Coercion in Mental Health Services

1. Coercion in Mental Health Services Thomas W. Kallert Park-Hospital Leipzig, Department of Psychiatry, Psychosomatic Medicine and Psychotherapy & Soteria Hospital Leipzig & Medical Faculty, Dresden University of Technology Royal College of Psychiatrists, Faculty of Rehabilitation and Social Psychiatry, Annual Residential Conference Prague, 13 November 2008

2. Aim and Method Aims: To highlight issues in the field of coercion in mental health services which have gained recent importance, and To stimulate the discussion in our profession „Methods“: systematic literature review, and personal involvement in initiatives like the EC-funded project „European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (Acronym: EUNOMIA) (own position: project co-ordinator) and the first WPA-co-sponsored Thematic Conference „Coercive Treatment in Psychiatry: A Comprehensive Review“, June 2007 in Dresden (own position: Chair of the Organizing Committee)

3. The issues addressed in this presentation Findings on involuntary hospital admission Two important papers on coercion and the law Patient's perspective, and family burden of coercion Outpatient commitment Coercion in special (health care) settings and patient subgroups Decision variables for involuntary commitment Clinical guidelines re the use of coercive measures Minimization of coercive measures

4. Findings on (outcomes of) involuntary hospital admission3 systematic reviews First paper: 18 studies on outcomes, and predictors of outcomes Results: Most involuntarily admitted patients showed substantial clinical improvement over time Retrospectively, between 33% and 81% of patients regarded the admission as justified and/or the treatment as beneficial Inconsistent data on predictors of outcomes: patients with more marked clinical improvement tended to have more positive judgements. It is unclear, however, which patients are likely to fall into this group.

5. Findings on (outcomes of) involuntary hospital admission (ctd.) Second review on 5 qualitative studies of patient’s experiences of involuntary hospital admission and treatment Results: Patients mentioned both positive and negative consequences in the following main areas: perceived autonomy and participation in decisions for themselves, feeling of whether or not being cared for, and sense of identity. To assess differences in these areas between different patient groups may be an important future research area.

6. Findings on (outcomes of) involuntary hospital admission (ctd.) Third paper: 41 references on the outcome of acute hospitalization for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily. Main results: Length of stay, readmission risk, and risk of involuntary readmission were at least equal or greater for involuntary patients. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. Involuntary patients demonstrated lower levels of social functioning, and equal levels of general psychopathology and treatment compliance; they were more dissatisfied with treatment and more frequently felt that hospitalization was not justified.

7. Limitations of research on involuntary hospital admission vastly different sizes of the samples assessed, follow-up periods and attrition rates majority of the studies carried out in English-speaking countries limited use of comparable standardized instruments for assessing observer-based clinical, and, in particular, subjective outcome domains most outcome results have been established in middle-aged samples of general psychiatric patients with a diagnostic focus on psychotic or, even more specifically, on schizophrenic disorders overall methodological quality of the studies reviewed rather low; only results on service-related outcomes have been established with sufficient methodological quality

8. What could be concluded? Acute involuntary hospitalization may not be automatically associated with a higher risk for overall negative outcome, but might bear specific risks on selected outcome domains that might be therapeutically influenced. This could be an important message helping to de-stigmatize this treatment approach. Further research should clarify if the legal admission status is sufficiently valid for differentiating the outcome of acute hospitalization. In this respect, new concepts of coercion in which the patient’s perspective plays a more dominant role should be explored.

9. Two important papers on coercion and the law Analysis of civil law issues associated with involuntary hospitalization in psychiatric establishments of 12 European countries Result: major cross-national differences (for details: see next slide)

10. Major cross-national differences of legal regulations with relevance for the clinical practice of involuntary hospitalization appeared for the following issues basic conditions as well as additional criteria for involuntary admission time periods for making decisions patients’ rights to register complaints the association between involuntary placement and treatment regulations referring to specific involuntary treatment measures during hospitalization roles of relatives professional qualifications of the physicians involved in the legally-defined decision processes safeguard procedures of these processes, and inclusion and specification of outpatient commitment

11. Most important issues that could be standardized cross-nationally The legal basis for treatment decisions (including the treatment setting ) must be simplified to the greatest extent possible The powers of decision must be clearly subdivided and assigned to different professional roles; their standard of professional competency needs to be defined Time periods for the judicial decisions and performance of judicial authorities should be cross-nationally standardized At each stage of judicial proceedings mandating involuntary hospitalization and coercive treatment measures, the patient should have to the right to a legal representative

12. Most important issues that could be standardized cross-nationally (ctd.) Regulations to lodge appeals must be as simple and transparent as possible Regulations about the involvement of relatives or advocates must be as simple and transparent as possible Permanent and active monitoring procedures for supervising authorities should be established in order to increase the legal safety of all parties involved

13. Two important papers on coercion and the law (ctd.) Review of the European Court of Human Rights (ECHR) case law concering psychiatric commitment. Result: Of the almost 118,000 decisions taken by the ECHR in a 50-years period only 108 dealt with situations concerning psychiatric commitment. Conclusion (most worrying): The possibility of an individual to access to ECHR depends on the degree of democracy in his country and on the access to legal assistance through non-governmental organizations or individual intervening parties.

