Patient characteristics and symptoms associated with perceived coercion during hospital treatment

Investigating the Associations between Patient-Reported Quality of Care and Perceived Coercion: A Norwegian Cross-Sectional Study

Patient perspectives on the quality of care received are fundamental to mental health care. This study aimed to investigate the association between patient-reported mental health care quality, perceived coercion, and various demographic, clinical, and ward-related factors. Using a cross-sectional design, data were collected from 169 patients in Norwegian mental health wards using the quality in psychiatric care-inpatient (QPC-IP) instrument and experienced coercion scale (ECS). The analysis revealed a consistent pattern in which patients with higher perceived coercion consistently rated lower quality on all QPC-IP dimensions. The significant findings of the multiple regression models further supported this association. Beyond coercion, the factors influencing quality ratings include self-reported treatment results, participation in treatment planning, and knowledge of complaint procedures. Emphasizing the pivotal role of coercion in enhancing mental health care quality, these findings contribute to a nuanced understanding of patient experiences and underscore the importance of patient participation in mental health care improvement efforts.

How do decision making and fairness mediate the relationship between involuntary hospitalisation and perceived coercion among psychiatric inpatients?

BACKGROUND

Coercion perceived by psychiatric inpatients is not exclusively determined by formal measures such as involuntary admissions, seclusion or restraint, but is also associated with patients' characteristics and professionals' attitude.

AIMS

This study examined how inpatients' involvement in the decision making process, the respect of their decision making preference, and their feeling of having been treated fairly mediate the relationship between involuntary hospitalisation and perceived coercion both at admission and during hospital stay.

METHODS

Mediation analysis were performed in order to study the relationship between involuntary hospitalisation and perceived coercion among 230 patients, voluntarily and involuntarily admitted in six psychiatric hospitals.

RESULTS

32.2% of the participants were involuntarily hospitalised. Taken individually, stronger participants' involvement in decision making process, better respect for their decision making preference and higher level of perceived fairness partially mediated the relationship between involuntary hospitalisation and perceived coercion by reducing the level of the latter both at admission and during the hospitalisation. In multiple mediator models, only involvement and respect played an important role at admission. During the hospitalisation, perceived fairness was the most relevant mediator, followed by involvement in decision making.

CONCLUSIONS

During psychiatric hospitalisation patients' involvement in decision making, respect of their decision making preference and perceived fairness determined the relationship between involuntary hospitalisation and perceived coercion, but not in the same way at admission and during the stay. Involving patients in decision making and treating them fairly may be more relevant than taking account of their decision making preference in order to reduce perceived coercion.

Revisiting the psychometric properties of the McArthur admission experience survey: Validating the Portuguese version using a bifactor approach

Cultural factors play a significant role in shaping the perception of coercion during psychiatric admissions. The present study aimed to assess the psychometric properties of the Portuguese Admission Experience Survey(P-AES). The study employed a cross-sectional approach in five psychiatric departments in three regions of Portugal. A total of 208 patients participated in the survey. Reliability was assessed through internal consistency and test-retest procedures. Internal validity was analyzed using a two-parameter logistic item response model, exploring three models, including a bifactor model. Convergent validity was determined by correlating AES scores with the Coercion Ladder (CL), Client Assessment of Satisfaction (CAT), and Global Assessment of Functioning (GAF) scale. Discriminatory power was assessed by comparing scores between patients with voluntary and involuntary admission status. The P-AES demonstrated satisfactory internal consistency and test-retest reliability. The bifactor model exhibited superior fit compared to the one-factor and three-factor models. Correlations between P-AES and CL, as well as CAT scores, indicated good convergent validity. Additionally, P-AES scores were notably higher in patients with compulsory psychiatric hospital admission compared to those admitted voluntarily, confirming its discriminatory power. The bifactor model suggests that all three domains of the AES should be used to measure the subjective experience of coercion.

Association between perceived coercion and perceived level of information in involuntarily admitted patients: Results from a multicenter observational study in Switzerland

BACKGROUND

Involuntary admissions (IA) to psychiatric hospitals are controversial because they interfere with people's autonomy. In some situations, however, they appear to be unavoidable. Interestingly, not all patients perceive the same degree of coercion during IA. The aim of this study was to assess whether the level of knowledge about one's own IA is associated with perceived coercion.

METHODS

This multicenter observational study was conducted on n = 224 involuntarily admitted patients. Interviews were conducted at five study centers from April 2021 to November 2021. The Macarthur Admission Experience Survey was administered to assess perceived coercion. Knowledge of involuntary admission, perceptions of information received, and attitudes towards legal aspects of involuntary admission were also assessed.

RESULTS

We found that higher levels of knowledge about IA were negatively associated with perceived coercion at admission. Perceived coercion did not differ between study sites. Only half of the patients felt well informed about their IA, and about a quarter found the information they received difficult to understand.

DISCUSSION

Legislation in Switzerland requires that patients with IA be informed about the procedure. Strategies to improve patients' understanding of the information given to them about IA might be helpful to reduce perceived coercion, which is known to be associated with negative attitudes towards psychiatry, a disturbed therapeutic relationship, avoidance of psychiatry, and the risk of further coercion.

What is the role of gender in perceived coercion during psychiatric admission?

OBJECTIVES

This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission.

METHODS

We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020.

RESULTS

Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation.

CONCLUSIONS

Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.

Predicting coercion during the course of psychiatric hospitalizations

BACKGROUND

Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail.

METHODS

In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland's largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure.

RESULTS

Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity.

CONCLUSIONS

Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.

Selection bias in clinical studies of first-episode psychosis: A follow-up study

OBJECTIVES

Selection bias is a concern in studies on psychotic disorders due to high dropout rates and many eligibility criteria for inclusion. We studied how representative the first-episode psychosis study sample in the Turku Early Psychosis Study (TEPS) was.

METHODS

We screened 3772 consecutive admissions to the clinical psychiatric services of Turku Psychiatry, Finland, between October 2011 and June 2016. A total of 193 subjects had first-episode psychosis and were suitable for TEPS. Out of 193 subjects, 101 participated (PA) and 92 did not participate (NPA) in TEPS due to refusal or contact problems. We retrospectively used patient register data to study whether NPA and PA groups differed in terms of clinical outcomes during 1-year follow-up.

