Changing aspects of psychiatric inpatient treatment. A census investigation in five European countries

The association between the admission to wards with open- vs. closed-door policy and the use of coercive measures

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.

Opportunities, risks and challenges in global mental health and population neuroscience: a case of Sino-German cooperation

Large scale prospective cohorts have now been established across several countries, and continents, and among the aims include an assessment of the developmental trajectory of mental disorders. This level of international cooperation helps transfer research findings to new social contexts as well as enabling an assessment of which findings can be replicated, and which interventions are most effective, in different social and cultural settings. However, data sharing across different regional and national health care systems requires a careful consideration of different standards in ethical research, data protection and patient care, including respect for patients' rights, in cooperating jurisdictions. In our review, we discuss ethical, legal and practical challenges associated with such cooperation with a focus on research participants, specifically patient recruitment, by considering the instance of China and Germany. Our broader aim is to promote international cooperation by identifying key challenges that arise in international cooperation, and to facilitate an exchange in relation to legal and practical approaches.

[Open doors in psychiatric hospitals : An overview of empirical findings]

BACKGROUND

Currently, it is a topic of debate whether psychiatric hospitals can and should be managed with a full open door policy. The revised legislation of public law for involuntary commitment explicitly allows or even encourages such practice in several German federal states. In parts of Austria, open doors are required for legal reasons. A systematic literature search was conducted for articles providing empirical data related to this issue.

METHOD

Literature search in PubMed augmented by a manual search in references of retrieved papers and reviews with similar objectives.

RESULTS

A total of 26 articles reporting empirical data could be identified. Most of these articles came from Germany or Switzerland. The majority were published within the past 5 years. The definition of "open doors" ranged from an only vaguely defined open door policy up to explicit set time periods with open doors. Some studies reported a decrease in coercive interventions. No study reported any associated adverse events resulting from open doors in psychiatric wards.

DISCUSSION

Generally, all studies had methodological weaknesses. Prospective randomized controlled studies or quasi-experimental studies are missing in the context of European healthcare systems. The risk of bias was considerable in most studies. A final conclusion regarding the possible extent of psychiatry with open doors and the associated risks is currently not possible. There is an urgent need for future high-quality prospective studies.

Patients' experiences of isolation in psychiatric inpatient care: Insights from a meta-ethnographic study

Historically, people with mental ill-health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill-health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients' experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta-ethnographic synthesis. The findings were twofold: 'being admitted to prison' and 'having access to shelter'. The experience of isolated care as prison-like symbolizes patients' longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill-health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self-stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.

Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals' and patients' view: a qualitative interview study

BACKGROUND

Treating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.

METHODS

Semi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.

RESULTS

The interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.

CONCLUSIONS

For psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders' suggestions also illustrate that fundamental clinical changes depend on resource investments which - at least at a certain point - might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

[The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study]

The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study Abstract.

INTRODUCTION

Psychiatric Special Observation (PSO) is an intervention often used by nurses to prevent service users of harming themselves or to protect others. The intervention ranges between control and therapy and is resource intensive. Despite the widespread use of PSO, there is still no data on the practice of the intervention in Switzerland.

AIM

What is the current practice of PSO in adults in psychiatric hospitals in the German-speaking part of Switzerland?

METHOD

Descriptive cross-sectional study. Nurses from inpatient psychiatric services in the German-speaking part of Switzerland completed a questionnaire based on a concept analysis of PSO.

RESULTS

538 questionnaires were analysed. PSO was more often conducted intermittent than as constant observation. In more than one out of four cases, suicidality reasoned as a cause for prescription. Nurses generally used standardized instruments to assess the risk of harming oneself or others. The duration of PSO lasted eight hours or more in three out of four cases. In every fifth case, there was no validation of the need of the intervention taking place during one shift. Nurses have a neutral attitude towards the intervention and are experiencing no or weak negative feelings during performance of PSO.

