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Välimäki M, Lantta T, Kontio R. Risk assessment for aggressive behaviour in schizophrenia. Cochrane Database Syst Rev 2024; 5:CD012397. [PMID: 38695777 PMCID: PMC11064887 DOI: 10.1002/14651858.cd012397.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings. OBJECTIVES To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia. DATA COLLECTION AND ANALYSIS At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach. MAIN RESULTS We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs. AUTHORS' CONCLUSIONS Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.
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Affiliation(s)
- Maritta Välimäki
- School of Public Health, University of Helsinki, Helsinki, Finland
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Raija Kontio
- Department of Nursing Science, University of Turku, Turku, Finland
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O'Callaghan AK, Plunkett R, Kelly BD. What is the role of gender in perceived coercion during psychiatric admission? Ir J Psychol Med 2023:1-5. [PMID: 36803581 DOI: 10.1017/ipm.2023.6] [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] [Indexed: 02/22/2023]
Abstract
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.
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Affiliation(s)
- Aoife K O'Callaghan
- Department of Psychiatry, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin 24, D24 NR0A, Ireland
| | - Róisín Plunkett
- Psychological Medicine Department, St James's Hospital, Dublin 8, Ireland
| | - Brendan D Kelly
- Department of Psychiatry, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin 24, D24 NR0A, Ireland
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Mengelers AMHJ, Bleijlevens MHC, Verbeek H, Capezuti E, Hamers JPH. A Quasi-experimental study on prevention and reduction of involuntary treatment at home (PRITAH) in people with dementia. J Clin Nurs 2022; 31:3250-3262. [PMID: 34878198 PMCID: PMC9788076 DOI: 10.1111/jocn.16163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/08/2021] [Accepted: 11/10/2021] [Indexed: 12/30/2022]
Abstract
AIM AND OBJECTIVES To examine the implementation (reach, dose, fidelity, adaptations, satisfaction), mechanisms of impact (attitude, subjective norm, perceived behavioural control and intention) and context of the PRITAH intervention. BACKGROUND Involuntary treatment, defined as care provided against one's will, is highly prevalent in home care. The PRITAH intervention comprises policy, workshops, coaching and alternative measures for professional caregivers to prevent and reduce involuntary treatment in home care. DESIGN Quasi-experimental study. METHODS Eight home care teams from two care organisations participated in this study. Guided by the Theory of Planned Behavior, the mechanisms of impact were evaluated with questionnaires. Implementation and context were assessed using attendance lists, evaluation questionnaires, focus groups and logbooks. The study adhered to the TREND checklist. RESULTS 124 of 133 eligible professional caregivers participated (93%). All four components were delivered with minor deviations from protocol. Participants' subjective norms and perceived behavioural control changed over time in favour of the intervention group. No effects were seen for attitude and intention. Barriers included an unclear policy and lack of communication between stakeholders. The multidisciplinary approach and possibility to discuss involuntary treatment with the specialised nurse were described as facilitators. CONCLUSIONS Prevention and reduction of involuntary treatment at home is feasible in home care practice and contributes to changing professional caregivers' subjective norms and perceived behavioural control, prerequisites for behavioural change in order to prevent and reduce involuntary treatment. A follow-up study on the effectiveness of PRITAH on actual use, prevention and reduction of involuntary treatment in home care is needed. Future studies should emphasise the role of family caregivers and GPs and actively involve them in the prevention and reduction of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE Involuntary treatment is commonly used in dementia home care and professional and family caregivers need to be supported in prevention and reduction of involuntary treatment in people with dementia.
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Affiliation(s)
- Angela M. H. J. Mengelers
- Department of Health Services ResearchFaculty of Health, Medicine and Life SciencesCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Living Lab in Ageing and Long‐Term CareMaastrichtThe Netherlands
| | - Michel H. C. Bleijlevens
- Department of Health Services ResearchFaculty of Health, Medicine and Life SciencesCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Living Lab in Ageing and Long‐Term CareMaastrichtThe Netherlands
| | - Hilde Verbeek
- Department of Health Services ResearchFaculty of Health, Medicine and Life SciencesCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Living Lab in Ageing and Long‐Term CareMaastrichtThe Netherlands
| | - Elizabeth Capezuti
- Hunter College and the Graduate Center of City University of New YorkNew YorkNew YorkUSA
| | - Jan P. H. Hamers
- Department of Health Services ResearchFaculty of Health, Medicine and Life SciencesCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Living Lab in Ageing and Long‐Term CareMaastrichtThe Netherlands
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Välimäki M, Lantta T, Anttila M, Vahlberg T, Normand SL, Yang M. An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2229076. [PMID: 36040740 PMCID: PMC9428738 DOI: 10.1001/jamanetworkopen.2022.29076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive. OBJECTIVE To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice. DESIGN, SETTING, AND PARTICIPANTS In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021. INTERVENTIONS Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period. MAIN OUTCOMES AND MEASURES The primary outcome was the occurrence of patient seclusion (events per total number of patients). RESULTS Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02724748.
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Affiliation(s)
- Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland
- Xiangya Nursing School, Xiangya Research Center of Evidence-based Healthcare, Central South University, Hunan, China
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
- Now with Faculty of Health and Education, Department of Nursing, Manchester Metropolitan University, Manchester, UK
| | - Minna Anttila
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Tero Vahlberg
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Min Yang
- West China School of Public Health, Sichuan University, Chengdu, China
- Faculty of Design, Health, and Art, Swinburne University of Technology, Hawthorn, Victoria, Australia
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Wullschleger A, Vandamme A, Mielau J, Stoll L, Heinz A, Bermpohl F, Bechdolf A, Stelzig M, Hardt O, Hauth I, Holthoff-Detto V, Mahler L, Montag C. Effect of standardized post-coercion review on subjective coercion: Results of a randomized-controlled trial. Eur Psychiatry 2021; 64:e78. [PMID: 34872630 PMCID: PMC8715283 DOI: 10.1192/j.eurpsy.2021.2256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- A Wullschleger
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Thônex, Switzerland
| | - A Vandamme
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - J Mielau
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - L Stoll
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Heinz
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - F Bermpohl
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Bechdolf
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Hospital Am Urban and Vivantes Hospital im Friedrichshain/Charité Medicine Berlin, Berlin, Germany.,Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - M Stelzig
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Wenckebach Clinic, Berlin, Germany
| | - O Hardt
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Clinic Neukölln, Berlin, Germany
| | - I Hauth
- Department of Psychiatry, Psychotherapy and Psychosomatics, St. Joseph Hospital Berlin-Weissensee, Berlin, Germany
| | - V Holthoff-Detto
- Department of Psychiatry, Psychotherapy and Psychosomatics, Alexianer Hospital Hedwigshöhe, St. Hedwig Kliniken Berlin, Berlin, Germany.,Medical Faculty, University of Technology, Dresden, Germany
| | - L Mahler
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Psychiatry, Clinics in the Theodor-Wenzel-Werk, Berlin, Germany
| | - C Montag
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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Seclusion in an enriched environment versus seclusion as usual: A quasi-experimental study using mixed methods. PLoS One 2021; 16:e0259620. [PMID: 34762714 PMCID: PMC8584674 DOI: 10.1371/journal.pone.0259620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/25/2021] [Indexed: 11/27/2022] Open
Abstract
Background For patients, seclusion during psychiatric treatment is often a traumatic experience. To prevent such experiences, adjustments in the design of seclusion rooms have been recommended. Methods As there have been no empirical studies on the matter, we used a quasi-experimental design to compare the experiences in seclusion of two groups of patients: 26 who had been secluded in a room designed according to the principles of healing environment, a so called ‘Enriched Environment Seclusion room’ (EES), and 27 who had been secluded in a regular seclusion (RS) room. The enrichment included audio-visual facilities, a fixed toilet, a couch and a self-service system to adjust light, colour, blinds and temperature according to the patient’s preferences. Insight into their experiences was obtained using the Patient View-of-Seclusion Questionnaire, which comprises nine statements on seclusion, supplemented with open-ended questions. Results The responses regarding seclusion experiences between the two groups did not differ significantly (U = 280.00, p = .21, r = -.17). Although those who had been secluded in the specially designed room had greatly appreciated the opportunities for distraction, and those who had been secluded in a regular seclusion room expressed the need for more distracting activities during seclusion, both groups described seclusion as a dreadful experience. If seclusion cannot be avoided, patients recommend facilities for distraction (such as those provided in an enriched environment seclusion room) to be available. Conclusion Whatever the physical environment and facilities of a seclusion room, we may thus conclude that seclusion is a burdensome experience.