RESULTS

In overall sample, the NPA group had a significantly higher rate of discontinuation of clinical treatment than the PA group (48.9 % vs 29.7 %, p = 0.01). In the hospital-treated subsample chi-square tests did not indicate statistically significant differences between the NPA and PA groups in the rate of involuntary care (69.7 % vs 62.7 %, p = 0.34), coercive measures (36.0 % vs 22.7 %, p = 0.06), and readmissions during the follow-up (41.5 % vs 33.8 %, p = 0.31), respectively.

CONCLUSION

The differences in clinical outcomes and treatment characteristics in the non-participating and participating groups were relatively modest. The results do not support a major sample selection bias that would complicate the interpretation of results in this first-episode psychosis study.

Risk assessment and its influencing factors of involuntary admission in patients with mental disorders in Shanghai, China

BACKGROUND

The 'risk criterion' for involuntary admission (IA) has been adopted by Mental Health Law of the People's Republic of China since 2013. How the new legal regulation influences daily practices in psychiatric institutes are still unclear.

AIMS

The present study sought to explore the application of risk criterion in IA cases; especially risk assessed by psychiatrists at admission and its influencing factors.

METHOD

Socio-demographic and clinical data including risk assessment for admission of 3,529 involuntary admitted patients from two typical hospitals in Shanghai from 2013 to 2014 were consecutively collected. Personal information of psychiatrists who made admission assessment was collected separately.

RESULTS

Among the 3,529 cases, 1,890 (53.6%) were admitted because of actual harmful behaviors to self or others, while 1,639 (46.4%) were admitted with some kinds of risk, but 265 (7.5%) were admitted without any records on risk assessment checklists. Patients who were unemployed, of younger age, single status, diagnosed with schizophrenia were more likely to be admitted without any records on the checklist. Male gender, older age, and lower professional title are influencing factors that psychiatrists made no risk assessment records.

CONCLUSIONS

The vast majority (92.5%) of risk assessment in IA patients were qualified in our study. In order to protect the legal rights of patients better, operational and reasonable procedures of risk assessment should be developed, such include more detailed rules to IA, systematic training of psychiatrists on IA assessment, mechanism improving doctor-patient relationship, and alternative mental health services for patients and so on.

Effect of standardized post-coercion review on subjective coercion: Results of a randomized-controlled trial

Background

Post-coercion review has been increasingly regarded as a useful intervention in psychiatric inpatient setting. However, little is known about its effect on perceived coercion.

Methods

A multicenter, two-armed, randomized controlled trial was conducted, aiming at analyzing the effect of post-coercion review on perceived coercion. People with severe mental disorders, who experienced at least one coercive measure during inpatient treatment, were randomized using Zelen’s design to an intervention group receiving standardized post-coercion review, or a control group treated as usual. The MacArthur admission experience scale (AES) and the coercion ladder (CL) were used to assess perceived coercion during inpatient treatment. The coercion experience scale (CES) measured experienced coercion during the coercive intervention. Analyses of covariance were performed to determine group differences.

Results

Of 422 randomized participants, n = 109 consented to participate in the trial. A restricted intention-to-treat analysis of all individuals who consented revealed no significant effect of the intervention on perceived coercion. A significant interaction effect between the factors gender and intervention on the AES scores was found. Sensitivity analysis revealed significant effects of the intervention on both AES and CL scores and an interaction effect between intervention and gender, indicating a higher efficacy in women. No effect of the intervention on CES scores was found.

Conclusions

Standardized post-coercion review sessions did not alleviate the subjective perception of coercion in the total sample. However, post hoc analysis revealed a significant effect of the intervention in women. Results indicate the need to further address gender-specific issues related to coercion.

The association between perceived coercion on admission and formal coercive practices in an inpatient psychiatric setting

Involuntary care is a feature of mental health services around the world. In addition to involuntary admission and treatment, specific coercive practices include seclusion and physical restraint. Our study aimed to determine the relationships, if any, between these practices and perceived coercion on admission among psychiatry inpatients in Ireland, as well as any relationships between perceived coercion on admission and variables such as age, gender and diagnosis. We included 107 psychiatry inpatients aged 18 years or over who were admitted to the acute psychiatry admission units in Tallaght University Hospital and Connolly Hospital, Dublin, Ireland over a 30-month period between September 2017 and February 2020. Over a quarter (27.1%) of participating patients had involuntary status; nine (8.4%) had experienced at least one episode of seclusion, and ten (9.3%) had experienced at least one episode of restraint. Perceived coercion on admission was significantly associated with involuntary status and female gender; perceived negative pressures on admission were significantly associated with involuntary status and positive symptoms of schizophrenia; perceived procedural injustice on admission was significantly associated with fewer negative symptoms, involuntary status, cognitive impairment and female gender; and negative affective reactions to hospitalisation on admission were significantly associated with birth in Ireland and being employed. Total score across these four subscales was significantly associated with involuntary status and positive symptoms, and had borderline significant associations with birth in Ireland, being employed and female gender. Overall, perceived coercion on admission, assessed in retrospect by the patient, is more closely associated with involuntary status and symptoms than it is with subsequent formal coercive practices, such as seclusion and restraint. The role of gender merits particular attention in future research, especially in relation to procedural injustice on admission and perceived coercion on admission.

Effects of Recovery-Orientation on the Use of Forced Medication and Maximum Daily Drug Dose: The "Weddinger Modell"

Objective: The aim of the present study was to analyze the effects of the implementation of the Recovery-orientated psychiatric care concept "Weddinger Modell" on the incidence of forced medication, the total number of forced medication incidents per affected case, the maximum dose of a singular forced medication and the maximum voluntary daily drug dose of different psychotropic drugs administered during an inpatient stay. Methods: This retrospective case-control study included 234 patients. A pre/post-comparison of patients on two acute psychiatric wards before (control group, n = 112) and after (intervention group, n = 122) the implementation of the Weddinger Modell in 2010 was performed. Patient data was selected at two reporting periods before and at two reporting periods after 2010. Results: No significant differences were found in the incidence of forced medication and the total number of forced medications. A significant reduction of the maximum forced medication dose of haloperidol in the intervention group was seen. Furthermore, the analysis of the intervention group showed a significant reduction of the maximum voluntary daily drug doses of clozapine, haloperidol and risperidone. Discussion: The results indicate that the implementation of the Weddinger Modell had no effect on the incidence of forced medication, but it can help to improve the approach to psychotropic drugs. Despite the reduction of mechanical coercive measures by the model, as shown in a previous study, there is no increase in forced medications or administered drug doses. Focus on Recovery helps in reducing coercion in acute psychiatric care.