CONCLUSIONS

The results suggest that there is an inconsistent performance of PSO in Switzerland as well as in other countries. The validation of the need of the intervention is insufficient. To facilitate PSO as a justified performance, the preparation of an interprofessional guideline is recommended.

Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years

BACKGROUND

Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication.

METHOD

In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models.

RESULTS

In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; η_p²=0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; η_p²=0.70; odds ratio: 0.90).

CONCLUSION

This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

Involuntary admissions in Italy: the impact of seasonality

OBJECTIVE

The aim of this study is to assess the prevalence of involuntary admissions with regard to seasonality and clinical associated features, in a sample of patients admitted to a psychiatric unit in a period of 24 months.

METHODS

All subjects consecutively admitted to the Psychiatric Inpatient Unit of the San Luigi Gonzaga Hospital, Orbassano (University of Turin, Italy) from September 2013 to August 2015 were recruited. Socio-demographic and clinical characteristics were collected.

RESULTS

Seven hundred and thirty admissions in psychiatric ward were recognized. The prevalence of involuntary admission was 15.4%. Patients with involuntary hospitalizations showed a higher education level, a higher prevalence of admission in spring/summer with a significant peak in June, a longer duration of hospitalization and a lower suicide ideation. Among involuntary admissions, physical restraint and suicide attempts were more prevalent during spring compared to the other seasons.

CONCLUSIONS

Seasonality has an important role in the psychopathology of psychiatric disorders, particularly in bipolar and related disorder, and may represent an influencing factor in hospital admissions and hospitalizations. Seasonal pattern must be considered while managing diagnosis and treatment of mental disorders, with regard to prevention and psychoeducation of patients.

Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study

BACKGROUND

Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes.

METHODS

In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data.

FINDINGS

In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p<0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63).

INTERPRETATION

Locked doors might not be able to prevent suicide and absconding.

FUNDING

None.

"A world crazier than us": Vanishing social contexts and the consequences for psychiatric practice in contemporary Romania

Since the end of Communism, mental health care in Romania has increasingly sought to align its practices with idealized models of Western psychiatric practice. Much of this realignment has been made possible by accessing and integrating new pharmaceuticals into psychiatric hospital settings. Less straightforward have been the painful attempts to create a system modeled on international standards for training and certifying psychotherapists. Unfortunately, the political, economic, infrastructural, and epistemological environment of the Romanian mental health care system has prevented many other reforms. This paper examines the ironic trajectory that Romanian psychiatry has taken since the end of state socialism. Specifically, this paper shows how psychiatric practice in most places (outside of university-training hospitals) is increasingly disconnected from a concern with the social conditions that surround mental illness during a period when social upheaval is profoundly impacting the lives of many people who receive mental health care. Thus, as the contribution of social problems to the suffering of those with mental illnesses has increased, some Romanian mental health practitioners have moved away from a concern with these social problems under the guise of aligning their psychiatric practices with (imagined) Western standards of biomedical care. The paper provides a brief history of Romanian psychiatry and explores contemporary challenges and contradictions in many Romanian psychiatric treatment settings through the case study of a 31-year-old Romanian female diagnosed with paranoid schizophrenia.

Predictors of vocational status in schizophrenia patients--Results from the Polish nationwide survey

BACKGROUND

Steady employment constitutes one of most important aspects of functional recovery in schizophrenia. Therefore, there is a need for understanding clinical and demographic factors predicting vocational status in schizophrenia.

METHODS

Clinical and demographic data of 1,010 schizophrenia patients were gathered from public outpatient clinics. We compared patients who maintained employment between the diagnosis time point and the day of assessment, with the patients who were employed in the diagnosis time point but were unemployed on the day of assessment with respect to clinical and demographic variables.