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Nielson S, Bray L, Carter B, Kiernan J. Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. J Child Health Care 2021; 25:342-367. [PMID: 32633554 PMCID: PMC8422777 DOI: 10.1177/1367493520937152] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.
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Affiliation(s)
- Simon Nielson
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Lucy Bray
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Joann Kiernan
- Faculty of Health and Social Care, Edge Hill University, UK
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Mann K, Gröschel S, Singer S, Breitmaier J, Claus S, Fani M, Rambach S, Salize HJ, Lieb K. Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics. BMC Psychiatry 2021; 21:419. [PMID: 34419009 PMCID: PMC8380405 DOI: 10.1186/s12888-021-03410-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.
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Affiliation(s)
- Klaus Mann
- Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131, Mainz, Germany.
| | - Sonja Gröschel
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Department of Neurology, University Medical Center, Mainz, Germany
| | - Susanne Singer
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Jörg Breitmaier
- Department of Psychiatry and Psychotherapy, Krankenhaus Zum Guten Hirten, Ludwigshafen, Germany
| | - Sylvia Claus
- Department of Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Markus Fani
- Department of Geriatric Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Stephan Rambach
- Clinic for Psychiatry and Psychotherapy, Municipal Hospital, Pirmasens, Germany
| | - Hans-Joachim Salize
- grid.413757.30000 0004 0477 2235Central Institute of Mental Health, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Klaus Lieb
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
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Beeker T, Mills C, Bhugra D, te Meerman S, Thoma S, Heinze M, von Peter S. Psychiatrization of Society: A Conceptual Framework and Call for Transdisciplinary Research. Front Psychiatry 2021; 12:645556. [PMID: 34149474 PMCID: PMC8211773 DOI: 10.3389/fpsyt.2021.645556] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/10/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose: Worldwide, there have been consistently high or even rising incidences of diagnosed mental disorders and increasing mental healthcare service utilization over the last decades, causing a growing burden for healthcare systems and societies. While more individuals than ever are being diagnosed and treated as mentally ill, psychiatric knowledge, and practices affect the lives of a rising number of people, gain importance in society as a whole and shape more and more areas of life. This process can be described as the progressing psychiatrization of society. Methods: This article is a conceptual paper, focusing on theoretical considerations and theory development. As a starting point for further research, we suggest a basic model of psychiatrization, taking into account its main sub-processes as well as its major top-down and bottom-up drivers. Results: Psychiatrization is highly complex, diverse, and global. It involves various protagonists and its effects are potentially harmful to individuals, to societies and to public healthcare. To better understand, prevent or manage its negative aspects, there is a need for transdisciplinary research, that empirically assesses causes, mechanisms, and effects of psychiatrization. Conclusion: Although psychiatrization has highly ambivalent effects, its relevance mainly derives from its risks: While individuals with minor disturbances of well-being might be subjected to overdiagnosis and overtreatment, psychiatrization could also result in undermining mental healthcare provision for the most severely ill by promoting the adaption of services to the needs and desires of the rather mild cases. On a societal level, psychiatrization might boost medical interventions which incite individual coping with social problems, instead of encouraging long-term political solutions.
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Affiliation(s)
- Timo Beeker
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - China Mills
- School of Health Sciences, City, University of London, London, United Kingdom
| | - Dinesh Bhugra
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Sanne te Meerman
- School of Education, Hanze University of Applied Sciences, Groningen, Netherlands
| | - Samuel Thoma
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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11
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Mengelers AMHJ, Bleijlevens MHC, Verbeek H, Moermans VRA, Capezuti E, Hamers JPH. Prevention and reduction of involuntary treatment at home: A feasibility study of the PRITAH intervention. Geriatr Nurs 2020; 41:536-543. [PMID: 32139030 DOI: 10.1016/j.gerinurse.2020.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
Sometimes care is provided to a cognitively impaired person against the person's will, referred to as involuntary treatment. We developed the PRITAH intervention, aimed at prevention and reduction of involuntary treatment at home. PRITAH consists of a policy discouraging involuntary treatment, workshops, coaching by a specialized nurse and alternative interventions. A feasibility study was conducted including 30 professional caregivers. Feasibility was assessed by attendance lists (reach), a logbook (dose delivered and fidelity), evaluation questionnaires and focus group interviews (dose received, satisfaction & barriers). The workshops and coach were positively evaluated and the average attendance rate was 73%. Participants gained more awareness and knowledge and received practical tips and advice to prevent involuntary treatment. Implementation of the intervention was feasible with minor deviations from protocol. Recommendations for improvement included more emphasis on involvement of family caregivers and general practitioners and development of an extensive guideline to comply with the policy.
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Affiliation(s)
- Angela M H J Mengelers
- Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, the Netherlands.
| | - Michel H C Bleijlevens
- Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, the Netherlands.
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, the Netherlands.
| | - Vincent R A Moermans
- Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, the Netherlands; Department of Nursing, White Yellow Cross Limburg, Genk, Belgium.
| | - Elizabeth Capezuti
- Hunter College and the Graduate Center of City University of New York, New York, United States.
| | - Jan P H Hamers
- Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, the Netherlands.
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12
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Wong AH, Ray JM, Rosenberg A, Crispino L, Parker J, McVaney C, Iennaco JD, Bernstein SL, Pavlo AJ. Experiences of Individuals Who Were Physically Restrained in the Emergency Department. JAMA Netw Open 2020; 3:e1919381. [PMID: 31977058 PMCID: PMC6991263 DOI: 10.1001/jamanetworkopen.2019.19381] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. OBJECTIVE To characterize how individuals experience episodes of physical restraint during their ED visits. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018. MAIN OUTCOMES AND MEASURES Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED. RESULTS Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. CONCLUSIONS AND RELEVANCE In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Lauren Crispino
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | | | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Anthony J. Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
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13
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Abstract
OBJECTIVE Seclusion and mechanical restraint are coercive interventions used at psychiatric hospitals when patients are at imminent risk of harming themselves and/or others. Although these interventions have been used for decades, it remains unclear whether seclusion or mechanical restraint is superior in terms of efficacy and safety. Therefore, we aimed to systematically review studies comparing the intended and unintended effects of seclusion and mechanical restraint. METHODS A systematic search of PubMed and Embase was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Quantitative studies comparing the intended and unintended effects of seclusion and mechanical restraint were included. RESULTS The search identified 868 unique records. Fourteen of these (3 reporting on randomized controlled trials and 11 reporting on observational studies) met the predefined inclusion criteria. The study methodology including outcome measures varied significantly across studies. The results of the 11 studies using a subjective outcome measure (patient preference/emotions) were in favour of seclusion, while the 3 studies using an objective outcome measure (duration of coercion/need for transition to other coercive measure) favoured mechanical restraint. There was a high risk of residual confounding by indication and/or bias affecting the reported results. CONCLUSION Based on the available literature, it cannot be determined whether seclusion is superior to mechanical restraint or vice versa. Further studies using stringent methodology are required to answer this question. A cautious conclusion based on this review is that the availability of both methods seems necessary - as both have their pros and cons.
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14
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Goz K, Rudhran V, Blackburn J, Schäfer MR, O'Donoghue B. Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit. Early Interv Psychiatry 2019; 13:1105-1110. [PMID: 30328276 DOI: 10.1111/eip.12739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/12/2018] [Accepted: 09/09/2018] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The use of restrictive interventions is one of the most controversial practices in medicine. They are utilized in an inpatient setting to manage agitated or aggressive behaviour or to ensure that an individual receives the necessary treatments. However, restrictive interventions remove autonomy and adverse events can be associated with their practice. Youth-specific inpatient units (IPUs) are now being established and it is imperative that the use of restrictive interventions is reduced. In order to inform and facilitate prevention and reduction strategies, this study aimed to determine the prevalence and determinants of restrictive interventions (restraint, seclusion and medication without consent) in a youth specialist mental health IPU. METHODS This study was set at a 16-bed youth specialist acute IPU of Orygen Youth Health, a specialist youth mental health service that provides inpatient care for those aged 18 to 25 years within a catchment area of west and north-western regions of Melbourne, Australia. A retrospective file audit was conducted of all the admissions to the unit from 01 January 2015 to 30 June 2015. RESULTS Over the 6-month study period, 159 young people were admitted and this accounted for 188 admissions. Over half (54.3%) of admissions were involuntary and restrictive intervention were used in 17.6% of admissions. Specifically, 15.7% (N = 25) of young people experienced restraint, 10.1% (N = 16) were secluded, and 8.1% (N = 12) experienced medication without consent. Absent insight and involuntary status on admission were associated with restrictive interventions. CONCLUSION As youth mental health services develop, interventions aimed at reducing restrictive interventions are needed.