Patient satisfaction and acute psychiatric inpatient treatment

Background: Patient satisfaction (PS) with treatment is one of different outcome- and quality measures used by health care providers worldwide to improve service. We report from a study of patients admitted to the Department of Acute Psychiatry at the Oslo University Hospital where we investigated PS and difference between genders, days of hospital stay, diagnostic groups, voluntary-and involuntary admitted patients according to hospital records and perceived voluntary-and involuntary admittance.Materials and methods: All admitted patients during a 9-month period in 2014 were asked to participate by written consent. We used The Psychiatric Inpatient Questionnaire (PIPEQ), a self-report survey validated for assessment post-discharge. Analyses were conducted for a general dimension of PS and individual questions. A user representative was a part of the study from the beginning.Results: A total of 357 patients were asked and 256 consented. Results show that 68% were over all satisfied and 14% dissatisfied. Highest PS was found for cooperation with relatives and lowest for influence on choice of treatment and medication. We found no significant difference in PS between men and women, but patients with a personality disorder and with short stay were less satisfied. PS was significantly less for those perceiving involuntary admission regardless of legal status.Conclusion: The PIPEQ gives important input of patient's experience with the delivery of care. Answers range from very much satisfied to not at all depending on what was asked for. Exploring PS provides valuable information for quality improvements for different patient groups.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care

OBJECTIVE

Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients.

METHODS

Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables.

RESULTS

Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001).

DISCUSSION

These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

An exploration of perceived coercion into psychological assessment and treatment within a low secure forensic mental health service

Psychologists working within forensic mental health (FMH) services face challenges around supporting clients' informed consent when engaging in psychological assessment and treatment. Given that there is little research in this area, this qualitative study interviewed ten forensic inpatients from a low secure FMH service, to determine the impact of any perceived coercion to engage with psychologists. Interviews were transcribed and subject to Thematic Analysis. Three over-arching themes emerged from the analysis: 'Awareness of Coercive Power', 'Experiencing and Responding to Coercion' and 'Psychological Treatment is Helpful, But…'. Participants perceived coercion to engage with psychologists. Perceived coercion led to psychological distress, wanting to resist, and superficial engagement. Despite this, therapeutic alliance was established with the psychologist but the quality of the therapeutic alliance was compromised. The findings have implications for psychologists working in FMH services. Suggestions for reducing perceived coercion and future directions for research are discussed.

Factors associated with satisfaction of inpatient psychiatric care: a cross country comparison

BACKGROUND

Patient satisfaction is a key indicator of inpatient care quality and is associated with clinical outcomes following admission. Different patient characteristics have been inconsistently linked with satisfaction. This study aims to overcome previous limitations by assessing which patient characteristics are associated with satisfaction within a large study of psychiatric inpatients conducted across five European countries.

METHODS

All patients with a diagnosis of psychotic (F2), affective (F3) or anxiety/somataform (F4) disorder admitted to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and the UK were included. Data were collected from medical records and face-to-face interviews, with patients approached within 2 days of admission. Satisfaction with inpatient care was measured on the Client Assessment of Treatment Scale.

RESULTS

Higher satisfaction scores were associated with being older, employed, living with others, having a close friend, less severe illness and a first admission. In contrast, higher education levels, comorbid personality disorder and involuntary admission were associated with lower levels of satisfaction. Although the same patient characteristics predicted satisfaction within the five countries, there were significant differences in overall satisfaction scores across countries. Compared to other countries, patients in the UK were significantly less satisfied with their inpatient care.

CONCLUSIONS

Having a better understanding of patient satisfaction may enable services to improve the quality of care provided as well as clinical outcomes for all patients. Across countries, the same patient characteristics predict satisfaction, suggesting that similar analytical frameworks can and should be used when assessing satisfaction both nationally and internationally.

Different forms of informal coercion in psychiatry: a qualitative study

Objectives

The objective of the study was to investigate how mental health professionals describe and reflect upon different forms of informal coercion.

Results

In a deductive qualitative content analysis of focus group interviews, several examples of persuasion, interpersonal leverage, inducements, and threats were found. Persuasion was sometimes described as being more like a negotiation. Some participants worried about that the use of interpersonal leverage and inducements risked to pass into blackmail in some situations. In a following inductive analysis, three more categories of informal coercion was found: cheating, using a disciplinary style and referring to rules and routines. Participants also described situations of coercion from other stakeholders: relatives and other authorities than psychiatry. The results indicate that informal coercion includes forms that are not obviously arranged in a hierarchy, and that its use is complex with a variety of pathways between different forms before treatment is accepted by the patient or compulsion is imposed.

Caregivers' Attitude and Perspective on Coercion and Restraint Practices on Psychiatric Inpatients from South India

Background:

Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date.

Aims:

Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients.

Methodology:

This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers’ attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables.

Results:

The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients.

Conclusion:

Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

Manic episode, aggressive behavior and poor insight are significantly associated with involuntary admission in patients with bipolar disorders

Objectives

Serious mental illnesses, such as bipolar disorders and schizophrenia, are closely associated with involuntary admission. Many studies have focused on involuntary admission in people with schizophrenia, but little is known about the factors associated with involuntary admission in Chinese patients with bipolar disorders. This study aimed to investigate socio-demographic and clinical factors associated with involuntary admission in Chinese patients with bipolar disorders.

Methods

In this multi-center cross-sectional survey in China, a total of 155 newly admitted patients with bipolar disorders were consecutively recruited from 16 psychiatric institutions from 15 March to 14 April, 2013. Patients' socio-demographic and clinical data were collected from their medical records. The Modified Overt Aggression Scale and the Insight and Treatment Attitudes Questionnaire were used to measure patients' level of aggression and insight of current psychiatric illness.

Results

The prevalence of involuntary admission was 52% in this sample of Chinese inpatients with bipolar disorders. In multiple logistic regression, a high level of aggression (odds ratio (OR) = 2.48), diagnosis of manic episode (OR = 3.65), poor insight (OR = 7.52), and a low level of education (OR = 3.13) were significantly associated with involuntary admission.

Conclusion

Manic episode, aggressive behavior, and poor insight were the significant contributing factors to involuntary admission in Chinese patients with bipolar disorders.

