[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]

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Estimating costs of bedside assessment by a judge in each case of mechanical restraint in Germany after new legislation

Background

In 2018, the German Federal Constitutional Court decided that mechanical restraint is the most intrusive coercive measure and its use requires a judge's decision after bedside assessment if lasting longer than 30 min. Subsequently, legal changes were realized. The objective of our study was to determine the number of saved coercive episodes and saved hours in seclusion or restraint in 2019 compared to the average of the previous years, 2015-2017, as well as costs per saved episode, hour, and case saved from any coercive measure.

Methods

We used data from the Baden-Wuerttemberg case registry for coercive measures, covering all 32 psychiatric hospitals of the Federal State and 435,767 admissions in the study period. Time expenditure was calculated as 3.5 h with an average of 51.95 € per working hour on the side of the justice system and 1.5 h (45.94 €/h) on the side of the hospital per case.

Results

The number of coercive episodes decreased by 10.0% from 28,181 (average 2015-2017) to 25,371 (2019). The number of hours in seclusion or restraint decreased by 17.9% from 321,956 (2015-2017) to 264,423 (2019). This resulted in the cost of 872.33 € per saved episode and 42.61 € per saved hour in seclusion or restraint.

Conclusion

Given the correctness of our estimations, saving 1 h in coercion by less than 1 h of an expert's work might be justified from an ethical and economic perspective.

Law and psychiatry-current and future perspectives

We describe relevant interfaces between law and psychiatry and current ethical and legal views and changes within the past decades. Ideas of patient autonomy and patients' rights have been major drivers of changes in legal frameworks. We describe developments in the areas of patient information and informed consent, involuntary placement and involuntary treatment, use of coercive measures, forensic psychiatry, digital mental health, data privacy, physician liability, suicide, assisted suicide, euthanasia, end of life decision-making, advance directives, legal and illegal drugs, and delegation and substitution of professional activities. There is no unidirectional pathway between law and ethics. Views, conflicts, and requirements differ between countries and within countries and will need to be balanced according to the societies' changing values also in the future.

[Monitoring of coercive measures and compulsory treatment in Germany]

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