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Steinert T, Wiedmer J. [Coercive Medication: Who, how, how Long? A Retrospective Chart Analysis in 6 Hospital Sites in Baden-Wuerttemberg]. PSYCHIATRISCHE PRAXIS 2024. [PMID: 38232744 DOI: 10.1055/a-2225-2162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Evaluation of the practice of coercive treatment in Germany after the Constiutional Court's decision in 2011. METHODS The documented emergency treatments (N=86) and judicially approved compulsory treatments (N=62) in 2015 and 2016 at 6 hospital locations in Baden-Württemberg were retrospectively analysed. RESULTS Patients had an average of 8 previous psychiatric hospitalisations with a cumulative duration of 645 days on average and 87% had a psychotic disorder. 34% received subsequent compulsory treatment within one year. The median duration of compulsory treatment was 15 days. 92% of the patients were taking an antipsychotic at discharge, 45% received further treatment in a day hospital or a psychiatric outpatient clinic. CONCLUSION Coercive treatment affects a relatively small, chronically severely ill group of patients and is frequently recurrent among them. For considerable part, no consecutive treatment setting can be established after discharge.
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Affiliation(s)
- Tilman Steinert
- Klinik für Psychiatrie und Psychotherapie I der Universität Ulm, Forschung und Lehre, Zentren für Psychiatrie Südwürttemberg, Ravensburg
| | - Jana Wiedmer
- Allgemeinpsychiatrie, ZfP Südwürttemberg, Bad Schussenried
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Krückl JS, Moeller J, Imfeld L, Schädelin S, Hochstrasser L, Lieb R, Lang UE, Huber CG. The association between the admission to wards with open- vs. closed-door policy and the use of coercive measures. Front Psychiatry 2023; 14:1268727. [PMID: 37953938 PMCID: PMC10634515 DOI: 10.3389/fpsyt.2023.1268727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Psychiatric treatment on a ward with open-door policy is associated with reduced numbers of coercive measures. The effect of the door policy of previous stays, however, has not been investigated. Methods The data set consisted of 22,172 stays by adult inpatients in a psychiatric university hospital between 2010 and 2019. Pairs of consecutive stays were built. The outcome variable was the occurrence of coercive measures during the second stay. Results Compared to treatments on wards with a closed-door policy at both stays, treatments on wards with an open-door policy at the second stay had smaller odds for coercive measures (OR ranging between 0.09 and 0.33, p < 0.01). In addition, coercive measures were more frequent in treatment histories where patients previously treated on a closed ward were admitted to a ward with an open-door policy and subsequently transferred to a ward with a closed-door policy at the second stay (OR=2.97, p = 0.046). Discussion Treatment under open-door policy is associated with fewer coercive measures, even in patients with previous experience of closed-door settings. The group of patients who were admitted to a ward with an open-door, then transmitted to a ward with a closed-door policy seem to be prone to experience coercive measures. Clinical strategies to keep these patients in treatment in an open-door setting could further reduce coercive measures.
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Affiliation(s)
- Jana S. Krückl
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Julian Moeller
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Lukas Imfeld
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Sabine Schädelin
- Department Clinical Research, c/o University Hospital Basel, Basel, Switzerland
| | - Lisa Hochstrasser
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Roselind Lieb
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Undine E. Lang
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Christian G. Huber
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
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Choy O. Nutritional factors associated with aggression. Front Psychiatry 2023; 14:1176061. [PMID: 37415691 PMCID: PMC10320003 DOI: 10.3389/fpsyt.2023.1176061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/16/2023] [Indexed: 07/08/2023] Open
Abstract
Although the vast majority of patients in forensic psychiatry are treated using pharmacological agents, clinical and ethical concerns about their use have led to the consideration of alternative strategies to reduce aggression that is common in forensic psychiatric settings. One non-invasive and benign biologically-based treatment approach involves nutrition. This article provides a mini-review of the recent evidence on four salient nutritional factors associated with aggressive behavior, namely omega-3 fatty acids, vitamin D, magnesium, and zinc. The current evidence base indicates that lower omega-3 levels are associated with increased aggression. Although research on vitamin D and zinc in relation to aggressive behavior is more limited, there is initial evidence that they are negatively associated with aggression in healthy participants and in psychiatric samples. The relationship between magnesium and aggression varies depending on how magnesium is assessed. Findings from experimental trials reveal that nutritional intervention in the form of omega-3 supplementation has the potential to serve as an effective mode of treatment, with effects that can last beyond the intervention period. There is also support for the utility of nutrition to improve our understanding of how social processes are linked to aggression. In light of the nascent, but promising findings on the role of nutritional factors on aggressive behavior, directions for future research are discussed.