Perceived Coercion Among Patients Admitted in Psychiatric Wards: Italian Results of the EUNOMIA Study

The decision to use coercive measures (restraint, seclusion and forced medication) in psychiatric practice is controversial in mental health care. The EUNOMIA study was funded by the European Commission and carried out in 11 countries in order to develop European recommendations for good clinical practice on the use of coercive measures. The aim of the study is to identify sociodemographic and clinical predictors of the levels of perceived coercion in a sample of Italian patients with severe mental disorders at hospital admission. A total of 294 patients were recruited in five Italian psychiatric hospitals and screened with the MacArthur Perceived Coercion Scale to explore the levels of perceived coercion. Patients were assessed three times: within the first seven days after admission as well as after 1 and 3 months. At each time point, data on changes of perceived coercion, assessed by the Cantril Ladder of Perceived Coercion Scale, information on coercive measures received during hospitalization and the levels of satisfaction with the received treatments were collected. According to the multivariable regression model, being compulsorily admitted (OR: 2.5; 95% CI: 1.3-3.3, p < .000), being male (OR: 0.7; 95% CI: 0.9-1.4; p < .01), being older (OR: 0.03; 95% CI: 0.01-0.06) and less satisfied with received treatments (OR: -0.2; 95% CI: -0.3 to -0.1; p < .05) are all associated with higher levels of perceived coercion, even after controlling for the use of any coercive measure during hospitalization. Satisfaction with received treatment predicts the levels of perceived coercion and this should represent an important challenge for mental health professionals.

How dangerousness evolves after court-ordered compulsory psychiatric admission: explorative prospective observational cohort study

BACKGROUND

Compulsory admission is commonly regarded as necessary and justified for patients whose psychiatric condition represents a severe danger to themselves and others. However, while studies on compulsory admissions have reported on various clinical and social outcomes, little research has focused specifically on dangerousness, which in many countries is the core reason for compulsory admission.AimsTo study changes in dangerousness over time in adult psychiatric patients admitted by compulsory court order, and to relate these changes to these patients' demographic and clinical characteristics.

METHOD

In this explorative prospective observational cohort study of adult psychiatric patients admitted by compulsory court order, demographic and clinical data were collected at baseline. At baseline and at 6 and 12 month follow-up, dangerousness was assessed using the Dangerousness Inventory, an instrument based on the eight types of dangerousness towards self or others specified in Dutch legislation on compulsory admissions. We used descriptive statistics and logistic regression to analyse the data.

RESULTS

We included 174 participants with a court-ordered compulsory admission. At baseline, the most common dangerousness criterion was inability to cope in society. Any type of severe or very severe dangerousness decreased from 86.2% at baseline to 36.2% at 6 months and to 28.7% at 12 months. Being homeless at baseline was the only variable which was significantly associated with persistently high levels of dangerousness.

CONCLUSIONS

Dangerousness decreased in about two-thirds of the patients after court-ordered compulsory admission. It persisted, however, in a substantial minority (approximately one-third).Declaration of interestNone.

Clinician attitude and perspective on the use of coercive measures in clinical practice from tertiary care mental health establishment - A cross-sectional study

BACKGROUND

Use of coercive measures in mental health care is an important issue for research. There are scarce data available on perception and attitudes toward coercion among Indian psychiatrists.

AIMS

This study aims to study psychiatrists' attitude and perspectives on the use of coercive measure in clinical practice against the background of family and patients' opinion.

MATERIALS AND METHODS

The study was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India. Psychiatrist in charge of the inpatients was asked about their general opinion on coercion and was administered Staff Attitude to Coercion Scale questionnaire. Findings were compared to previously published studies on patients' opinion and family opinion in the same sample. Data were analyzed using descriptive statistics.

RESULTS

Coercion proved to be a common measure applied in nearly 70% of the patients studied. The 189 psychiatrists participating in the study almost all perceived coercion as care, protection and safety, and as protection from dangerous situations. About 66% of psychiatrists perceived physical and chemical restraint (sedation) as necessary and acceptable in acute emergency care. One-third of the psychiatrists felt their patients lost autonomy, dignity, and the possibility of interpersonal contact. The same amount agreed that some patients could have been treated with less restriction and fewer coercive measures.

CONCLUSION

Psychiatrists felt that physical and chemical restraints are necessary and acceptable in acute emergencies. Most psychiatrists considered coercion as a caring protective and safety attitude but also acknowledged its potential negative impact on patient dignity and therapeutic relationships.

Reduction of Involuntary Admissions in Patients With Severe Psychotic Disorders Treated in the ACCESS Integrated Care Model Including Therapeutic Assertive Community Treatment

Objective: The ACCESS treatment model offers assertive community treatment (ACT) embedded in an integrated care program to patients with severe psychotic disorders. Compared to standard care, it proved to be more effective in terms of service disengagement and other outcomes in patients with psychotic disorders over 12, 24, and 48 months. Many patients with severe mental disorders experience involuntary admissions which can be potentially traumatic. In this study, we assessed the effect of ACT on reducing involuntary admissions over an observation period of 4 years. Method: One hundred seventy-one patients treated in ACCESS were included in this study. The primary outcome was rate of involuntary admissions during 48 months. Secondary outcomes were differences between those with and without involuntary admissions in the 2 years prior to ACCESS regarding change of psychopathology, severity of illness, psychosocial functioning, quality of life, satisfaction with care, medication non-adherence, and service-disengagement. Results: Of 171 patients, 58 patients (33.9%) were involuntarily admitted to hospital in the past 2 years before entry. During the 4 years of treatment, 16 patients (9.4%) were involuntarily admitted to hospital which was a significantly lower rate compared to the 2 years before inclusion in ACCESS (p < .001). Comparing the two groups, larger improvements in severity of illness (p = .004) and functional status (p = .043) were detected in the group with no history of involuntary admissions. At 4-year follow-up, of the remaining patients, 69.2% (n = 81) were full adherent (p < .001), compared to 18.9% (n = 31) at baseline with no differences between the two groups over the study period (p = .25). Over 4 years, only 13 patients (13.2%) were service-disengaged due to non-practical reasons. Conclusions: In this long-term study, we were able to demonstrate a reduction in involuntary admissions in four treatment years compared to the 2 years prior to admission to the ACCESS model in patients with severe and mostly multiphase schizophrenia spectrum disorders and affective disorders with psychotic features. This may help prevent patients from suffering from a potentially traumatic experience during treatment in the psychiatric system. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT01888627.