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Affiliation(s)
- Kubra Goz
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Brian O'Donoghue
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Orygen Youth Health, Melbourne, Victoria, Australia
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15
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Hu F, Muir-Cochrane E, Oster C, Gerace A. An examination of the incidence and nature of chemical restraint on adult acute psychiatric inpatient units in Adelaide, South Australia. Int J Ment Health Nurs 2019; 28:909-921. [PMID: 30931546 DOI: 10.1111/inm.12591] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
Reducing and/or eliminating the use of coercive measures in psychiatric services is a priority worldwide. Chemical restraint is one such measure, yet to date has been poorly defined and poorly investigated. The aim of this study was to examine chemical restraint use in 12 adult acute inpatient psychiatric units in Adelaide, South Australia. Methods involved the analysis of all reported chemical restraint events occurring over a 12-month period analysed using a descriptive quantitative design. There were 166 chemical restraint events involving 110 consumers. The highest prevalence rate in an individual unit was 28.78 events per 1000 occupied bed days, with the lowest being 0.12 events per 1000 occupied bed days. More males (n = 69, 57.5%) were involved in chemical restraint than females. Schizophrenia, schizotypal, and delusional disorders were the predominant diagnoses among consumers who were chemically restrained. The most events occurred during three time blocks: 14.00-14.59 pm, 16.00-16.59 pm, and 21.00-21.59 pm. The two most common medications used were olanzapine and clonazepam. The study presents a general picture of the practice of chemical restraint in Adelaide and identifies areas of concern in relation to the need for monitoring of side effects and completion of systematic processes of documentation regarding chemical restraint events. Findings highlight the need for sustained focus on reducing the need for chemical restraint and exploring less restrictive measures with those most likely to receive medication against their will.
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Affiliation(s)
- Feyan Hu
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia.,School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, South Australia, Australia
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16
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Hotzy F, Jaeger M, Buehler E, Moetteli S, Klein G, Beeri S, Reisch T. Attitudinal variance among patients, next of kin and health care professionals towards the use of containment measures in three psychiatric hospitals in Switzerland. BMC Psychiatry 2019; 19:128. [PMID: 31035954 PMCID: PMC6489208 DOI: 10.1186/s12888-019-2092-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 03/27/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In psychiatric treatment containment measures are used to de-escalate high-risk situations. These measures can be characterized by their immanent amount of coercion. Previous research could show that the attitudes towards different containment measures vary throughout countries. The aim of this study was to compare the attitudes towards containment measures between three study sites in Switzerland which differ in their clinic traditions and policies and their actual usage of these measures. METHODS We used the Attitude to Containment Measures Questionnaire (ACMQ) in three psychiatric hospitals in Switzerland (Zurich, Muensingen and Monthey) in patients, their next of kin (NOK) and health care professionals (HCP). Furthermore, we assessed the cultural specifics and rates of coercive measures for these three hospitals. RESULTS We found substantial differences in the usage of and the attitudes towards some containment measures between the three study sites. The study site accounted for a variance of nearly zero in as needed medication to 15% in seclusion. The differences between study sites were bigger in the HCPs' attitudes (up to 50% of the variance), compared to NOK and patients. In the latter the study site accounted for up to 6% of the variance. The usage/personal experience of containment measures in general was associated with higher agreement. CONCLUSIONS Although being situated in the same country, there are substantial differences in the rates of containment measures between the three study sites. We showed that the HCP's attitudes are more associated with the clinic traditions and policies compared to patients' and their NOKs' attitudes. One can conclude that patients' preferences depend less on clinic traditions and policies. Therefore, it is important to adapt treatment to the individual patients' attitudes. TRIAL REGISTRATION The study was reviewed and approved by the Cantonal Ethics Commission of Zurich, Switzerland (Ref.-No. EK: 2016-01526, decision on 28.09.2016) and the Cantonal Ethics Commission of Bern, Switzerland (Ref.-Nr. KEK-BE 2015-00074). This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The permission for conduction of the study was granted by the medical directors at the three study sites. The authors informed the respondents (patients, NOK, HCP) of their rights in the study in an oral presentation and/or a cover letter. They assured the participants of the confidentiality and anonymity of the data, and the voluntariness of participation. Patients were given an information sheet with the possibility to consent in the conduction of the study. Return of the completed questionnaires from HCP and NOK was constituted as confirmation of their consent. No identifying factors were collected to ensure privacy. This article does not contain any studies with animals performed by any of the authors.
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Affiliation(s)
- Florian Hotzy
- Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Lenggstrasse 31, Postfach 1931, 8032, Zürich, Switzerland.
| | - Matthias Jaeger
- 0000 0004 0478 9977grid.412004.3Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Lenggstrasse 31, Postfach 1931, 8032 Zürich, Switzerland
| | - Etienne Buehler
- 0000 0004 0478 9977grid.412004.3Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Lenggstrasse 31, Postfach 1931, 8032 Zürich, Switzerland
| | - Sonja Moetteli
- 0000 0004 0478 9977grid.412004.3Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Lenggstrasse 31, Postfach 1931, 8032 Zürich, Switzerland
| | - Georges Klein
- Département de Psychiatrie et Psychothérapie du Centre Hospitalier du Valais Romand, Route de Morgins 10, 1870 Monthey, Valais Switzerland
| | - Simone Beeri
- Hospital of Psychiatry Muensingen, Hunzigenallee 1, 3110 Münsingen, Bern, Switzerland
| | - Thomas Reisch
- Hospital of Psychiatry Muensingen, Hunzigenallee 1, 3110 Münsingen, Bern, Switzerland ,0000 0001 0694 3235grid.412559.eUniversity Hospital of Psychiatry and Psychotherapy, Bern, Switzerland
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17
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Guzmán-Parra J, Aguilera-Serrano C, García-Sanchez JA, García-Spínola E, Torres-Campos D, Villagrán JM, Moreno-Küstner B, Mayoral-Cleries F. Experience coercion, post-traumatic stress, and satisfaction with treatment associated with different coercive measures during psychiatric hospitalization. Int J Ment Health Nurs 2019; 28:448-456. [PMID: 30239098 DOI: 10.1111/inm.12546] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/04/2023]
Abstract
Coercive measures are frequently used in psychiatric hospitalization. However, there are few studies that analyse perceived coercion, post-traumatic stress, and subjective satisfaction with the hospitalization treatment associated with different types of coercive measures. The sample consisted of 111 patients admitted to two psychiatric units and divided into three groups based on the measure applied: involuntary medication (N = 41), mechanical restraint (N = 32), and combined measures (mechanical restraint and involuntary medication; N = 38). The outcome variables were perceived coercion evaluated with the Coercion Experience Scale (CES), post-traumatic stress evaluated with the Davidson Trauma Scale (DTS), and satisfaction with the treatment evaluated with the Client's Assessment of Treatment (CAT). The results found higher levels of perceived coercion associated with the use of mechanical restraint (P = 0.002) and combined measures (P < 0.001) in comparison with involuntary medication. Additionally, in relation to post-traumatic stress, mechanical restraint (P = 0.013) and combined measures (P = 0.004) were more stressful compared to involuntary medication. Finally, the use of combined measures was associated with lower satisfaction with inpatient psychiatric treatment compared to the use of involuntary medication (P = 0.006). The following recommendation would be consistent with the results found: if a patient does not specify a preference for some type of measure, involuntary medication could be used and mechanical restraint avoided, especially when used in combination with involuntary medication.