RESULTS

Lower educational attainment, lower-income region of residence, medical comorbidities (obesity, diabetes and hypertension), first hospitalization at inpatient unit in comparison with the day hospital, higher total number of hospitalizations and the number of inpatient hospitalizations were found to serve as predictors of unemployment throughout the course of schizophrenia. After application of Bonferroni correction and logistic binary regression analysis, lower educational attainment, higher number of inpatient hospitalizations and obesity predicted unemployment.

CONCLUSION

Education, obesity and the number of inpatient hospitalizations seem to predict vocational outcome in schizophrenia. This study warrants further investigation of medical comorbidities in schizophrenia in terms of social consequences in order to indicate the direction of this relationship.

[Comorbid somatic illnesses in psychiatric inpatients - an analysis of administrative data]

PURPOSE

This study intended to analyze the prevalence of physical diagnoses at psychiatric inpatient hospital wards.

METHODS

For this purpose we used partially aggregated administrative data from routine diagnostic documentation of Austrian hospitals. All psychiatric and physical main and secondary diagnoses according to ICD-10 of all psychiatric inpatient units in Austria of the years 2007 were used.

RESULTS

Of 79,027 psychiatric hospital admissions 75,224 received a psychiatric and 3803 a somatic main diagnosis at discharge. Diseases of the vascular system (20 %) were the most frequent somatic diagnoses, followed by endocrine and metabolic diseases (16.4 %) and neurological diseases (14.4 %). Among patients suffering from schizophrenia, the most frequent physical diagnoses were endocrine and metabolic diseases. Among those with affective disorders, vascular diseases as well as endocrine and metabolic diseases were found most often.

CONCLUSIONS

Physical diagnoses are very common among psychiatric inpatients. Mass screening and specialized prevention programs should be evaluated regarding their effectiveness for this population.

[Psychiatry with open doors. Part 1: Rational for an open door for acute psychiatry]

Despite the reform efforts of the last decades modern acute psychiatry still stands between conflicting priorities in everyday practice. The protection of patient autonomy might conflict with a regulatory mandate of psychiatry in societal contexts and the necessity of coercive measures and involuntary treatment might become problematic with respect to presumed but contentious interests of the patient. The conflicts particularly concern questions of involuntary commitment, door closing, coercive and isolation measures. Research on the topic of therapeutic effectiveness of these practices is rare. Accordingly, the practice depends on the federal state, hospital and ward and is very heterogeneous. Epidemiological prognosis predicts an increase of psychiatric disorders; however, simultaneously in terms of medical ethics the warranty of patient autonomy, shared decision-making and informed consent in psychiatry become increasingly more important. This challenges structural and practical changes in psychiatry, particularly in situations of self and third party endangerment which are outlined and a rationale for an opening of the doors in acute psychiatric wards is provided.

Understanding psychiatric institutionalization: a conceptual review

BACKGROUND

Since Goffman's seminal work on psychiatric institutions, deinstitutionalization has become a leading term in the psychiatric debate. It described the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. Yet, there is a lack of clarity on what exactly the concept of institutionalization means in present-day psychiatry. This review aims to identify the meaning of psychiatric institutionalization since the early 1960s to present-day.

METHOD

A conceptual review of institutionalization in psychiatry was conducted. Thematic analysis was used to synthesize the findings.

RESULTS

Four main themes were identified in conceptualizing institutionalization: bricks and mortar of care institutions; policy and legal frameworks regulating care; clinical responsibility and paternalism in clinician-patient relationships; and patients' adaptive behavior to institutionalized care.

CONCLUSIONS

The concept of institutionalization in psychiatry reflects four distinct themes. All themes have some relevance for the contemporary debate on how psychiatric care should develop and on the role of institutional care in psychiatry.