The Admission Experience Survey Italian Version (I-AES): A factor analytic study on a sample of 156 acute psychiatric in-patients

Coercive treatments are often regarded as an inevitable and yet highly debated feature of psychiatric care. Perceived coercion is often reported by patients involuntarily committed as well as their voluntary counterparts. The Admission Experience Survey (AES) is a reliable tool for measuring perceived coercion in mental hospital admission. We developed the Italian AES (I-AES) through translation back-translation and administered it to 156 acutely hospitalized patients (48% women, 69% voluntarily committed) in two university hospitals in Rome (Policlinico Umberto I, Sant'Andrea Hospital). A principal component analysis (PCA) with equamax rotation was conducted. The I-AES showed good internal consistency (Cronbach's alpha = 0.90); Guttmann split-half reliability coefficient was 0.90. AES total score significantly differed between voluntary and involuntary committed patients (5.08 ± 4.1 vs. 8.1 ± 4.9, p < .05). PCA disclosed a three-factor solution explaining 59.3 of the variance. Some discrepancies were found between the factor structure of the I-AES and the original version. I-AES total score was positively associated with numbers of previous involuntarily hospitalization (r = 0.20, p < .05) and psychiatric symptoms' severity (r = 0.22, p < .02). I-AES and its proposed new factor structure proved to be reliable to assess perceived coercion in mental hospital admission. Consequently, it may represent a helpful instrument for the study and reduction of patients' levels of perceived coercion.

[Coercive interventions: historical summary and review of subjective experience]

Psychiatric treatment has always been associated with violence and coercion. Involuntary admission and coercive measures are still frequently occurring components in everyday clinical practice.Up to 15% of psychiatric inpatients experience coercive treatment at least once during hospital stay. Particularly patients suffering from schizophrenia, organic mental disorders and mania have a high risk for such incidents.There is an ongoing intense debate on the need and justification of coercive measures, although most clinicians and scientists currently agree that there is no alternative. Several investigations have shown that seclusion and mechanical restraint go along with physical and psychological problems affecting both, patients and staff. However, it was possible to identify aspects that could be improved: Maintaining an objective and professional communication during coercive treatment seems just as important as making comprehensible decisions. Alternative treatment options should be focus of further investigations.

How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study

BACKGROUND

The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication.

METHODS

The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document.

RESULTS

Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times.

CONCLUSION

The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

Restraint prevalence and perceived coercion among psychiatric inpatients from South India: A prospective study

BACKGROUND

The Indian Mental Health Care Act 2017 (MHCA -2017) advocates the duty to provide treatment in the least coercive manner. Little data exists on how Indian patients perceive coercion in medical settings.

AIMS

To study the prevalence of restraint in a Indian psychiatric inpatient unit, and to examine the level of perceived coercion correlating to various forms of restraint.

METHODOLOGY

This is a hospital based prospective observational study. Two hundred patients were recruited through computer generated random number sampling. In eligible subjects, demographic and clinical data, restraints used and assessments related to perceived coercion were completed within 3 days of admission. Perceived coercion was reassessed at the time or within 3 days before discharge.

RESULTS

In 66.5% one or more restraint measures were used, physical restraints in 20%, chemical restraints in 58%, seclusion in 18%, and involuntary medication in 32%. ECT is associated with the lowest level of perceived coercion followed by isolation/seclusion, chemical restraint, involuntary medication and physical restraint. Male gender, being married, rural background, low socioeconomic status, having a mood disorder, and alcohol or drug dependence was associated with an increased risk of physical or chemical restraint. Having a mood disorder, being from a rural area and a lower socioeconomic status was associated with being subjected to more than one form of coercion.

CONCLUSION

Restraint measures are more prevalent in psychiatric hospital care in India than in Europe. Physical restraint is particularly associted with higher perceived coercion.

A cross-sectional study of experienced coercion in adolescent mental health inpatients

Background

Involuntary care and coercive measures are frequently present in mental healthcare for adolescents. The purpose of this study was to examine to what extent adolescents perceive or experience coercion during inpatient mental health care, and to examine predictors of experienced coercion.

Methods

A cross-sectional sample of 96 adolescent inpatients from 10 Norwegian acute and combined (acute and sub-acute) psychiatric wards reported their experienced coercion on Coercion Ladder and the Experienced Coercion Scale in questionnaires. Staff reported use of formal coercion, diagnoses, and psychosocial functioning. We used two tailed t-tests and mixed effects models to analyze the impact from demographics, alliance with parents, use of formal coercion, diagnostic condition, and global psychosocial functioning.

Results

High experienced coercion was reported by a third of all patients. In a mixed effects model, being under formal coercion (involuntary admission and / or coercive measures); a worse relationship between patient and parent; and lower psychosocial functioning, significantly predicted higher experienced coercion. Twenty-eight percent of the total sample of patients reported a lack of confidence and trust both in parents and staff.

Conclusions

Roughly one third of patients in the sample reported high experienced coercion. Being under formal coercion was the strongest predictor. The average scores of experienced coercion in subgroups are comparable with adult scores in similar care situations. There was one exception: Adolescents with psychosis reported low experienced coercion and almost all of them were under voluntary care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3208-5) contains supplementary material, which is available to authorized users.

Involuntary admission in Norwegian adult psychiatric hospitals: a systematic review

Background

It is an important objective of the psychiatric services to keep the use of involuntary procedures to a minimum, as the use of coercion involves clinical, ethical, and legal issues. It has been claimed that Norway has a relatively high rate of involuntary admissions. We reviewed the peer-reviewed literature on the use of involuntary admission in Norway, with the purpose of identifying the current state of knowledge and areas in need of further research.

Methods

A systematic review following the PRISMA statement was conducted. We searched the electronic databases PsycInfo, PubMed, Web of Science, CINAHL, and Embase for studies relating to involuntary admission to Norwegian adult psychiatric hospitals published in the period 1 January 2001 to 8 August 2016. The database searches were supplemented with manual searches of relevant journals, reference lists, and websites.

Results

Seventy-four articles were included and grouped into six categories based on their main topics: Patients’ experiences, satisfaction and perceived coercion (21 articles), the Referral and admission process (11 articles), Rates of admission (8 articles), Characteristics of the patients (17 articles), Staff attitudes (9 articles), and Outcomes (8 articles). Four of the included articles described intervention studies. Fifty-seven of the articles had a quantitative design, 16 had a qualitative design, and one a mixed-method design. There was a broad range of topics that were studied and considerable variation in study designs. The findings were largely in line with the international literature, but the particularities of Norwegian legislation and the Norwegian health services were reflected in the literature. The four intervention studies explored interventions for reducing rates of involuntary admission, such as modifying referring routines, improving patient information procedures, and increasing patients’ say in the admission process, and represent an important avenue for future research on involuntary admission in Norway.