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Affiliation(s)
- José Guzmán-Parra
- Department of Mental Health, Biomedical Research Institute of Malaga (IBIMA), University General Hospital of Málaga, Málaga, Spain
| | - Carlos Aguilera-Serrano
- Department of Mental Health, Biomedical Research Institute of Malaga (IBIMA), University General Hospital of Málaga, Málaga, Spain.,Andalucía Tech, Faculty of Psychology, University of Málaga, Málaga, Spain
| | - Juan Antonio García-Sanchez
- Department of Mental Health, Biomedical Research Institute of Malaga (IBIMA), University General Hospital of Málaga, Málaga, Spain
| | | | | | | | - Berta Moreno-Küstner
- Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Grupo GAP, Faculty of Psychology, University of Málaga, Málaga, Spain
| | - Fermín Mayoral-Cleries
- Department of Mental Health, Biomedical Research Institute of Malaga (IBIMA), University General Hospital of Málaga, Málaga, Spain
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18
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Aguilera-Serrano C, Guzmán-Parra J, Miranda-Paez J, García-Spínola E, Torres-Campos D, Villagrán-Moreno JM, Moreno-Küstner B, García-Sanchez JA, Mayoral-Cleries F. Validation of a short version of the Coercion Experience Scale (CES-18): Psychometric characteristics in a Spanish sample. Psychiatry Res 2019; 272:284-289. [PMID: 30594761 DOI: 10.1016/j.psychres.2018.12.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/23/2018] [Accepted: 12/23/2018] [Indexed: 11/17/2022]
Abstract
The Coercion Experience Scale (CES) is a questionnaire that evaluates the subjective experience of coercion during psychiatric hospitalization. This study aimed to assess a short version of the Coercion Experience Scale (CES-18) in a Spanish Sample (N = 114). Two authors independently selected the items, choosing those that could also be applied to the experience of coercion after the use of forced medication. Reliability was estimated using internal consistency coefficients. Internal validity was assessed by means of a factorial analysis based on the method of extraction of main components and using orthogonal rotation VARIMAX. Convergent and discriminatory validity was evaluated by correlation between the total score of the CES-18 with the original CES and a Visual Analogue Scale, The Davidson Trauma Scale and the Client Assessment of Treatment Scale. The CES-18 showed adequate internal consistency (Cronbach α = 0.940). Factor analysis resulted in a two-factor solution (Coercion and Humiliation and Fear) explaining 64.2% of the total variance. The correlation between the original CES and CES-18 was adequate (r = 0.968). The scores suggested good divergent and convergent validity. The Spanish language CES-18 demonstrated adequate psychometric proprieties in order to assess perceived coercion during psychiatric hospitalization.
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Affiliation(s)
- Carlos Aguilera-Serrano
- Department of Mental Health, University General Hospital of Málaga, Biomedical Research Institute of Malaga (IBIMA), Málaga, Spain; University of Málaga, Andalucía Tech, Faculty of Psychology, Málaga, Spain
| | - José Guzmán-Parra
- Department of Mental Health, University General Hospital of Málaga, Biomedical Research Institute of Malaga (IBIMA), Málaga, Spain.
| | - Jesús Miranda-Paez
- University of Málaga, Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Faculty of Psychology, Málaga, Spain
| | | | | | | | - Berta Moreno-Küstner
- University of Málaga, Departamento de Personalidad, Evaluación y Tratamiento Psicológico. Grupo GAP, Faculty of Psychology, Málaga, Spain
| | - Juan Antonio García-Sanchez
- Department of Mental Health, University General Hospital of Málaga, Biomedical Research Institute of Malaga (IBIMA), Málaga, Spain
| | - Fermín Mayoral-Cleries
- Department of Mental Health, University General Hospital of Málaga, Biomedical Research Institute of Malaga (IBIMA), Málaga, Spain
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19
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Pudalov LR, Swogger MT, Wittink M. Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology? Int Rev Psychiatry 2018; 30:210-223. [PMID: 30821187 DOI: 10.1080/09540261.2018.1552125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.
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Affiliation(s)
- Lauren R Pudalov
- a Chronic Pain Rehabilitation Program and Bariatric & Metabolic Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Marc T Swogger
- b Department of Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Marsha Wittink
- c Departments of Family Medicine and Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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20
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[Coercive interventions: historical summary and review of subjective experience]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2018; 32:175-181. [PMID: 30194609 DOI: 10.1007/s40211-018-0282-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
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.
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21
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Mann-Poll PS, Smit A, Noorthoorn EO, Janssen WA, Koekkoek B, Hutschemaekers GJM. Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change? Psychiatr Q 2018. [PMID: 29527618 DOI: 10.1007/s11126-018-9571-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.
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Affiliation(s)
| | - Annet Smit
- Pro Persona Mental Health Care, Wolfheze, the Netherlands
| | - Eric O Noorthoorn
- GGNet Mental Health Centre, 7231 PA, Warnsveld, Netherlands. .,Stichting Benchmark GGz, Rembrantlaan 46, 3723 BK, Bilthoven, the Netherlands.
| | - Wim A Janssen
- The Hague University of Applied Science, Hague, the Netherlands
| | - Bauke Koekkoek
- Pro Persona Mental Health Care, Wolfheze, the Netherlands.,University of Applied Sciences, Nijmegen, the Netherlands
| | - Giel J M Hutschemaekers
- Pro Persona Mental Health Care, Nijmegen, the Netherlands.,Clinical Psychology, Behavioral Science Institute, Radboud University Nijmegen, Nijmegen, the Netherlands
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Mielau J, Altunbay J, Lehmann A, Bermpohl F, Heinz A, Montag C. The influence of coercive measures on patients' stances towards psychiatric institutions. Int J Psychiatry Clin Pract 2018; 22:115-122. [PMID: 28978249 DOI: 10.1080/13651501.2017.1383437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To examine the impact of coercive interventions (CI) on patients' evaluations of psychiatric hospitals as adversaries versus allies. METHODS Self-constructed interviews were conducted relating to quantitative and subjective aspects of coercion and the attitude towards psychiatry of 79 patients with psychotic and bipolar disorders. The Coercion Experience Scale (CES) and the Admission Experience Survey (AES) were used to establish the subjective impact of CI. Instruments measuring psychopathological symptoms and the Global Assessment of Functioning (GAF) were applied alongside the Schedule for the Assessment of Illness (SAI) and the Beck Cognitive Insight Scale (BCIS). Using a logistic regression approach, considered influencing factors such as number, type and patients' subjective experiences of CI, cognitive and clinical insight, psychopathological symptoms and patients' global perceptions of their hospitalisation were analysed for their predictive value of patients' attitudes towards psychiatry. RESULTS Binary logistic regression revealed that the subjective experience of CI and the perception of fairness and effectiveness during the treatment process predict patients' attitudes towards psychiatry to a greater extent than symptom-related measures or the quantity of CI. Patients presenting a higher degree of self-reflectiveness perceive psychiatric institutions more likely as allies. CONCLUSIONS The manner in which coercion is subjectively experienced has direct influence on patients' perceptions of psychiatry.
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Affiliation(s)
- Juliane Mielau
- a Department of Psychiatry, Psychotherapy and Psychosomatics , Alexianer Krankenhaus Hedwigshöhe , Berlin , Germany
| | - Jasmin Altunbay
- b Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin , Berlin , Germany
| | - Anja Lehmann
- b Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin , Berlin , Germany
| | - Felix Bermpohl
- b Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin , Berlin , Germany
| | - Andreas Heinz
- b Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin , Berlin , Germany
| | - Christiane Montag
- b Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin , Berlin , Germany
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23
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Eguchi R, Onozuka D, Ikeda K, Kuroda K, Ieiri I, Hagihara A. Psychological assessment of acute schizophrenia patients who experienced seclusion either alone or in combination with restraint. Int J Psychiatry Med 2018; 53:171-188. [PMID: 29280688 DOI: 10.1177/0091217417749788] [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] [Indexed: 11/17/2022]
Abstract
Objective Numerous studies on the effects of seclusion and/or restraint in acute psychiatric treatment have reported both positive and negative effects. However, no studies to date have evaluated the effects of seclusion and/or restraint on schizophrenia patients using a rating scale. Thus, to examine the effects of seclusion and/or restraint on schizophrenia patients, we used the Brief Psychiatric Rating Scale and assessed the psychological condition of patients. Methods Factor analysis was conducted to create subscales of Brief Psychiatric Rating Scale, and psychiatric changes were assessed with respect to each subscale using multiple logistic regression analyses. Analyses were performed on three groups (i.e. entire, higher functioning, and lower functioning groups) involving a total of 1559 schizophrenia patients aged 18 to 65 years. Results In the entire and lower functioning groups, seclusion was a significant predictor of improvements related to the "hostility/suspiciousness" subscale. Seclusion combined with restraint was associated with improvements related to the "psychosis/thinking disorder" subscale. In the higher functioning group, there were no significant predictors. Conclusions It is implied that seclusion and/or restraint is related to improved psychiatric symptoms only among patients whose functioning is impaired. To verify the present findings, further studies involving multiple sites and additional psychiatric measures are necessary.