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Shi XL, Li LY, Fan ZG. Psychiatrists’ occupational stigma conceptualization, measurement, and intervention: A literature review. World J Psychiatry 2023; 13:298-318. [PMID: 37383285 PMCID: PMC10294130 DOI: 10.5498/wjp.v13.i6.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/05/2023] [Accepted: 05/11/2023] [Indexed: 06/19/2023] Open
Abstract
Psychiatrists require frequent contact with and treatment of patients with mental illnesses. Due to the influence of associative stigma, psychiatrists may also be targets of stigma. Occupational stigma warrants special consideration because it significantly affects psychiatrists' career advancement, well-being, and their patients’ health. Given that there is no complete summary of this issue, this study reviewed the existing literature on psychiatrists' occupational stigma to clearly synthesize its concepts, measurement tools, and intervention strategies. Herein, we emphasize that psychiatrists’ occupational stigma is a multifaceted concept that simultaneously encompasses physically, socially, and morally tainted aspects. Currently, standardized methods to specifically measure psychiatrists’ occupational stigma are lacking. Interventions for psychiatrists’ occupational stigma may consider the use of protest, contact, education, comprehensive and systematic methods, as well as the use of psychotherapeutic approaches. This review provides a theoretical basis for the development of relevant measurement tools and intervention practices. Overall, this review seeks to raise public awareness of psychiatrists' occupational stigma, thereby promoting psychiatric professionalism and reducing its stigma.
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Affiliation(s)
- Xiao-Li Shi
- School of Education, Jilin International Studies University, Changchun 130000, Jilin Province, China
| | - Lu-Yao Li
- School of Education, Jilin International Studies University, Changchun 130000, Jilin Province, China
| | - Zhi-Guang Fan
- School of Education, Jilin International Studies University, Changchun 130000, Jilin Province, China
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Brenig D, Gade P, Voellm B. Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings? - A systematic review of the literature. BMC Psychiatry 2023; 23:246. [PMID: 37046228 PMCID: PMC10099889 DOI: 10.1186/s12888-023-04714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/24/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Inpatient violence is a relevant issue in forensic psychiatric settings. Relevant guidelines recommend that restrictive measures are to be used exclusively if de-escalation and other preventive strategies have failed and there is a risk of harm to patients or staff if no action is taken. However, restrictive measures are untherapeutic and can be harmful. In order to enable staff to intervene before inpatient violence or other serious incidents occur and thus to avoid restrictive measures, mental health staff training programs including de-escalation components are being adopted in general as well as forensic mental health settings. There is growing evidence for the efficacy of mental health staff training in de-escalation techniques in the field of general psychiatry. However, there are no reviews evaluating the effectiveness of these interventions in reducing violent incidents in forensic psychiatric settings. Here we present the first literature review on the effectiveness staff training in de-escalation techniques in the field of forensic psychiatry. METHOD We searched relevant databases for original research on the effectiveness of reducing violence in forensic psychiatric settings. Studies were included if they investigated staff training programs with de-escalation techniques in forensic mental health settings. RESULTS A total of 5 relevant studies were identified. None of the studies was a randomized controlled trial. Four studies were before and after comparisons without control group. A one group post-test-only design was used in one study. Methodological quality was low. The maximum sample size was 112 participants. Results indicated no relevant impact of mental health staff training in de-escalation techniques on the rate of violent incidents in forensic psychiatric wards. However, staff seemed to feel safer following the training. Results have to be interpreted cautiously due to several methodological and content-related limitations. DISCUSSION Evidence for the effectiveness of staff training in de-escalation techniques on reducing verbal and physical aggression in forensic settings remains very limited. The existing definitions of terms like de-escalation, de-escalation training and de-escalation techniques in the healthcare context appear rather vague. Although some positive changes are reported across a variety of outcome measures it remains unclear to what extent staff training in de-esclation techniques contributes to a reduction in aggressive incidents and restrictive measures in forensic psychiatry. The clinical implications of this review are therefore limited. Yet, an important implication for future research is that a more comprehensive approach might prove worthwhile. Conducting a further review integrating a wide range of complex interventions aimed at the reduction of inpatient violence rather than focusing on de-escalation only, might be a worthwhile approach.
