, 95% CrI = 0.62-1.01 for hospital admissions). The Bayes factors were 0.925 and 0.936 for ED visits and unplanned hospital admissions, respectively, interpreted as weak evidence in support of the null hypothesis of no difference between the interventions.

CONCLUSIONS

Involuntary treatment of alcohol dependence was associated with reduced health service utilization in the year following treatment, and the outcomes did not differ from those of a matched control group.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

Risk factors associated with use of coercive practices in adult mental health inpatients: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Coercive practices such as restraint (physically holding a person) or seclusion (containing a person in locked room) are frequently used in mental health care. How often and which specific practices are used is not consistent across different healthcare systems, hospitals or wards. Internationally, there is agreement on the need to monitor and reduce the use of coercive practices. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The reviewed evidence suggests a number of different factors affect a person's risk of experiencing coercive practices, while admitted to a mental health ward. However, there is currently not enough high-quality research evidence to say which factors are most important or how they work to influence the likelihood of a person experiencing coercive practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When carrying out risk assessments, mental health professionals must take into account that a number of different factors are important and explore these with the patient. Care plans aimed at minimizing the use of coercive practices, such as restraint, must be personalized and developed with the individual. ABSTRACT: Introduction Coercive practices, such as physical restraint and seclusion, are a common feature of all mental healthcare systems. However, there is considerable variation in their use, concern about their iatrogenic potential and agreement internationally on the need to monitor and reduce their use. Aims To examine the evidence concerning risk factors associated with use of coercive practices in adults admitted to inpatient psychiatric services. Method A systematic review, consistent with PRIMSA guidelines, of four databases (PsychINFO, Medline, CINHAL and Embase). Peer-reviewed, English language articles from database inception to February 2020 were included. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies. Results Twenty studies met inclusion criteria. Risk factors examined in the studies organized around four categories: patient socio-demographic; patient clinical; staff; and organizational factors. Overall, methodological quality of papers was deemed weak, and there was insufficient evidence to support any singular risk factor. Discussion The reviewed evidence suggests risk of coercive practice in inpatient mental health settings is multifactorial. Further research to standardize concept definitions and elucidate the mechanisms behind variance in use is required. Implications for Practice Assessment of patients at risk of coercive practice must take a multifactorial approach.

Human rights of persons with mental disability: from discourse to reality

Since 1989, the major professional organization of psychiatrists has expressed concern for the human rights of people with mental disorders: "Involuntary intervention is a great infringement of the human rights and the fundamental freedom of a patient. Therefore, specific, and carefully defined criteria and safeguards are needed for such intervention. Hospitalization or treatment against the will of a patient should not be conducted unless the patient suffers from serious mental illness. Involuntary intervention must be conducted in accordance with the least restrictive principle.

Measurement Properties of the Staff Attitude to Coercion Scale: A Systematic Review

OBJECTIVE

The Staff Attitude to Coercion Scale (SACS) was developed to assess mental health care staff's attitudes to the use of coercion in treatment. The staff's attitudes to the use of coercion may also influence their willingness to engage in professional development projects aimed at reducing use of coercion. This study systematically reviews the existing evidence related to the measurement properties of the SACS in papers published since the publication of SACS in 2008.

METHODS

Seven databases were searched for studies published until October 2021 assessing the measurement properties of SACS or using SACS. All original studies reporting data relevant for the assessment of measurement properties of the SACS were eligible for inclusion. The methodological quality of the studies was assessed and rated using the COnsensus-based Standard for the selection of health Measurement INstruments (COSMIN).

RESULTS

Of the 81 identified publications, 13 studies with a total of 2,675 respondents met the inclusion criteria. Most studies reported data on structural validity and internal consistency, with high methodological quality, but there were almost no data on any other measurement properties.

CONCLUSION

We found evidence for adequate structural validity and internal consistency of the SACS, while other important measurement properties were not addressed in any of the reviewed studies. Caution is needed when interpreting results of the SACS in terms of aspects such as reliability, criterion validity and measurement error. The relationship between staff attitudes to coercion and the actual use of coercion also remains unclear and needs to be further investigated.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021239284.