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Affiliation(s)
- Rika Eguchi
- 1 Department of Health Services Management and Policy, Graduate School of Medicine, Kyushu University, Fukuoka, Japan.,2 Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan
| | - Daisuke Onozuka
- 1 Department of Health Services Management and Policy, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | | | | | - Ichiro Ieiri
- 2 Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- 1 Department of Health Services Management and Policy, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
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24
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Tezenas du Montcel C, Kowal C, Leherle A, Kabbaj S, Frajerman A, Le Guen E, Hamdani N, Schürhoff F, Leboyer M, Pelissolo A, Pignon B. Isolement et contention mécanique dans les soins psychiatriques : modalités de prescription, prise en charge et surveillance. Presse Med 2018; 47:349-362. [DOI: 10.1016/j.lpm.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/22/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
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25
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Horvath J, Steinert T, Jaeger S. Antipsychotic treatment of psychotic disorders in forensic psychiatry: Patients' perception of coercion and its predictors. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 57:113-121. [PMID: 29548498 DOI: 10.1016/j.ijlp.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Despite the major encroachment of coercive measures on the fundamental rights of affected forensic psychiatric patients, there is relatively few research done in this field. Considering the relevance of this subject for psychiatric care and the recent changes of the legal basis of coercive treatment in Germany, more studies are needed. The present study examines forensic psychiatric inpatients' perception of coercion regarding the prescribed antipsychotic medication and factors associated with the perception of coercion. MATERIAL AND METHODS Patients with schizophrenia, schizotypal and delusional disorders in two forensic psychiatric institutions in Southern Germany were interviewed about their experience of coercion related to antipsychotic medication. Due to a lack of appropriate psychometric scales, the perception of coercion regarding antipsychotic medication was assessed using an adapted version of the MacArthur Admission Experience Survey (aAES). The influence of sociodemographic and illness-related factors, of the attitude towards medication, insight into illness and symptom severity on the extent to which patients felt coerced to take the prescribed medication was analyzed. Two Visual Analog Scales, the Drug Attitude Inventory DAI-10, the Positive and Negative Syndrome Scale PANSS, the Fragebogen zur Krankheitseinsicht (Questionnaire about insight into illness) FKE-10 and the Coercion Experience Scale CES were used as psychometric scales. RESULTS 50% of all patients eligible for the study gave their written consent. 70% of all participants had experienced coercive measures between admission and time of data assessment. The DAI-10 and the aAES correlated moderately, a high level of insight into illness being correlated to less perceived coercion. The FKE-10 and the aAES correlated moderately as well, a high level of insight into illness being correlated to less perceived coercion. The severity of symptoms (PANSS score) and the level of perceived coercion (aAES score) correlated weakly, participants with more severe symptoms perceived more coercion than those with less marked symptoms. A linear regression model showed that to what extent patients felt coerced to take the prescribed antipsychotic medication was mainly influenced by their attitude towards medication and the degree of insight into illness, to a lesser extent by symptom severity (R2 = 0.565, p < 0.001). Sociodemographic factors were not related to the extent to which patients felt coerced to take the antipsychotic medication. CONCLUSIONS Predictors of the experience of coercion related to the prescribed antipsychotic medication of forensic psychiatric inpatients with schizophrenia and related disorders are not so much sociodemographic or illness-related factors as education or past medical history, but rather potentially influenceable variables such as insight into illness or attitude towards medication.
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Affiliation(s)
- Juliane Horvath
- Zentrum für Psychiatrie Südwürttemberg, Klinik für Psychiatrie und Psychotherapie Weissenau, Weingartshofer Straße 2, 88214 Ravensburg, Germany.
| | - Tilman Steinert
- Zentrum für Psychiatrie Südwürttemberg, Klinik für Psychiatrie und Psychotherapie Weissenau, Weingartshofer Straße 2, 88214 Ravensburg, Germany
| | - Susanne Jaeger
- Zentrum für Psychiatrie Südwürttemberg, Klinik für Psychiatrie und Psychotherapie Weissenau, Weingartshofer Straße 2, 88214 Ravensburg, Germany
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26
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Barr L, Wynaden D, Heslop K. Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings. Int J Ment Health Nurs 2018; 27:168-177. [PMID: 28337845 DOI: 10.1111/inm.12306] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2016] [Indexed: 01/23/2023]
Abstract
Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non-forensic acute mental health settings. The "Attitudes towards PRN medication use survey" was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.
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Affiliation(s)
- Lesley Barr
- State Forensic Mental Health Services, Perth, Western Australia, Australia
| | - Dianne Wynaden
- Nursing and Midwifery, Curtin University, Perth, Western Australia, Australia
| | - Karen Heslop
- Nursing and Midwifery, Curtin University, Perth, Western Australia, Australia
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27
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Aguilera-Serrano C, Guzman-Parra J, Garcia-Sanchez JA, Moreno-Küstner B, Mayoral-Cleries F. Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A Systematic Review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:129-144. [PMID: 29069981 PMCID: PMC5788134 DOI: 10.1177/0706743717738491] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This systematic review presents evidence regarding factors that may influence the patient's subjective experience of an episode of mechanical restraint, seclusion, or forced administration of medication. METHOD Two authors searched CINAHL, PubMed, SCOPUS, Web of Science, and Psych-Info, considering published studies between 1 January 1992 and 1 February 2016. Based on the inclusion criteria and methodological quality, 34 studies were selected, reporting a total sample of 1,869 participants. RESULTS The results showed that the provision of information, contact and interaction with staff, and adequate communication with professionals are factors that influence the subjective experience of these measures. Humane treatment, respect, and staff support are also associated with a better experience, and debriefing is an important procedure/technique to reduce the emotional impact of these measures. Likewise, the quality of the working and physical environment and some individual and treatment variables were related to the experience of these measures. There are different results in relation to the most frequently associated experiences and, despite some data that indicate positive experiences, the evidence shows such experiences to be predominantly negative and frequently with adverse consequences. It seems that patients find forced medication and seclusion to be more tolerable than mechanical restraint and combined measures. CONCLUSIONS It appears that the role of the staff and the environmental conditions, which are potentially modifiable, affect the subjective experience of these measures. There was considerable heterogeneity among studies in terms of coercive measures experienced by participants and study designs.
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Affiliation(s)
- Carlos Aguilera-Serrano
- 1 Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain.,2 University of Málaga, Andalucía Tech, Faculty of Psychology, Málaga, Spain
| | - Jose Guzman-Parra
- 1 Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain.,3 Departamento Personalidad, Evaluación y Tratamiento Psicológico, Grupo GAP, Facultad de Psicología, Universidad de Málaga, Spain
| | - Juan A Garcia-Sanchez
- 1 Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | | | - Fermin Mayoral-Cleries
- 1 Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
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28
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Tingleff EB, Bradley SK, Gildberg FA, Munksgaard G, Hounsgaard L. "Treat me with respect". A systematic review and thematic analysis of psychiatric patients' reported perceptions of the situations associated with the process of coercion. J Psychiatr Ment Health Nurs 2017; 24:681-698. [PMID: 28665512 DOI: 10.1111/jpm.12410] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 12/27/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Psychiatric patients have generally negative experiences of being exposed to coercive measures. Existing research has generally not investigated coercion as a process; that is, it does not address issues that arise before, during and after exposure to coercion. A part of existing research within the area does not clarify and define the type of coercive measure(s) investigated. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients place great significance on the link between the positive and negative perceived impact of a coercive situation and the professionals' ability and willingness to interact and communicate respectfully. Psychiatric patients associate the use of seclusion, physical restraint/holding, mechanical restraint and forced medication with strong negative perceptions and wish to be treated with respect by professionals, rather than being subjected to the professionals' control. What patients perceive as moderating factors in regard to the use of coercive measures is currently under-researched. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Increased sensitivity to the patient's views of the situation at each point in the coercive process would help professionals to respond to the patients' individual needs. Professionals need to articulate concern and empathy towards patients and to improve communication skills before, during and after a coercive incident. Greater emphasis should be placed on de-escalation and the use of non-coercive strategies or coping skills before the initiation of coercive measures. ABSTRACT Introduction There is a lack of research into psychiatric patients' perceptions of coercion that discriminates between different types of coercive measures, while also investigating patients' perceptions of undergoing coercion as a process. This knowledge is required to improve our understanding and provide a foundation for improving clinical practice. Aims To review existing research literature in order to investigate adult psychiatric patients' reported perceptions of situations before, during and after specific and defined types of coercive measures, and to investigate what patients perceive as moderating factors, in regard to the use of these coercive measures. Method A systematic review and thematic analysis of 26 peer-reviewed studies was undertaken. Results The analysis identified six themes and additional subthemes, where "interactions with professionals" and "communication" were predominant themes across the timeline of coercion. Altogether, themes were associated with either "positive or negative patient-perceived impact." Implications for practice Increased sensitivity to patients' views of the situation at each point in the process is desirable in order to respond to the patients' individual needs. Professionals also need to articulate concern and empathy towards the patient and to improve communication skills before, during and after a coercive incident. Use of de-escalation and noncoercive strategies is required. Relevance statement Coercion within psychiatric/mental health care remains controversial, and repeated international calls have recommended a reduction of their use. This review indicates that greater attention to how patients perceive the use of coercive measures (before, during, and after incidents) needs to be considered in order to improve the evidence-based and clinical practice.