The experience of working on a locked acute psychiatric ward

This study's aim was to elucidate health-care staff experience of working on a locked acute psychiatric ward. In many countries changes in health care has contributed to fewer beds available in inpatient care, and a concentration of patients with severe psychiatric conditions. This implies a changing work environment in acute psychiatric care. Qualitative interviews with health-care staff (n= 10) were carried out on a ward for patients with affective disorder and eating disorder in a Swedish hospital. Qualitative content analysis was used. Four themes were identified from the data: 'undergoing changes in care delivery', 'feeling a need for security and control', 'managing the demands at work' and 'feeling a sense of responsibility'. This study adds to earlier research into how a sense of responsibility can place a significant burden on health-care staff working on a locked psychiatric ward and also contribute to increased control of patients. This study also shows that relationships and power structures among health-care staff need to be addressed when organizational changes are made in care delivery. Further research is needed to reach a comprehensive understanding of care on locked acute psychiatric wards, including a development of nursing and medicine as knowledge domains in one common context.

Door locking and exit security measures on acute psychiatric admission wards

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

The relationship between substance use and exit security on psychiatric wards

AIM

In this paper we report on the rates of drug/alcohol use on acute psychiatric wards in relation to levels and intensity of exit security measures.

BACKGROUND

Many inpatient wards have become permanently locked, with staff concerned about the risk of patients leaving the ward and harming themselves or others, and of people bringing illicit substances into the therapeutic environment.

METHODS

In 2004/2005, a cross sectional survey on 136 acute psychiatric wards across three areas of England was undertaken. A comprehensive range of data including door locking and drug/alcohol use were collected over 6 months on each ward. In 2006, supplementary data on door locking and exit security were collected. Door locking, additional exit security measures and substance misuse rates of the 136 wards were analysed and the associations between these were investigated.

RESULTS

No consistent relationships were found with exit security features, intensity of drug/alcohol monitoring procedures, or the locking of the ward door. There were indications that use of breath testing for alcohol might reduce usage and that the use of 'sniffer' dogs was associated with greater alcohol use.

CONCLUSION

Greater exit security or locking of the ward door had no influence on rates of use of alcohol or illicit drugs by inpatients and thus cannot form part of any strategy to control substance use by inpatients. There are some grounds to believe that a greater use of screening might help reduce the frequency of alcohol/substance use on wards and may lead to a reduction in verbal abuse.

Psychiatric services for the "old" old

BACKGROUND

Few studies have specifically examined mental health service delivery to persons aged over 84 years, often described as the "old" old. Our aim was to compare mental health service provision in Australia to persons aged 85 years and over with the "young" old and other age groups. We hypothesized that the "old" old would differ from the "young" old (65-84 years) by diagnostic category, rates of specialist psychiatric hospital admission, and use of Medicare funded psychiatric consultations in the community.

METHODS

Mental health service delivery data for 2001-02 to 2005-06 was obtained from Medicare Australia on consultant psychiatrist office-based, home visit and private hospital services subsidized by the national healthcare program and the National Hospital Morbidity database for separations (admitted episodes of patient care) from all public and most private hospitals in Australia on measures of age, gender, psychiatric diagnosis, location and type of psychiatric care.

RESULTS

Use of specialist psychiatric services in the community per annum per 1000 persons declined with age in men and women from 137.28 and 191.87 respectively in those aged 20-64 years to 11.84 and 14.76 respectively in those over 84 years. However, men and women over 84 years received psychiatric home visits at 377% and 472% respectively of the rates of persons under 65. The annual hospital separation rate per 1000 persons for specialist psychiatric care was lowest in those aged over 84 (3.98) but for inpatient non-specialized psychiatric care was highest in those over 84 (21.20). Depression was the most common diagnosis in specialized psychiatric hospitalization in those aged over 84 while organic disorders predominated in non-specialized care in each age group over 64 years with the highest rates in those aged over 84.

CONCLUSION

Mental health service delivery to persons aged over 84 is distinctly different to that provided to other aged groups being largely provided in non-specialist hospital and residential settings.