Good practices in Italian therapeutic communities. Outcomes 2020 of quality accreditation program “Visiting DTC Project”

Purpose

This paper aims to present results achieved by the first, and to date only, Democratic Therapeutic Communities (DTC) quality improvement program developed in Italy, in the past 10 years, named “Visiting DTC Project.” Process of bottom-up identification, definition and evaluation of good practices of TCs for adult users with long term severe mental disorders will be described. In addition, a five-phase clinical care pathway will be presented for the same user category, developed by the “Visiting DTC Project” to comply with Italian National Health Service accreditation standards for TCs.

Design/methodology/approach

“Visiting DTC Project” involved 40 Italian TCs, since 2012 until 2020, in an action research on good practices developed throw a democratic and bottom-up methodology. Project’s methodology is the “Democratic Peer-to-peer Accreditation,” a kind of professional scientific quality accreditation and continuous improvement process for community mental health services. Scientific model for the definition of service standards and principles of treatment is the British “Democratic Therapeutic Community,” which the “Visiting DTC Project” is organizationally inspired by.

Findings

In the eighth annual cycle of the program for TC with adult users of mental health services a significantly effective good practice procedure (GPP), with good practical efficacy, was finally identified (for the first time after eight years), but still no best practice. GPP with the title “Multi-family Community Meeting” is the Good Practice of the year 2020. No Best Practice has yet been identified. An integrated clinical care pathway for Adult DTCs Users in five phases is also presented. This care pathway organizes advanced standards of Community Group Quality in a map, to support the description and planning of the five phases of the user’s clinical work in DTC treatment.

Originality/value

Cooperation with local community services, organizations and networks, as well as a therapeutic environment based on informal coexistence and cooperation between TC members, are thus, together with care of family relationships, the main characteristics of the Italian experience of implementing and developing the Italian DTC treatment model. These characteristics make it clear how fragile Italian DTCs are at this moment. They are still in an early stage of development. All the most applied and effective best practice procedures are dependent on a wide and dense network of relationships, formal and informal, which cross the therapeutic environment and interconnect TC members with all other stakeholders.

Physical Restraint in Psychiatric Care: Soon to Fall Out of Use?

International directives all recommend that using restraints on psychiatric patients should be avoided, yet scientific literature shows that such practices are still largely in use. This article aims to lay out strategies that could be put in place in order to gradually discard the use of restraints, particularly through a "restraint-free" approach, nursing, logistic-environmental pathways, and locally centered health care provision. All such tools have proven valuable for the purpose of safeguarding the health of psychiatric patients. Hence, the failure to put in place such measures may lead to litigation and lawsuits against physicians and particularly health care facilities. Undoubtedly, the ability to effectively implement such methods largely depends on the financial resources available, which in countries such as Italy are poorer than in others. Still, the risk of being sued and held professionally liable may constitute a factor in raising awareness among operators, facilities, and public health care management, leading to the implementation of policy changes aimed at minimizing the use of restraints.

Participation preferences of health service users in health care decision-making regarding rehabilitative care in Germany-A cross-sectional study

BACKGROUND

Involving patients and citizens in health care decision-making is considered increasingly important in Germany. Participatory structures have been implemented, especially in rehabilitative care. However, it is unknown whether and to what extent German patients and citizens want to participate in decisions that exceed their own medical treatment.

OBJECTIVE

This study aimed to survey participation preferences and associated factors of health service users in decisions regarding rehabilitative care at micro, meso and macro levels.

METHODS

A questionnaire was sent to 3872 former rehabilitants. We collected participation preferences using the Control Preference Scale or an adapted form. Possible influencing factors were examined using logistic regression models.

RESULTS

The response rate was 5.7% (n = 217). At all decision-making levels, joint decision-making was preferred. At the macro level, preferences for actively participating were the highest. Preferences were significantly interrelated between decision-making levels. At the micro level, an orthopaedic indication significantly decreased the desire for participation compared to psychosomatic indications (odds ratio = 0.44, p = .019).

DISCUSSION

Participants wanted to be equally involved in decision-making as experts. Higher preferences for active participation at the macro level might be due to dissatisfaction with the current health care organisation and lack of trust in politicians. Compared to the general public, our study sample was older (73.3% between 50 and 69 years) and more often chronically ill-factors associated with increased participation preferences in the literature.

CONCLUSION

Contrary to the identified preferences, participation opportunities in the German health care system are rare. Further research on participation preferences and structures that enable meaningful involvement are needed.

Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics

BACKGROUND

Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors.