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Affiliation(s)
- E B Tingleff
- Department of Clinical Research, Odense Patient data Explorative Network (OPEN), Odense University Hospital/University of Southern Denmark, Odense, Denmark.,Research & Development Unit, Department of Psychiatry Middelfart, Region of Southern Denmark, Middelfart, Denmark.,The Department of Nursing, University College Lillebaelt, Vejle, Denmark.,Health Sciences Research Center, University College Lillebaelt, Vejle, Denmark.,Center for Psychiatric Nursing and Health Research, Faculty of Health Science, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - S K Bradley
- Catherine McAuley School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, UK
| | - F A Gildberg
- Research & Development Unit, Department of Psychiatry Middelfart, Region of Southern Denmark, Middelfart, Denmark.,Center for Psychiatric Nursing and Health Research, Faculty of Health Science, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - G Munksgaard
- Research & Development Unit, Department of Psychiatry Middelfart, Region of Southern Denmark, Middelfart, Denmark.,Center for Psychiatric Nursing and Health Research, Faculty of Health Science, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - L Hounsgaard
- Department of Clinical Research, Odense Patient data Explorative Network (OPEN), Odense University Hospital/University of Southern Denmark, Odense, Denmark.,Health Sciences Research Center, University College Lillebaelt, Vejle, Denmark.,Center for Psychiatric Nursing and Health Research, Faculty of Health Science, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Institute of Nursing & Health Science, University of Greenland, Nuuk, Greenland
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29
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Molewijk B, Kok A, Husum T, Pedersen R, Aasland O. Staff's normative attitudes towards coercion: the role of moral doubt and professional context-a cross-sectional survey study. BMC Med Ethics 2017; 18:37. [PMID: 28545519 PMCID: PMC5445484 DOI: 10.1186/s12910-017-0190-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified (i.e. experiencing moral doubt) is related to professionals’ normative attitudes regarding the use of coercion. Methods This paper describes an explorative statistical analysis based on a cross-sectional survey across seven wards in three Norwegian mental health care institutions. Results Descriptive analyses showed that in general the 379 respondents a) were not so sure whether coercion should be seen as offending, b) agreed with the viewpoint that coercion is needed for care and security, and c) slightly disagreed that coercion could be seen as treatment. Staff did not report high rates of moral doubt related to the use of coercion, although most of them agreed there will never be a single answer to the question ‘What is the right thing to do?’. Bivariate analyses showed that the more they experienced general moral doubt and relative doubt, the more one thought that coercion is offending. Especially psychologists were critical towards coercion. We found significant differences among ward types. Respondents with decisional responsibility for coercion and leadership responsibility saw coercion less as treatment. Frequent experience with coercion was related to seeing coercion more as care and security. Conclusions This study showed that experiencing moral doubt is related to some one’s normative attitude towards coercion. Future research could investigate whether moral case deliberation increases professionals’ experience of moral doubt and whether this will evoke more critical thinking and increase staff’s curiosity for alternatives to coercion.
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Affiliation(s)
- Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway. .,Department Medical Humanities, EMGO+, VU University medical centre (VUmc), Amsterdam, The Netherlands.
| | - Almar Kok
- Department Epidemiology & Biostatistics, EMGO+, VU University medical centre (VUmc), Amsterdam, The Netherlands
| | - Tonje Husum
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Olaf Aasland
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.,Institute for Studies of the Medical Profession, Oslo, Norway
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30
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Danzer G, Wilkus-Stone A. The give and take of freedom: The role of involuntary hospitalization and treatment in recovery from mental illness. Bull Menninger Clin 2016; 79:255-80. [PMID: 26366982 DOI: 10.1521/bumc.2015.79.3.255] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The authors reviewed and synthesized scholarly literature on the topic of involuntary confinement and treatment for severely mentally ill adults. Objectively, all facets of the issue are reported, including recurrent positive outcomes, negative outcomes, and patient experiences in common. Patient experiences are organized into related subthemes of autonomy, patient satisfaction, relationships with staff, perceived coercion, traumatization, and humiliation. The literature suggests that short-term involuntary hospitalization is sometimes necessary in order to prevent the mentally ill from psychiatrically decompensating or harming themselves or others. Understandably, hospitalization is often experienced by the mentally ill as a demoralizing violation of their rights and tends to lead them to disengage further from the professional help they need in order to recover. In turn, disengagement leads to further decompensation and resulting risk for rehospitalization. In order to intervene in this cycle and instill severely mentally ill patients with hope in the recovery process, the use of coercive tactics must be decreased in favor of cooperative engagement measures to the greatest extent possible. Patients must be empowered to make choices within the limits of their illnesses through positive interactions with staff, particularly in potentially negative, autonomy-compromising situations. Cooperative measures may help to minimize the potentially traumatic and humiliating effects of being involuntarily hospitalized and medicated. In turn, trusting patient-provider relationships may develop. Thereafter, the severely mentally ill may become more likely to seek professional help on their own volition in the future.
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31
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Välimäki M, Lantta T, Hätönen HM, Kontio R, Zhang S. Risk assessment for aggressive behaviour in schizophrenia. Hippokratia 2016. [DOI: 10.1002/14651858.cd012397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maritta Välimäki
- University of Turku; Department of Nursing Science; Turku Finland
- The Hong Kong Polytechnic University; Hong Kong China
| | - Tella Lantta
- University of Turku; Department of Nursing Science; Turku Finland
| | - Heli M Hätönen
- University of Turku; Department of Nursing Science; Turku Finland
| | - Raija Kontio
- University of Turku; Department of Nursing Science; Turku Finland
| | - Shuying Zhang
- Tongji University, School of Medicine; Nursing; 1239 Si Ping Road Shangai China 200092
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32
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Subjective experience of coercion in psychiatric care: a study comparing the attitudes of patients and healthy volunteers towards coercive methods and their justification. Eur Arch Psychiatry Clin Neurosci 2016; 266:337-47. [PMID: 25900468 DOI: 10.1007/s00406-015-0598-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
Under certain conditions, coercive interventions in psychotic patients can help to regain insight and alleviate symptoms, but can also traumatize subjects. This study explored attitudes towards psychiatric coercive interventions in healthy individuals and persons suffering from schizophrenia, schizoaffective or bipolar disorder. The impact of personal history of coercive treatment on preferences concerning clinical management of patients unable to consent was investigated. Six case vignettes depicting scenarios of ethical dilemmas and demanding decisions in favour of or against coercive interventions were presented to 60 healthy volunteers and 90 patients. Structured interviews focusing on experienced coercion were performed in conjunction with the Coercion Experience Scale and the Admission Experience Survey. Symptom severity, psychosocial functioning and insight into illness were assessed as influencing variables. Student's t tests compared patients' and controls' judgments, followed by regression analyses to define the predictive value of symptoms and measures of coercion on judgments regarding the total patient sample and patients with experience of fixation. Patients and non-psychiatric controls showed no significant difference in their attitudes towards involuntary admission and forced medication. Conversely, patients more than controls significantly disapproved of mechanical restraint. Subjective experience of coercive interventions played an important role for the justification of treatment against an individual's "natural will". Factors influencing judgments on coercion were overall functioning and personal experience of treatment effectiveness and fairness. Qualitative and quantitative aspects of perceived coercion, in addition to insight into illness, predicted judgments of previously fixated patients. Results underline the importance of the quality of practical implementation and care, if coercive interventions cannot be avoided.
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33
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A nationwide study of why and how acute adolescent psychiatric units use restraint. Psychiatry Res 2016; 237:60-6. [PMID: 26921053 DOI: 10.1016/j.psychres.2016.01.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/20/2015] [Accepted: 01/27/2016] [Indexed: 12/28/2022]
Abstract
The purpose of this study was to examine the type, reason, and duration of restraint episodes in acute adolescent psychiatric units. In a retrospective design we included data from paper-based protocols on all episodes of restraint and data from electronic patient records during 2008-2010 in all acute adolescent psychiatric in-patient units in Norway (N=16). The episodes of restraint included mechanical and pharmacological restraint, seclusion and physical holding that was not part of the implementation of forced feeding. Six-and-a-half per cent of all 4099 adolescents admitted to the acute units experienced restraint. Of the 2277 episodes, 13.4% were mechanical restraint, 1.6% were pharmacological restraint, 5.9% were seclusion and 78.7% were physical holding. The median number of restraint episodes per patient was two, the range was 1-171 and 47 patients (18%) experienced ≥10 episodes. The most common reason for using restraint was harming others. The median duration of the mechanical restraint episodes was 3.5h. The median duration of seclusion was 30min and the median duration of physical holding was 10min.