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Affiliation(s)
- Daniel Brenig
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany.
| | - Pauline Gade
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany
| | - Birgit Voellm
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany
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Tseligkaridou G, Egger ST, Spiller TR, Schneller L, Frauenfelder F, Vetter S, Seifritz E, Burrer A. Relationship between antipsychotic medication and aggressive events in patients with a psychotic disorder hospitalized for treatment. BMC Psychiatry 2023; 23:205. [PMID: 36978013 PMCID: PMC10052831 DOI: 10.1186/s12888-023-04692-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Disruptive and aggressive behavior is frequent in patients with a psychotic disorder; furthermore, it is a recurrent reason for compulsory admission. Even during treatment, many patients continue to show aggressive behavior. Antipsychotic medication is posed to have anti-aggressive properties; its prescription is a common strategy for the treatment (and prevention) of violent behavior. The present study aims to investigate the relation between the antipsychotic class, according to the dopamine D2-Receptor binding affinity (i.e., "loose" - "tight binding"), and aggressive events perpetrated by hospitalized patients with a psychotic disorder. METHODS We conducted a four-year retrospective analysis of legally liable aggressive incidents perpetrated by patients during hospitalization. We extracted patients' basic demographic and clinical data from electronic health records. We used the Staff Observation Aggression Scale (SOAS-R) to grade the severity of an event. Differences between patients with a "loose" or "tight-binding" antipsychotic were analyzed. RESULTS In the observation period, there were 17,901 direct admissions; and 61 severe aggressive events (an incidence of 0.85 for every 1,000 admissions year). Patients with a psychotic disorder perpetrated 51 events (incidence of 2.90 for every 1,000 admission year), with an OR of 15.85 (CI: 8.04-31.25) compared to non-psychotic patients. We could identify 46 events conducted by patients with a psychotic disorder under medication. The mean SOAS-R total score was 17.02 (2.74). The majority of victims in the "loose-binding" group were staff members (73.1%, n = 19), while the majority of victims in the "tight-binding" group were fellow patients (65.0%, n = 13); (X2(3,46) = 19.687; p < 0.001). There were no demographic or clinical differences between the groups and no differences regarding dose equivalents or other prescribed medication. CONCLUSIONS In aggressive behaviors conducted by patients with a psychotic disorder under antipsychotic medication, the dopamine D2-Receptor affinity seems to have a high impact on the target of aggression. However, more studies are needed to investigate the anti-aggressive effects of individual antipsychotic agents.
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Affiliation(s)
- Georgia Tseligkaridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Stephan T Egger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Tobias R Spiller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Lena Schneller
- Legal and Compliance, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Fritz Frauenfelder
- Department of Nursing, Therapies and Social Work, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Vetter
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Achim Burrer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
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Spießl H. [Hospital Security by Security Officers?]. PSYCHIATRISCHE PRAXIS 2022; 49:342-344. [PMID: 36198320 DOI: 10.1055/a-1875-0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Flammer E, Eisele F, Hirsch S, Steinert T. Increase in coercive measures in psychiatric hospitals in Germany during the COVID-19 pandemic. PLoS One 2022; 17:e0264046. [PMID: 36044407 PMCID: PMC9432719 DOI: 10.1371/journal.pone.0264046] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To examine whether the pandemic in 2020 caused changes in psychiatric hospital cases, the percentage of patients exposed to coercive interventions, and aggressive incidents. Methods We used the case registry for coercive measures of the State of Baden-Wuerttemberg, comprising case-related data on mechanical restraint, seclusion, physical restraint, and forced medication in each of the State’s 31 licensed hospitals treating adults, to compare data from 2019 and 2020. Results The number of cases in adult psychiatry decreased by 7.6% from 105,782 to 97,761. The percentage of involuntary cases increased from 12.3 to 14.1%, and the absolute number of coercive measures increased by 4.7% from 26,269 to 27,514. The percentage of cases exposed to any kind of coercive measure increased by 24.6% from 6.5 to 8.1%, and the median cumulative duration per affected case increased by 13.1% from 12.2 to 13.8 hrs, where seclusion increased more than mechanical restraint. The percentage of patients with aggressive incidents, collected in 10 hospitals, remained unchanged. Conclusions While voluntary cases decreased considerably during the pandemic, involuntary cases increased slightly. However, the increased percentage of patients exposed to coercion is not only due to a decreased percentage of voluntary patients, as the duration of coercive measures per case also increased. The changes that indicate deterioration in treatment quality were probably caused by the multitude of measures to manage the pandemic. The focus of attention and internal rules as well have shifted from prevention of coercion to prevention of infection.