METHODS

Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated.

RESULTS

Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9).

CONCLUSIONS

The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.

Reasons for endorsing or rejecting self-binding directives in bipolar disorder: a qualitative study of survey responses from UK service users

BACKGROUND

Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human rights.

METHODS

This qualitative study used data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision making for patients with bipolar disorder. We included participants who reported that they have been diagnosed with bipolar disorder by a professional (doctor or psychiatrist). In a previous study, quantitative analysis of a closed question about self-binding directives had shown endorsement among a high proportion of participants with bipolar disorder who completed the survey. In this study, we did a thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was done within a multidisciplinary team, including team members with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methods associated with all these areas of expertise were used in the thematic analysis to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues.

FINDINGS

Between Oct 23, 2017, and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 individuals (154 men, 400 women, 11 transgender or other), predominantly white British, providing free-text answers to the open question. 463 (82%) of the 565 participants endorsed self-binding directives, of whom 411 (89%) describing a determinate shift to distorted thinking and decision making when unwell as their key justification. Responses indicating ambivalence (37 [7%) of the 565 responses) were dominated by logistical concerns about the drafting and implementation of self-binding directives, whereas those who rejected self-binding directives (65 [12%] of the 565 responses) cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights.

INTERPRETATION

This study is, to our knowledge, the first large study assessing the reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health services as well as advance decision-making practice and policy, and might help address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations.

FUNDING

The Wellcome Trust.

Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis

BACKGROUND

Disparities in involuntary psychiatric hospitalisation between population subgroups have been identified in adults, but little is known about the factors associated with involuntary hospitalisation in children or adolescents. We did a systematic review, meta-analysis, and narrative synthesis to investigate the social and clinical factors associated with involuntary psychiatric hospitalisation among children and adolescents.

METHODS

We searched MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials for studies of any type up to July 22, 2020, that compared the characteristics of voluntary and involuntary psychiatric inpatients (mean age of sample ≤18 years). We synthesised results using random effects meta-analysis on unadjusted data and by narrative synthesis. Heterogeneity between studies was calculated using I2. This study is registered on PROSPERO, CRD42020099892.

FINDINGS

23 studies from 11 countries were included in the systematic review and narrative synthesis, of which 19 studies (n=31 212) were included in the meta-analysis. On meta-analysis, involuntary rather than voluntary hospitalisation of minors was associated with a diagnosis of psychosis (eight studies; odds ratio 3·63, 95% CI 2·43-5·44, p<0·0001), substance misuse (five studies; 1·87, 1·05-3·30, p=0·032), or intellectual disability (four studies; 3·33, 1·33-8·34, p=0·010), as well as presenting with a perceived risk of harm to self (eight studies; 2·05, 1·15-3·64, p=0·015) or to others (five studies; 2·37, 1·39-4·03, p=0·0015). Involuntary hospitalisation was also found to be associated with being aged 12 years or older (three studies; 3·57, 1·46-8·73, p=0·0052) and being from a Black rather than a White ethnic group (three studies; 2·72, 1·88-3·95, p<0·0001). There was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 51·3% to 92·3%). Narrative synthesis found that more severe illness and poorer global functioning was associated with involuntary hospitalisation.

INTERPRETATION

Over-representation of involuntary psychiatric hospitalisation in certain groups might begin in childhood, potentially establishing a cycle of inequality that continues into adulthood. Further research into the systemic factors underlying these health-care inequalities and the barriers to accessing less coercive psychiatric treatment is urgently required, with specific consideration of racial and ethnic factors.

FUNDING

UK National Institute for Health Research and Wellcome Trust.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders

The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.

Methods

Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.

Results

An increment of involuntary hospitalizations was associated with male gender [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively].

Conclusions

The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Coping with Criticism and Embracing Change—Further Reflexions on the Debate on a Mental Health Care System without Coercion

In August 2019, a manuscript was published in this journal that aimed at imagining a mental health care system that renounces the judicial control to better focus on the will and preferences of those who require support. Alternative scenarios for dealing with risk, inpatient care, and police custody were presented that elicited strong and emotionally laden reactions. This article adds further reflections to this debate, aiming at contributing explanations for this unsettlement. A productive notion of criticism is discussed, and ways to achieve change toward a more human rights-oriented psychiatric practice are outlined.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.