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34
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[Violence by and against people with mental illnesses]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015; 59:98-104. [PMID: 26515051 DOI: 10.1007/s00103-015-2262-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There is robust evidence for an increased risk of violence through people with psychotic disorders. Until recently this was frequently denied to prevent stigmatization. Alcohol and drug abuse equally increases the risk, while appropriate treatment reduces it drastically. Staff in psychiatric hospitals is exposed to an elevated risk of aggressive assaults. A limited number of severely ill and socially disintegrated patients accounts for these incidents, which are often recurrent. Besides patient characteristics, factors such as ward climate, staffing levels, education and attitudes of staff, and physical environment play a major role in aggressive escalations. On the other hand, mentally ill people, particularly women, are themselves at a higher risk of becoming victims of violent and non-violent crime. This also applies after correction for variables such as social status and living environment. Additionally mentally ill people are confronted with violence in the form of coercive interventions legitimised by the state (involuntary admission, involuntary treatment, freedom-restrictive measures such as seclusion or manual/physical restraint). In contrast to other countries in Central and Western Europe, involuntary outpatient treatment has never been legalized in Germany. Efforts to reduce violence and coercion in psychiatric facilities by evidence-based interventions are widespread nowadays, treatment guidelines are available.
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35
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Guzman-Parra J, Garcia-Sanchez JA, Pino-Benitez I, Alba-Vallejo M, Mayoral-Cleries F. Effects of a Regulatory Protocol for Mechanical Restraint and Coercion in a Spanish Psychiatric Ward. Perspect Psychiatr Care 2015; 51:260-7. [PMID: 25346137 DOI: 10.1111/ppc.12090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/25/2014] [Accepted: 09/17/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE There is still limited information on what type of measures are most efficient to reduce coercion. The aim of this study was to determine if the introduction of a new regulatory protocol in a specific psychiatric ward in Andalusia (Spain) contributed to reducing the use of mechanical restraint. DESIGN AND METHODS The study included a comparison of two time periods: 2005 (one year before the implementation of the new regulatory protocol) and 2012, in all hospitalized patients (N=1,094). The study also analyzes with logistic regression the variables related to a shorter duration of mechanical restraint. FINDINGS Mechanical restraint rate per year was reduced, not significantly, from 18.2% to 15.1%. The average duration of each mechanical restraint episode was significantly reduced from 27.91 to 15.33 hr. The following variables have been associated with a shorter period of coercion: being female and the year of restraint (2012). PRACTICE IMPLICATIONS Specific plans are required, including different interventions, in order to achieve marked reduction in the use of coercive measures.
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Affiliation(s)
- Jose Guzman-Parra
- Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Juan A Garcia-Sanchez
- Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Isabel Pino-Benitez
- Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Mercedes Alba-Vallejo
- Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Fermin Mayoral-Cleries
- Department of Mental Health, University General Hospital of Malaga, Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
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Molewijk B, Hem MH, Pedersen R. Dealing with ethical challenges: a focus group study with professionals in mental health care. BMC Med Ethics 2015; 16:4. [PMID: 25591923 PMCID: PMC4417320 DOI: 10.1186/1472-6939-16-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 01/02/2015] [Indexed: 11/16/2022] Open
Abstract
Background Little is known about how health care professionals deal with ethical challenges in mental health care, especially when not making use of a formal ethics support service. Understanding this is important in order to be able to support the professionals, to improve the quality of care, and to know in which way future ethics support services might be helpful. Methods Within a project on ethics, coercion and psychiatry, we executed a focus group interview study at seven departments with 65 health care professionals and managers. We performed a systematic and open qualitative analysis focusing on the question: ‘How do health care professionals deal with ethical challenges?’ We deliberately did not present a fixed definition or theory of ethical challenge. Results We categorized relevant topics into three subthemes: 1) Identification and presence of ethical challenges; 2) What do the participants actually do when dealing with an ethical challenge?; and 3) The significance of facing ethical challenges. Results varied from dealing with ethical challenges every day and appreciating it as a positive part of working in mental health care, to experiencing ethical challenges as paralyzing burdens that cause a lot of stress and hinder constructive team cooperation. Some participants reported that they do not have the time and that they lack a specific methodology. Quite often, informal and retrospective ad-hoc meetings in small teams were organized. Participants struggled with what makes a challenge an ethical challenge and whether it differs from a professional challenge. When dealing with ethical challenges, a number of participants experienced difficulties handling disagreement in a constructive way. Furthermore, some participants plead for more attention for underlying intentions and justifications of treatment decisions. Conclusions The interviewed health care professionals dealt with ethical challenges in many different ways, often in an informal, implicit and reactive manner. This study revealed nine different categories of what health care professionals implicitly or explicitly conceive as ‘ethical challenges’. Future research should focus on how ethics support services, such as ethics reflection groups or moral case deliberation, can be of help with respect to dealing with ethical challenges and value disagreements in a constructive way.
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Affiliation(s)
- Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, Blindern, NO-0318, Oslo, Norway. .,Department of Medical Humanities, Free University medical centre (VUmc), EMGO+ (Quality of Care), Amsterdam, The Netherlands.
| | - Marit Helene Hem
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, Blindern, NO-0318, Oslo, Norway.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, Blindern, NO-0318, Oslo, Norway.
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Gonzalez-Torres MA, Fernandez-Rivas A, Bustamante S, Rico-Vilademoros F, Vivanco E, Martinez K, Angel Vecino M, Martín M, Herrera S, Rodriguez J, Saenz C. Impact of the creation and implementation of a clinical management guideline for personality disorders in reducing use of mechanical restraints in a psychiatric inpatient unit. Prim Care Companion CNS Disord 2014; 16:14m01675. [PMID: 25834763 DOI: 10.4088/pcc.14m01675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/28/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate the impact of the implementation of a guideline for the management of personality disorders on reducing the frequency of use of mechanical restraints in a psychiatric inpatient unit. METHOD This retrospective study was conducted in a psychiatric inpatient unit with 42 beds, which serves an urban area of 330,000 inhabitants. The sample consisted of all patients with a clinical diagnosis of personality disorder (DSM-IV-TR criteria) who were admitted to the unit from January 2010 to December 2010 and from January 2011 to December 2011 (ie, before and after, respectively, the implementation of the guideline). The guideline focused on cluster B disorders and follows a psychodynamic perspective. RESULTS Restraint use was reduced from 38 of 87 patients with personality disorders (43.7%) to 3 of 112 (2.7%), for a relative risk of 0.06 (95% CI, 0.02-0.19) and an absolute risk reduction of 41% (95% CI, 29.9%-51.6%). The risk of being discharged against medical advice increased after the intervention, with a relative risk of 1.84 (95% CI, 0.96-3.51). Restraint use in patients with other diagnoses was also reduced to a similar extent. CONCLUSIONS The use of mechanical restraints was dramatically reduced after the implementation of a clinical practice guideline on personality disorders, suggesting that these coercive measures might be decreased in psychiatric inpatient units.
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Affiliation(s)
- Miguel Angel Gonzalez-Torres
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Aranzazu Fernandez-Rivas
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Sonia Bustamante
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Fernando Rico-Vilademoros
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Esther Vivanco
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Karmele Martinez
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Miguel Angel Vecino
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Melba Martín
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Sonia Herrera
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Jorge Rodriguez
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
| | - Carlos Saenz
- Department of Neuroscience, University of the Basque Country, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante); Psychiatry Service, Basurto University Hospital, Bilbao, Spain (Drs Gonzalez-Torres, Fernandez-Rivas, and Bustamante; Mss Vivanco, Martinez, Martín, and Herrera; and Mssrs Vecino, Rodriguez, and Saenz); and Neuroscience Institute, Granada University, Granada, Spain (Dr Rico-Vilademoros)
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[Coercive measures in psychiatric clinics in Germany: current practice (2012)]. DER NERVENARZT 2014; 85:621-9. [PMID: 23979363 DOI: 10.1007/s00115-013-3867-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Due to the decisions of the German Constitutional Court on involuntary medication and the law on the prohibition of video surveillance in psychiatry in Nordrhine-Westfalia there has been an increasing discussion on coercive measures and how to conduct, supervise and prevent them. We conducted an online survey on the current practice of coercive measures in German psychiatric hospitals (2012). METHOD An online questionnaire was developed together with the working group for the prevention of violence and coercion in psychiatry and the regional association of psychiatry-experienced people in Baden-Wuerttemberg. The survey was conducted anonymously using the e-mail distribution lists of the psychiatric associations in Germany. RESULTS A total of 88 questionnaires from hospitals with obligatory responsibility for a catchment area (19.7% of those addressed) could be analyzed. Of these 99% used internal or external guidelines, 97.5% conducted de-escalation training, 23% participated in external benchmarking on the use of coercive measures. All hospitals used mechanical restraint, approximately 50% seclusion and physical restraint was practiced in 7%. Most, but not all hospital directors reported that mechanical restraint and seclusion were continuously (24/7) monitored. Changes in practice in the years to come were expected by the majority. CONCLUSIONS The survey revealed a high critical awareness concerning the use of coercive measures and the willingness to further change the practice.
