https://onlinelibrary.wiley.com/doi/pdf/10.1002/wps.20084

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems

European archives of psychiatry and clinical neuroscience

Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions. (Psychiatric Services 61: 1012-1017, 2010)

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Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries

Background: Existing studies of mental health interventions in low-resource settings have employed highly structured interventions delivered by non-professionals that typically do not vary by client Given high comorbidity among mental health problems and implementation challenges with scaling up multiple structured evidence-based treatments (EBTs), a transdiagnostic treatment could provide an additional option for approaching community-based treatment of mental health problems Our objective was to test such an approach specifically designed for flexible treatments of varying and comorbid disorders among trauma survivors in a low-resource setting Methods and Findings: We conducted a single-blinded, wait-list randomized controlled trial of a newly developed transdiagnostic psychotherapy, Common Elements Treatment Approach (CETA), for low-resource settings, compared with wait-list control (WLC) CETA was delivered by lay workers to Burmese survivors of imprisonment, torture, and related traumas, with flexibility based on client presentation Eligible participants reported trauma exposure and met severity criteria for depression and/or posttraumatic stress (PTS) Participants were randomly assigned to CETA (n=182) or WLC (n=165) Outcomes were assessed by interviewers blinded to participant allocation using locally adapted standard measures of depression and PTS (primary outcomes) and functional impairment, anxiety symptoms, aggression, and alcohol use (secondary outcomes) Primary analysis was intent-to-treat (n=347), including 73 participants lost to follow-up CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use (alcohol use analysis was confined to problem drinkers) The difference in mean change from pre-intervention to post-intervention between intervention and control groups was 2049 (95% CI: 2059, 2040) for depression, 2043 (95% CI: 2051, 2035) for PTS, 2042 (95% CI: 2058, 2027) for functional impairment, 2048 (95% CI: 2061, 2034) for anxiety, 2024 (95% CI: 2034, 2015) for aggression, and 2003 (95% CI: 2044, 050) for alcohol use This corresponds to a 77% reduction in mean baseline depression score among CETA participants compared to a 40% reduction among controls, with respective values for the other outcomes of 76% and 41% for anxiety, 75% and 37% for PTS, 67% and 22% for functional impairment, and 71% and 32% for aggression Effect sizes (Cohen’s d) were large for depression (d=116) and PTS (d=119); moderate for impaired function (d=063), anxiety (d=079), and aggression (d=058); and none for alcohol use There were no adverse events Limitations of the study include the lack of long-term follow-up, non-blinding of service providers and participants, and no placebo or active comparison intervention Conclusions: CETA provided by lay counselors was highly effective across disorders among trauma survivors compared to WLCs These results support the further development and testing of transdiagnostic approaches as possible treatment options alongside existing EBTs Trial registration: ClinicalTrialsgov NCT01459068 Please see later in the article for the Editors’ Summary

https://cyberleninka.org/article/n/1006038.pdf

A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand.

Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics The study includes data from 32 acute psychiatric wards Multilevel logistic regression using Stata was applied with data from 1016 involuntary admitted patients that were linked to data about wards The sample comprised two hierarchical levels (patients and wards) and the dependent variables had two values (0 = no use and 1 = use) Coercive measures were defined as use of seclusion, restraint and involuntary depot medication during hospitalization The total number of involuntary admitted patients was 1214 (35% of total sample) The percentage of patients who were exposed to coercive measures ranged from 0-88% across wards Of the involuntary admitted patients, 424 (35%) had been secluded, 117 (10%) had been restrained and 113 (9%) had received involuntary depot medication at discharge Data from 1016 patients could be linked in the multilevel analysis There was a substantial between-ward variance in the use of coercive measures; however, this was influenced to some extent by compositional differences across wards, especially for the use of restraint The substantial between-ward variance, even when adjusting for patients' individual psychopathology, indicates that ward factors influence the use of seclusion, restraint and involuntary medication and that some wards have the potential for quality improvement Hence, interventions to reduce the use of seclusion, restraint and involuntary medication should take into account organizational and environmental factors

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A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics