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Affiliation(s)
- Erich Flammer
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
- Centers for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Frank Eisele
- Centers for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
- Centers for Psychiatry Suedwuerttemberg, Biberach, Germany
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
- Centers for Psychiatry Suedwuerttemberg, Ravensburg, Germany
- Department Psychiatry, Tuebingen University, Tuebingen, Germany
- * E-mail:
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Steinert T, Hirsch S, Flammer E. [Effects of the Decision of the German Constitutional Court on mechanical restraint in 2018 : Coercive measures in the psychiatric hospitals in Baden-Wuerttemberg in 2019 compared to the years 2015-2017]. DER NERVENARZT 2022; 93:706-712. [PMID: 35303128 DOI: 10.1007/s00115-022-01267-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/29/2022]
Abstract
On 23 July 2018 the German Constitutional Court decided that mechanical restraint in psychiatric patients with 5 or 7‑point mechanical restraint lasting longer than 30 min requires a judicial authorization. On the same day, the German Association for Psychiatry and Psychotherapy (DGPPN) published guidelines on the prevention of coercion and violence. Together, this can be considered as the strongest intervention to reduce coercion on a national level worldwide. The registry for coercive measures in the Federal State of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2015 to 2017 compared to 2019 among a total of 438,003 admissions. The percentage of patients subjected to any kind of freedom-restricting coercion (restraint or seclusion) decreased from 6.7% (average 2015-2017) to 5.8% in 2019 (p < 0.001). Effects were strongest in patients with organic (F0) and schizophrenic disorders (F2). The percentage of patients subjected to mechanical restraint decreased from 4.8% to 3.6% in 2019, and the percentage of mechanical restraints less than 30 min increased from 1.8% to 10.5%. Vice versa, the percentage of patients subjected to seclusion increased from 2.9% to 3.3%. The median cumulated duration of restraint and seclusion per affected case decreased from 12.7h to 10.9 h (median). The intervention was probably responsible for a reduction of the percentage of cases subjected to coercive measures by about 13% and a reduction of the duration of these measures per affected case by about 14%.
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Affiliation(s)
- Tilman Steinert
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland.
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland.
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Deutschland.
- , Weingartshofer Str. 2, 88214, Ravensburg, Deutschland.
| | - Sophie Hirsch
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Biberach, Deutschland
| | - Erich Flammer
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland
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Flammer E, Hirsch S, Steinert T. Effect of the introduction of immediate judge's decisions in 2018 on the use of coercive measures in psychiatric hospitals in Germany: a population-based study. THE LANCET REGIONAL HEALTH. EUROPE 2021; 11:100233. [PMID: 34778858 PMCID: PMC8577163 DOI: 10.1016/j.lanepe.2021.100233] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion. Methods We analysed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2017 compared to 2019 among a total of 233,0273 admissions. Findings The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001). Interpretation There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions. Funding The registry is funded by the Ministry of Social Welfare and Integration.
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Affiliation(s)
- Erich Flammer
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany.,Tuebingen University, Dept Neurology
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany.,Tuebingen University, Dept Psychiatry
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