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Steinert T, Noorthoorn EO, Mulder CL. The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries. Front Public Health 2014; 2:141. [PMID: 25309893 PMCID: PMC4173217 DOI: 10.3389/fpubh.2014.00141] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/29/2014] [Indexed: 01/22/2023] Open
Abstract
In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.
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Affiliation(s)
- Tilman Steinert
- Centre for Psychiatry Suedwuerttemberg, Ulm University, Ulm, Germany
| | - Eric O. Noorthoorn
- Dutch Case Register on Coercive Measures, Expertise Centre for Aggression Management, Den Dolder, Netherlands
| | - Cornelis L. Mulder
- Epidemiological and Social Psychiatric Research Institute, Erasmus MC, Rotterdam, Netherlands
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Chambers M, Gallagher A, Borschmann R, Gillard S, Turner K, Kantaris X. The experiences of detained mental health service users: issues of dignity in care. BMC Med Ethics 2014; 15:50. [PMID: 24972627 PMCID: PMC4114162 DOI: 10.1186/1472-6939-15-50] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 06/20/2014] [Indexed: 11/24/2022] Open
Abstract
Background When mental health service users are detained under a Section of the Mental Health Act (MHA), they must remain in hospital for a specific time period. This is often against their will, as they are considered a danger to themselves and/or others. By virtue of being detained, service users are assumed to have lost control of an element of their behaviour and as a result their dignity could be compromised. Caring for detained service users has particular challenges for healthcare professionals. Respecting the dignity of others is a key element of the code of conduct for health professionals. Often from the service user perspective this is ignored. Methods This paper reports on the experiences of 19 adult service users who were, at the time of interview, detained under a Section of the MHA. These service users had experienced coercive interventions and they gave their account of how they considered their dignity to be protected (or not), and their sense of self respected (or not). Results The service users considered their dignity and respect compromised by 1) not being ‘heard’ by staff members, 2) a lack of involvement in decision-making regarding their care, 3) a lack of information about their treatment plans particularly medication, 4) lack of access to more talking therapies and therapeutic engagement, and 5) the physical setting/environment and lack of daily activities to alleviate their boredom. Conclusions Dignity and respect are important values in recovery and practitioners need time to engage with service user narratives and to reflect on the ethics of their practice.
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Affiliation(s)
- Mary Chambers
- Faculty of Health, Social Care and Education, Kingston University and St, George's, University of London, London, UK.
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Laiho T, Lindberg N, Joffe G, Putkonen H, Hottinen A, Kontio R, Sailas E. Psychiatric staff on the wards does not share attitudes on aggression. Int J Ment Health Syst 2014; 8:14. [PMID: 24778708 PMCID: PMC4002577 DOI: 10.1186/1752-4458-8-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/10/2014] [Indexed: 11/19/2022] Open
Abstract
Background The concept of ward culture has been proposed as a reason for the often reported differences in treatment decisions when managing inpatient aggression. We therefore studied whether staff on wards actually shares similar perceptions and attitudes about aggression and whether the specialty of the ward on which the staff members work influences these opinions. Methods The Attitudes Towards Aggression Scale was used to assess attitudes towards aggression in 31 closed psychiatric wards. Altogether 487 staff members working on the study wards were asked to fill in the scale. Respondent’s gender, age, educational level, working experience on the current ward, and specialty of this ward (acute, forensic, rehabilitation) served as background variables. Results Most of the variance found was due to differences between individuals. Belonging to the personnel of a particular ward did not explain much of the variance. Conclusions Psychiatric staff on the wards does not share attitudes on aggression. As each staff member has his/her own opinion about aggression, training for dealing with aggression or violent incidents should be done, at least partly, on an individual level. We also suggest caution in using the concept of ward culture as an explanation for the use of restrictive measures on psychiatric wards.
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Affiliation(s)
- Tero Laiho
- Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
| | - Nina Lindberg
- Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland ; Faculty of Medicine, Forensic Psychiatry, University of Helsinki, Helsinki, Finland
| | - Grigori Joffe
- Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
| | - Hanna Putkonen
- Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland ; Vanha Vaasa Hospital, Vaasa, Finland
| | - Anja Hottinen
- Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
| | - Raija Kontio
- Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland
| | - Eila Sailas
- Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Area, Tuusula, Finland
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Luciano M, Sampogna G, Del Vecchio V, Pingani L, Palumbo C, De Rosa C, Catapano F, Fiorillo A. Use of coercive measures in mental health practice and its impact on outcome: a critical review. Expert Rev Neurother 2014; 14:131-41. [PMID: 24382132 DOI: 10.1586/14737175.2014.874286] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Mario Luciano
- Department of Psychiatry, University of Naples SUN, Naples, Italy
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Nawka A, Kalisova L, Raboch J, Giacco D, Cihal L, Onchev G, Karastergiou A, Solomon Z, Fiorillo A, Del Vecchio V, Dembinskas A, Kiejna A, Nawka P, Torres-Gonzales F, Priebe S, Kjellin L, Kallert TW. Gender differences in coerced patients with schizophrenia. BMC Psychiatry 2013; 13:257. [PMID: 24118928 PMCID: PMC3852852 DOI: 10.1186/1471-244x-13-257] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 10/01/2013] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander Nawka
- Department of Psychiatry, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lucie Kalisova
- Department of Psychiatry, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiri Raboch
- Department of Psychiatry, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Domenico Giacco
- Unit for Social and Community Psychiatry, Queen Mary, University of London, London, UK
- Department of Psychiatry, University of Naples, Naples, Italy
| | - Libor Cihal
- Central land office, Ministry of Agriculture, Prague, Czech Republic
| | - Georgi Onchev
- Department of Psychiatry, Medical University of Sofia, Sofia, Bulgaria
| | | | - Zahava Solomon
- School of Social Work and Geha Mental Health Center, University of Tel Aviv, Tel Aviv, Israel
| | - Andrea Fiorillo
- Department of Psychiatry, University of Naples, Naples, Italy
| | | | - Algirdas Dembinskas
- Psychiatric Clinic, Vilnius Mental Health Centre, University of Vilnius, Vilnius, Lithuania
| | - Andrzej Kiejna
- Department of Psychiatry, Medical University, Wroclaw, Poland
| | - Petr Nawka
- Psychiatric private practice, Dresden, Germany
| | | | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary, University of London, London, UK
| | - Lars Kjellin
- Psychiatric Research Centre, Orebro County Council, Orebro, Sweden
- School of Health and Medical Sciences, Orebro University, Orebro, Sweden
| | - Thomas W Kallert
- Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, Park Hospital Leipzig, Leipzig, Germany
- Soteria Hospital Leipzig, Leipzig, Germany
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Dresden University of Technology, Dresden, Germany
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Georgieva I, Mulder CL, Noorthoorn E. Reducing seclusion through involuntary medication: a randomized clinical trial. Psychiatry Res 2013; 205:48-53. [PMID: 22951334 DOI: 10.1016/j.psychres.2012.08.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 02/16/2012] [Accepted: 08/04/2012] [Indexed: 10/28/2022]
Abstract
The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention. Patients admitted to an acute psychiatric ward were randomly allocated to two groups. In Group 1, involuntary medication was the intervention of first choice for dealing with agitation and risk of violence. In Group 2, seclusion was the intervention of first choice. Patients' characteristics between the groups were compared by Pearson χ(2) and two-sample t-tests; the incidence rates and risk ratios (RRs) were calculated to examine differences in number and duration of coercive incidents. In Group 1, the relative risk of being secluded was lower than in Group 2, whereas the risk of receiving involuntary medication was higher. However, the mean duration of the seclusion incidents did not differ significantly between the two groups; neither did the total number of coercive incidents. Although the use of involuntary medication could successfully replace and reduce the number of seclusions, alternative interventions are needed to reduce the overall number and duration of coercive incidents. A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met.
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Affiliation(s)
- Irina Georgieva
- Research Center O3, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands; Mental Health Center Western North-Brabant, Halsteren, The Netherlands.
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