Objective The aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions. Methods Combined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas. Results There are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries. Conclusions Databases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

http://www.cfmhas.org.uk/assets/Lepping-2010-seclusion.pdf

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

Several countries have established or are planning acute psychiatric in-patient services that accept around-the-clock emergency admission of adolescents. Our aim was to investigate the characteristics and clinical outcomes of a cohort of patients at four Norwegian units. We used a prospective pre-post observational design. Four units implemented a clinician-rated outcome measure, the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), which measures mental health problems and their severity. We collected also data about the diagnoses, suicidal problems, family situations, and the involvement of the Child Protection Service. Predictions of outcome (change in HoNOSCA total score) were analysed with a regression model. The sample comprised 192 adolescents admitted during one year (response rate 87%). Mean age was 15.7 years (range 10-18) and 70% were girls. Fifty-eight per cent had suicidal problems at intake and the mean intake HoNOSCA total score was 18.5 (SD 6.4). The largest groups of main diagnostic conditions were affective (28%) and externalizing (26%) disorders. Diagnoses and other patient characteristics at intake did not differ between units. Clinical psychiatric disorders and developmental disorders were associated with severity (on HoNOSCA) at intake but not with outcome. Of adolescents ≥ 16 years, 33% were compulsorily admitted. Median length of stay was 8.5 days and 75% of patients stayed less than a month. Compulsory admissions and length of stay varied between units. Mean change (improvement) in the HoNOSCA total score was 5.1 (SD 6.2), with considerable variation between units. Mean discharge score was close to the often-reported outpatient level, and self-injury and emotional symptoms were the most reduced symptoms during the stay. In a regression model, unit, high HoNOSCA total score at intake, or involvement of the Child Protection Service predicted improvement during admission. Acute psychiatric in-patient units for adolescents effectively meet important needs for young people with suicidal risks or other severe mental health problems. These units may act in suicide prevention, stabilizing symptom severity at a lower level within a short stay. It is important to explore the differences in outcome, compulsory admissions, and length of stay between units.

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Admissions to acute adolescent psychiatric units: a prospective study of clinical severity and outcome

The objective of the study was to investigate the experiences of humiliations by patients in the admission process to acute psychiatric wards. One-hundred-and-two patients were interviewed within 48 h after hospitalization about their experiences of the admission process. The structured Admission Experience Survey questionnaire was used to identify negative events of the admission process. Perceived humiliation was defined by a cut-off on the self-reported Cantrill's Ladder Scale. Six qualitative depth interviews of patients with high and low humiliation scores were performed in order to relate interview information on humiliation experiences to the self-report. Negative events during the admission process were significantly more common among patients with involuntary admission, but were also observed among those voluntary admitted. Humiliation in connection with negative events during the admission process was reported by 48 patients, 24 involuntary and 24 voluntary admitted. In univariate analyses, humiliation was significantly associated with events where the patients were exposed to verbal or physical force, as well as with the conviction that "the admission was not right". In multivariate analyses, the latter conviction was the only significant one, although "use of physical force" also showed a trend (P=0.06). Negative events are common among the routines, procedures, and situations of the admission process to acute psychiatric wards. Some of them can hopefully be modified such as the use of verbal and physical force. In contrast, the conviction that "the admission was not right", which showed the strongest association with humiliation, seems less modifiable in the admission process.

Patients’ experience of humiliation in the admission process to acute psychiatric wards

Internationally there has been a long debate regarding the use, and potential misuse, of coercion in psychiatry. One of the topics that has gained most attention is compulsory admissions. Only a few studies have published cross-country comparisons on the magnitude of compulsory admissions. This study presents data on voluntary and compulsory admissions to psychiatric hospitals in Norway in 1996. Approx 47% of all admissions were compulsory, and the rates were 147 per 100 000 inhabitants. These are both high figures compared to other countries. Regarding patient characteristics, our study confirms the international findings in most fields, except for a higher proportion of women and nonpsychotic patients admitted compulsory. The observed substantial regional differences in compulsory admission are primarily explained by variations in diagnoses. Whether the recent changes in the Norwegian Mental Health Act will reduce these figures are discussed.

Trond Hatling

Papers

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

Admissions to acute adolescent psychiatric units: a prospective study of clinical severity and outcome

Patients’ experience of humiliation in the admission process to acute psychiatric wards

Compulsory admissions to psychiatric hospitals in Norway - international comparisons and regional variations

Diversity and Consistency in the Legal Management of Involuntary Admission and Treatment Across Europe