The "social case": Illness, psychiatry, and deinstitutionalization in postsocialist Romania

In this article, I examine the use of an ad hoc medical category--the "social case"--by psychiatrists in contemporary Romania. "Social cases" receive intensive psychiatric care, usually through long institutional stays, remaining hospitalized because psychiatrists perceive them as too poor and, thus, "unfit" to survive without the welfare assistance provided by institutionalization. The "social case" label emerges at the intersection of (1) plans by the state to deinstitutionalize public mental health care, (2) the rise of a new class of downwardly mobile and increasingly poor formerly working-class people, and (3) the desire of psychiatrists to protect their patients in the face of neoliberal assaults on Romanian welfare state support for publicly funded mental health care. Disability status, illness categories, and everyday medical practices have become battlegrounds for struggles over medical understandings of the psychological distress and illnesses that grip what I call the "New Poor" in postsocialist Romania.

Locked doors in acute inpatient psychiatry: a literature review

Many acute inpatient psychiatric wards in the UK are permanently locked, although this is contrary to the current Mental Health Act Code of Practice. To conduct a literature review of empirical articles concerning locked doors in acute psychiatric inpatient wards, an extensive literature search was performed in SAGE Journals Online, EBM Reviews, British Nursing Index, CINAHL, EMBASE Psychiatry, International Bibliography of the Social Sciences, Ovid MEDLINE, PsycINFO and Google, using the search terms 'open$', 'close$', '$lock$', 'door', 'ward', 'hospital', 'psychiatr', 'mental health', 'inpatient' and 'asylum'. A total of 11 empirical papers were included in the review. Both staff and patients reported advantages (e.g. preventing illegal substances from entering the ward and preventing patients from absconding and harming themselves or others) and disadvantages (e.g. making patients feel depressed, confined and creating extra work for staff) regarding locked doors. Locked wards were associated with increased patient aggression, poorer satisfaction with treatment and more severe symptoms. The limited literature available showed the urgent need for research to determine the real effects of locked doors in inpatient psychiatry.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy

BACKGROUND

A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy.

METHOD

Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales.

RESULTS

Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions.

CONCLUSIONS

In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Safety and security in acute admission psychiatric wards in Ireland and London: a comparative study

AIMS AND OBJECTIVES

The comparative element of this study is to describe safety and security measures in psychiatric acute admission wards in the Republic of Ireland and London; to describe differences and similarities in terms of safety and security patterns in the Republic of Ireland and London; and to make recommendations on safety and security to mental health services management and psychiatric nurses.

BACKGROUND

Violence is a serious problem in psychiatric services and staff experience significant psychological reactions to being assaulted. Health and Safety Authorities in the UK and Ireland have expressed concern about violence and assault in healthcare, however, there remains a lack of clarity on matters of procedure and policy pertaining to safety and security in psychiatric hospitals.

DESIGN

A descriptive survey research design was employed.

METHODS

Questionnaires were circulated to all acute wards in London and in Ireland and the resulting data compared.

RESULTS

A total of 124 psychiatric wards from London and 43 wards from Ireland were included in this study and response rates of 70% (London) and 86% (Ireland) were obtained. Differences and similarities in safety and security practices were identified between London and Ireland, with Irish wards having generally higher and more intensive levels of security.

CONCLUSIONS

There is a lack of coherent policy and procedure in safety and security measures across psychiatric acute admission wards in the Republic of Ireland and London. Given the trends in European Union (EU) regulation, there is a strong argument for the publication of acceptable minimum guidelines for safety and security in mental health services across the EU.

RELEVANCE TO CLINICAL PRACTICE

There must be a concerted effort to ensure that all policy and procedure in safety and security is founded on evidence and best practice. Mental health managers must establish a review of work safety and security procedures and practices. Risk assessment and environmental audits of all mental health clinical environments should be mandatory.