Conclusions

The review suggests that Norway has a relatively high rate of involuntary admissions. The identified studies represent a broad mix of topics and designs. Four intervention studies were identified. More studies with strong designs are needed to bring research on involuntary admission in Norway to a next level.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0189-z) contains supplementary material, which is available to authorized users.

Perceived coercion in psychiatric hospital admission: validation of the French-language version of the MacArthur Admission Experience Survey

BACKGROUND

The MacArthur Admission Experience Survey (AES) is a widely used tool to evaluate the level of perceived coercion experienced at psychiatric hospital admission. The French-language AES was prepared using a translation/back-translation procedure. It consists of 16 items and 3 subscores (perceived coercion, negative pressures and voice). This study aimed to assess the psychometric properties of the French-language AES.

METHODS

152 inpatients were evaluated. Reliability was estimated using internal consistency coefficients and a test-retest procedure. Internal validity was assessed using a two-parameter logistic item response model. Convergent validity was estimated using correlations between the AES scores and the Coercion Ladder (CL), the Coercion Experience Scale (CES) and the Global Assessment of Functioning (GAF) scale. Discriminatory power was evaluated by comparing the scores of patients undergoing voluntary or compulsory admission.

RESULTS

The French-language AES showed good internal consistency and test-retest reliability. Internal validity of the three-factor model was excellent. Correlations between AES and CL, CES and GAF scores suggested good convergent validity. AES scores were significantly higher among patients subject to compulsory psychiatric hospital admission than among those admitted voluntarily.

CONCLUSIONS

Overall, the French-language version of the AES demonstrated very good psychometric proprieties.

Involuntary admission and treatment experiences of persons with schizophrenia: Implication for the Mental Health Care Bill 2016

BACKGROUND

Involuntary admission and treatment experiences may affect the attitude of patients toward subsequent treatment and further outcomes. This issue has received relatively less research attention in persons with schizophrenia from developing countries.

METHODOLOGY

In this hospital based prospective observational study, involuntary admission, treatment and coercion experiences among 76 persons with schizophrenia, admitted under special circumstances of Mental Health Act -1987 were studied. Demographic, clinical and assessments related to coercion experiences were completed within 3days of admission. In 67 subjects, a reassessment was done just before discharge.

RESULTS

Mean (SD) age was 33.1 (±11.5) years, 47.8% (n=32) were males and 32.8% (n=22) were married. 92.5% (n=62) had absent insight at admission. Mean CGI Severity score at admission was 6.27 (±0.53). Mean (SD) score on MacArthur Perceived Coercion Scale at admission was 4.04 (±1.61). This reduced to 2.43(±1.91) [p<0.001]. This reduction correlated significantly with improvements in global functioning (r=-0.40, p <0.001), insight level(r=0.26, p<0.001) and as well as symptom severity(r=0.36, p<0.001). At discharge, 70% (n=47) patients reported that their involuntary admission was justified.

CONCLUSION

Perceived coercion in schizophrenia though common clinical phenomena, it is a dynamic state which reduces over course of treatment. At Discharge, majority reported that their admission was justified, even though they were admitted involuntarily. The study underlines the need for a standardized rule of conduct based coercive practice in psychiatry.

A systematic review of factors associated with service user satisfaction with psychiatric inpatient services

BACKGROUND

Satisfaction is seen as an indicator of the quality of mental health services and has been related to outcomes and compliance with treatment. The current review seeks to examine the factors relating to satisfaction with inpatient services.

METHOD

A search was conducted of PsycInfo, Web of Science, Cinahl, Embase and Medline databases. Screening resulted in 32 papers being included in the review. Papers were subject to quality assessment using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Review of the included papers suggested factors relating to satisfaction could be broadly classified as either service user or service/ward related. Service user related factors included findings that satisfaction was higher when service users were admitted voluntarily. Service related factors included findings that satisfaction was negatively associated with experiences of coercion and positively associated with being on an open ward.

CONCLUSION

It appears that coercion has a key role in ratings of satisfaction. Additionally, service users reported an impact of staff relationships, and the ward environment. Satisfaction is associated with a range of factors, an awareness of which will allow for the development of quality services that meet the needs of service users.

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.

Clinical correlates and predictors of perceived coercion among psychiatric inpatients: A prospective pilot study

BACKGROUND

The current Mental Health Care Bill (MHCB) -2013 in India advocates least restrictive alternatives (LRA) in psychiatric treatment. However, we have little evidence on patient's perspectives of coercion and LRA.

METHODOLOGY

This was a hospital-based prospective pilot study. 170 subjects chosen by computer-generated random number sampling were screened. In 83 eligible subjects, all assessments including coercion assessment were completed within 3 days of admission and in 75 subjects reassessment was done within 3 days of discharge.

RESULTS

Perceived coercion as measured by the MacArthur Perceived Coercion Scale (MPCS) decreased significantly from 3.72±1.98 at admission to 1.77±1.8 (<0.001) at discharge. This was accompanied by significant increase in global functioning, insight score (from 1.5±1.0 to 3.8±1.1; p<0.001) and as well as decrease in symptom severity (CGI-S) (from 5.9±1.1 to 1.8±1.9; p<0.001). Coercion is predicted by family type, employment status, socio economic status, severity of illness and level of insight. 87% patients reported that their admission was justified even though many felt coerced during hospital stay.

CONCLUSION

Coercion is a dynamic state and changes with treatment and care. Clinical care may result in an improvement in global functioning, insight as well as in reduction in severity of illness consequently leading to less coercion. During the time of discharge, majority of patients reported that their admission was justified, even though they felt coerced during hospital stay and agreed for treatment against their will within a safe, standardised coercive practice.

Psychiatric patients' perception of physical restraint

OBJECTIVE

To investigate psychiatric patients' subjective perception during and after belt fixation.

METHOD

All patients who were involuntarily admitted and physically restrained at a psychiatric intensive care unit within an 18-month study period were analysed. Ratings were obtained at four visits when questioning was possible.

RESULTS

Within a heterogeneous diagnostic sample of 47 patients, only 12 patients were eligible to participate during belt fixation. After cessation of fixation, eight patients lacked any memory of restraint, while 36 could be questioned. Visual analogue scale median scores indicated powerlessness and depressiveness rather than anxiety and aggression. Patients' acceptance of the coercive measure was significantly higher (P = 0.003), while patients' memory was significantly lower than expected (P < 0.001). About 50% of the patients documented high perceived coercion, and post-traumatic stress disorder (PTSD) could be supposed in a quarter of the restrained individuals. Subjective perceptions concerning fixation showed no significant changes over time. Results showed high interindividual variability.

CONCLUSION

Visual analogue scale revealed that belt fixation seemed to be forgotten or accepted in the majority of patients, probably due to psychiatric intensive care, psychopharmacological treatment and clinical improvements. The responses of a quarter of the patients assessed before discharge may be in accordance with symptoms of PTSD.

Stigma in the context of schools: analysis of the phenomenon of stigma in a population of university students

BACKGROUND

Students have stereotyped views about people with mental illness. In particular, they believe that these persons are incurable, dangerous, unpredictable and responsible for their condition. This study aims to investigate the levels of public stigma in an Italian university population.

METHODS

The Attribution Questionnaire 27 - Italian Version (AQ-27-I) was administered to a sample of students from the Faculty of Medicine and Surgery of the University of Modena and Reggio Emilia. After examining the psychometric characteristics of the AQ-27-I (Cronbach's Alpha and Confirmatory Factor Analysis), multiple linear regression analyses were carried out to identify the predictors of stigmatizing attitudes in this population.

RESULTS

Three hundred and eleven students completed the questionnaire, with a response rate of 32.81 % (out of the 948 contacted by email). The AQ-27-I showed good psychometric properties with an α = .68, and the fit indices of the models that partially supported the factor structure and paths. The two variables identified as possible predictors of stigmatizing attitudes (total score of AQ-27-I) were age and time spent reading newspapers.

CONCLUSIONS

Antistigma campaigns are needed in university contexts, targeted in particular to students in health professions.

One-year incidence and prevalence of seclusion: Dutch findings in an international perspective

BACKGROUND

The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law.

OBJECTIVE

The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data.

METHODS

2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed.

RESULTS

12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia.

CONCLUSIONS

Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.

Predictors of Seclusion or Restraint Use Within Residential Treatment Centers for Children and Adolescents

This study identified predictors of seclusion or restraint use among licensed and/or accredited residential treatment centers (RTCs) for children and youth in the United States responding to a federally-sponsored survey of mental health services. 693 licensed and/or accredited child and adolescent RTCs responded to questions about the demographic and admission status of clients served on an identified date, services offered, size, ownership, funding, and their use of seclusion or restraint practices within the preceding 12 months. Logistic regression was used to determine factors predicting facility use of seclusion or restraint. A large majority of licensed and/or accredited child and adolescent RTCs (82 %) reported using seclusion or restraint in the prior year. Contrary to prior research, individual patient characteristics (percent of males, minorities, and involuntary admissions) did not predict the use of coercive techniques. Instead facility and funding variables accounted for approximately 27 % of the variance in the use of seclusion or restraint. Larger, privately-owned RTC's funded primarily through public monies and which offered medication and programming for SED youth were more likely to endorse having used seclusion or restraint in the previous year. Despite visible policy and advocacy efforts to reduce seclusion and restraint use over the past decade, a majority of licensed and/or accredited RTCs for children and adolescents report using such practices. Findings emphasize the importance of examining facility-level variables in predicting their use, and highlight the disconnect between nationally espoused goals and current practices regarding coercive techniques in child and adolescent RTCs.

Longer term outcomes of voluntarily admitted service users with high levels of perceived coercion

Voluntarily admitted service users can report levels of perceived coercion comparable to those admitted involuntarily, yet little is known of this groups longer term outcome. The 'coerced voluntary' had a score of 4 or above on the MacArthur perceived coercion scale and one year after discharge, they had a better therapeutic relationship compared to involuntarily admitted service users. There was no difference between the coerced voluntary, uncoerced voluntary and involuntary groups in engagement, satisfaction and functioning.

Caregivers' perceptions of coercion in psychiatric hospital admission

While knowledge on service users' perspective on their admissions to psychiatric wards has improved substantially in the last decade, there is a paucity of knowledge of the perspectives of caregivers. This study aimed to determine caregiver's perception of the levels of perceived coercion, perceived pressures and procedural justice experienced by service users during their admission to acute psychiatric in-patient units. The perspective of caregivers were then compared to the perspectives of their related service users, who had been admitted to five psychiatric units in Ireland. Caregivers were interviewed using an adapted version of the MacArthur admission experience interview. Sixty-six caregivers participated in this study and the majority were parents. Seventy one percent of service users were admitted involuntarily and nearly half had a diagnosis of schizophrenia or schizoaffective disorder. Caregivers of involuntarily admitted individuals perceived the service users' admission as less coercive than reported by the service users. Caregivers also perceived a higher level of procedural justice in comparison to the level reported by service users. Reducing the disparity of perceptions between caregivers and service users could result in caregivers having a greater understanding of the admission process and why some service users may be reluctant to be admitted.

EPA guidance on how to improve the image of psychiatry and of the psychiatrist

Stigma against mental illness and the mentally ill is well known. However, stigma against psychiatrists and mental health professionals is known but not discussed widely. Public attitudes and also those of other professionals affect recruitment into psychiatry and mental health services. The reasons for this discriminatory attitude are many and often not dissimilar to those held against mentally ill individuals. In this Guidance paper we present some of the factors affecting the image of psychiatry and psychiatrists which is perceived by the public at large. We look at the portrayal of psychiatry, psychiatrists in the media and literature which may affect attitudes. We also explore potential causes and explanations and propose some strategies in dealing with negative attitudes. Reduction in negative attitudes will improve recruitment and retention in psychiatry. We recommend that national psychiatric societies and other stakeholders, including patients, their families and carers, have a major and significant role to play in dealing with stigma, discrimination and prejudice against psychiatry and psychiatrists.

Preventing Compulsory Admission to Psychiatric Inpatient Care: Perceived Coercion, Empowerment, and Self-Reported Mental Health Functioning after 12 Months of Preventive Monitoring

OBJECTIVE

To evaluate the effects of a preventive monitoring program targeted to reduce compulsory rehospitalization and perceived coercion in patients with severe mental disorder. We analyze patient outcomes in terms of perceived coercion, empowerment, and self-reported mental health functioning at 12 months.