The involuntary treatment of adolescent psychiatric inpatients--a nation-wide survey from Finland

This national cross-sectional study investigates the prevalence rates, regional differences and factors associated with the involuntary inpatient treatment of adolescents in Finland on a chosen day in 2000. The proportion of inpatients with involuntary legal status was 29.5% (n=82) giving a prevalence rate of 2.5 per 10,000/12-17 years old inhabitants. Forty-eight per cent of involuntarily inpatients were 16-17 years old and 62% had psychotic disorders. Twenty-six per cent of inpatients with involuntary legal status were voluntarily admitted. Regional differences of involuntary treatment were rather modest. Psychotic disorders, suicidal acts, and substance use disorders were independently associated with involuntary legal status. There is a need for further studies to investigate the long-term effects of involuntary treatment on the adolescents' subsequent well-being. Further studies on alternatives methods for involuntary treatment are warranted, likewise the clinical guidelines for involuntary treatment practices.

Characteristics and activities of acute psychiatric in-patient facilities: national survey in Italy

BACKGROUND

Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care.

AIMS

To survey the main characteristics of Italian public and private in-patient facilities for acute psychiatric disorders.

METHOD

Structured interviews were conducted with each facility's head psychiatrist in all Italian regions, with the exception of Sicily.

RESULTS

Overall, Italy (except Sicily) has a total of 4108 public in-patient beds in 319 facilities, with 0.78 beds for every 10,000 inhabitants, and 4862 beds in 54 private in-patient facilities, with 0.94 beds per 10,000 inhabitants. In 2001 the rates of psychiatric admissions and admitted patients per 10,000 inhabitants were 26.7 and 17.8 respectively. In the same year the percentage of involuntary admissions was 12.9%, for a total of 114,570 hospital days. Many in-patient facilities showed significant limitations in terms of architectural and logistic characteristics. Staffing showed a great variability among facilities.

CONCLUSIONS

The overall number of acute beds per 10,000 inhabitants is one of the lowest in Europe. The survey has provided evidence of two parallel systems of in-patient care, a public one and a private one, which are not fully interchangeable.

Psychiatric care behind locked doors. A study regarding the frequency of and the reasons for locked psychiatric wards in Sweden

The general aim was to describe the frequency of and the reasons for locked doors at wards within Swedish psychiatric care. A questionnaire was answered by 193 ward managers. The findings demonstrated that 73% (n = 193) of the wards were locked on the day of investigation. Wards were sometimes locked in the absence of committed patients and sometimes open in the presence of committed patients. Wards were more often locked if at least one committed patient was present. Fewer wards for children and adolescents, than for adults and old people, were locked. More wards in the areas of Sweden's three largest cities, than in the rest of the country, were locked. Fourteen categories of reasons for locking wards were generated by a content analysis of answers to an open-ended question. Most answers were categorized as: prevent patients from escaping, legislation, provide patients and others with safety and security, prevent import and unwelcome visits, and staff's need of control. Staff working in psychiatric care ought to reflect upon and articulate reasons for, and decisions about, locking or opening entrance doors, with the limitation of patients' freedom in mind.

The health-care environment on a locked psychiatric ward: an ethnographic study

Recent changes in psychiatric hospital care involving a reduction in the number of beds and time spent in hospital motivated the study of conditions of inpatient care on such wards. An ethnographic study of a locked, acute psychiatric ward in a department of psychiatry was performed with the aim of describing the health-care environment in such a ward. The ward admitted patients on both a voluntarily and involuntarily basis. Data were collected by means of 3.5 months of participant observations. The results showed a health-care environment that was overshadowed by control. Staff were in control but they also lacked control; they attempted to master the situation in line with organizational demands and they sometimes failed. At the same time, the staff tried to share the responsibility of caring for patients and next of kin. Patients were controlled by staff; they were the underdogs and dependent on staff for their care and the freedom to leave the ward. Patients tried to make themselves heard and reacted to the control by developing counter-strategies. What this study adds to earlier research is patients' pressure on staff and sometimes quite an open struggle for more control, which may be an expression for an unacceptable imbalance in power between patients and staff.