METHODS

The program consists of individualized psychoeducation, crisis cards and, after discharge from the psychiatric hospital, a 24-month preventive monitoring. In total, 238 psychiatric inpatients who had had compulsory admission(s) during the past 24 months were included in the trial. T1-assessment 12 months after baseline was achieved for 182 patients.

RESULTS

Study participants reported lower levels of perceived coercion, negative pressures, and process exclusion, a higher level of optimism, and a lesser degree of distress due to symptoms, interpersonal relations, and social role functioning (significant time effects). However, improvements were not confined to the intervention group, but seen also in the treatment-as-usual group (no significant group or interaction effects). Altered perceptions were linked to older age, shorter illness duration, female sex, non-psychotic disorder, and compulsory hospitalization not due to risk of harm to others.

CONCLUSION

Our findings suggest that changes in the subjective perspective were fueled primarily by participation in this study rather than by having received the specific intervention. The study contributes to a better understanding of the interaction between "objective" measures (compulsory readmissions) and patients' perceptions and highlights the need for treatment approaches promoting empowerment in individuals with a history of involuntary psychiatric hospitalizations.

Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study

PURPOSE

This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries.

METHODS

Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect.

RESULTS

The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model.

CONCLUSIONS

The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

Patient experiences of autonomy and coercion while receiving legal leverage in forensic assertive community treatment

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.

Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness

Compulsory admission to psychiatric inpatient treatment can be experienced as disempowering and stigmatizing by people with serious mental illness. However, quantitative studies of stigma-related emotional and cognitive reactions to involuntary hospitalization and their impact on people with mental illness are scarce. Among 186 individuals with serious mental illness and a history of recent involuntary hospitalization, shame and self-contempt as emotional reactions to involuntary hospitalization, the cognitive appraisal of stigma as a stressor, self-stigma, empowerment as well as quality of life and self-esteem were assessed by self-report. Psychiatric symptoms were rated by the Brief Psychiatric Rating Scale. In multiple linear regressions, more self-stigma was predicted independently by higher levels of shame, self-contempt and stigma stress. A greater sense of empowerment was related to lower levels of stigma stress and self-contempt. These findings remained significant after controlling for psychiatric symptoms, diagnosis, age, gender and the number of lifetime involuntary hospitalizations. Increased self-stigma and reduced empowerment in turn predicted poorer quality of life and reduced self-esteem. The negative effect of emotional reactions and stigma stress on quality of life and self-esteem was largely mediated by increased self-stigma and reduced empowerment. Shame and self-contempt as reactions to involuntary hospitalization as well as stigma stress may lead to self-stigma, reduced empowerment and poor quality of life. Emotional and cognitive reactions to coercion may determine its impact more than the quantity of coercive experiences. Interventions to reduce the negative effects of compulsory admissions should address emotional reactions and stigma as a stressor.

Perceived coercion in voluntary hospital admission

The legal status of service users admitted to psychiatric wards is not synonymous with the level of coercion that they can perceive during the admission. This study aimed to identify and describe the proportion of individuals who were admitted voluntarily but experienced levels of perceived coercion comparable to those admitted involuntarily. Individuals admitted voluntarily and involuntarily to three psychiatric hospitals were interviewed using the MacArthur Admission Experience Interview and the Structured Clinical Interview for DSM-IV diagnoses. One hundered sixty-one individuals were interviewed and 22% of the voluntarily admitted service users had levels of perceived coercion similar to that of the majority of involuntarily admitted service users. Voluntarily admitted service users who experienced high levels of perceived coercion were more likely to have more severe psychotic symptoms, have experienced more negative pressures and less procedural justices on admission. Individuals brought to hospital under mental health legislation but who subsequently agreed to be admitted voluntarily and those treated on a secure ward also reported higher levels of perceived coercion. It needs to be ensured that if any service user, whether voluntary or involuntary, experiences treatment pressures or coercion that there is sufficient oversight of the practice, to ensure that individual's rights are respected.

Use of coercive measures in mental health practice and its impact on outcome: a critical review

Although coercive measures have always been part of the psychiatric armamentarium, the ethical dilemma between the use of a "therapeutic" coercion and the loss of patients' dignity is one of the major controversial issues in mental health research and practice. The aims of the present review are to explore the existing literature on predictors of use of coercive measures and to explore the relationship between coercive measures and patient outcome. A literature search was conducted using MEDLINE, PsychyINFO, Scopus, Web of Knowledge and the Cochrane Database. In all selected papers, references were cross-checked to identify other possible eligible papers. The use of coercive measures was predicted by patients' clinical and socio-demographic features, staff characteristics and ward-related factors. Coercive measures have only a limited impact on patients' clinical and social outcome. At the current level of knowledge, coercion is still a controversial issue in mental health practice. Only few studies with a solid methodology have been carried out. Large multicenter and rigorous studies, with long-term follow-ups, are highly needed.

Association between short-term structured risk assessment outcomes and seclusion

Research findings indicate that the symptoms and behaviour of acute psychiatric patients can fluctuate drastically within hours, and that structured daily risk assessments can reduce the risk of aggressive incidents and the duration of seclusion. The aim of this study was to investigate the validity of two structured observation tools, the Brøset Violence Checklist (BVC) and the Kennedy Axis V), as an aid in seclusion-related clinical decision-making. In this study, 7403 day-to-day risk assessments were collected over 10 725 admission days (72% of the maximum number of structured assessments). A total of 7055 daily assessment scores from 301 acute psychiatric patients were used for the multilevel analysis. The sample demonstrated that dynamic and static factors were related to seclusion. Dynamic factors included dysfunctional scores on the item 'confusion' of the Brøset Violence Checklist, and psychological impairment and impairment of social skills on the Kennedy Axis V. Static factors included non-Western descent, male sex, age less than 35 years, unmarried, and to some extent, a personality disorder. McFadden's pseudo R(2) value showed that most of the final model was related to the dynamic factors. We concluded that the incorporation of the BVC and the Kennedy Axis V into standard practice was helpful in identifying patients at high risk of seclusion.

Gender differences in coerced patients with schizophrenia

BACKGROUND

Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied.

METHODS

291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed.

RESULTS

When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men.

CONCLUSIONS

Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the "excitement/hostile" cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study

BACKGROUND

Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment.

AIMS

To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment.

METHOD

A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission.

RESULTS

A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement.

CONCLUSIONS

Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.