14. Patient's (negative) perspective, and family burden of coercion What is needed for improvement in this field (3 examples)? First study: compared three groups of patients – committed, voluntary and persuaded – admitted to acute psychiatric inpatient care in Norway Results: A substantial proportion of the patients did not know their legal status. Many reported restrictions on movement, forced medication and patronizing communication. Compared to voluntary patients, the two other groups were characterized by lack of influence and forced medication, but showed high satisfaction with the key worker.

15. Patient's (negative) perspective, and family burden of coercion (ctd.) Important conclusions for clinical practice would be that involuntariness might be associated with increased likelihood of feeling excluded from participation in the treatment, and that the key worker might have a prominent role for committed and persuaded patients This is more or less supported by the second example:

16. Patient's (negative) perspective, and family burden of coercion (ctd.) Assessment of a systematic intervention (standardized procedure of when and how a specifically tailored eight-page patient information brochure was presented) in a large sample of patients consecutively admitted in a emergency ward. Results: The patients’ general satisfaction scores increased only slightly during and after the intervention, but a robust and sustained improvement of the patients’ satisfaction with the information received was recorded. Furthermore, the patients also reported an increased knowledge about specific legal issues related to their hospitalization. Conclusion: In order to strengthen the empowerment of involuntarily admitted patients, such interventions should enter routine clinical practice. This could counterbalance the patients’ negative experience.

17. Family burden of coercion (ctd.) Little research so far Small qualitative Australian study using focus group methodology assessed impact of involuntary commitment on the burden experienced by the family. Results: The relevant Mental Health Act did little to assist the family in gaining access to mental health services Family members perceived that they were not listened to and their concerns were not acted upon Mental health services appeared to serve, to a large degree, to estrange the family from the consumer making relationships difficult and time-consuming to repair Conclusion: We should take this seriously!

18. Outpatient commitment Review article assessed RCT and non-RCT evidence for the effect of compulsory community treatment Results: No statistical differences in 12-month admission rates between subjects on involuntary out-patient treatment and controls Time to admission was equivocal Only regarding admissions of over 10 days patients receiving the intervention were less likely to have such long-term hospitalizations No clear differences in treatment adherence

19. Outpatient commitment (ctd.) Conclusions: In the light of the limited evidence of positive effects of involuntary outpatient treatment as a less restrictive alternative to admission, a wide range of outcomes should be evaluated if this type of legislation is introduced These results add to the legal concerns in several (European) countries to legitimize this treatment option

20. Coercion in special (health care) settings and patient subgroups (2 examples) Finnish study on basic commitment criterions for minors carried out reflexive dyadic interviews with psychiatrists working with children and adolescents Results: There was general agreement about what constitutes the (imprecise) commitment criterion “severe mental disorder” (established in a most recent mental health legislation) justifying the involuntary psychiatric treatment of minors The psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment

21. Coercion in special (health care) settings and patient subgroups (2 examples) Review of socially sanctioned coercion mechanisms for addiction treatment, an often negatively perceived approach Substantial findings Such mechanisms (available for decades like licensure sanctions and employee assistance programs) are effective in initiating recovery and achieving positive clinical outcomes. On contrast, social security disability benefits seem to be an area where an opportunity for “constructive” coercion was missed in the treatment of substance use disorders.

22. Coercion in special (health care) settings and patient subgroups (2 examples)(ctd.) The authors call for implementing socially sanctioned mechanisms of coercion, although this may be seen as a paradigm shift in mental health treatment. This shift would involve an acceptance of the involuntary aspects of addiction as well as concern about the impact of addiction on society, but may need to occur because of the increased understanding of the impact of addiction on brain functioning with subsequent compromise of volitional controls. It remains to be seen, if this position will attract broader professional and societal support.

23. Coercion in special (health care) settings and patient subgroups (ctd.) New research projects have been started in somatic settings, forensic psychiatric hospitals and settings for mentally retarded Further, mentally ill offenders received a special interest. An expert evaluation carried out in 15 European Union Member States showed a considerable variety of concepts and practice routines referred to the placement and treatment of mentally disordered offenders. Further, national health reporting standards and the quality of available administrative data was poor, and models of good practice in this field seemed to be hard to choose.

24. Decision variables for involuntary commitment Assessing the variables which drive the decision for involuntary commitment in psychiatric care is of high importance for service provision. The alarming result of a Belgian study was that involuntary commitment is mainly due to the inability of the mental health care system to provide more demanding patients with alternative forms of care. This needs to be urgently assessed in other countries.

25. Clinical guidelines re the use of coercive measures To establish guidelines on the use of coercive measures is an ongoing process (mostly carried out by national professional societies) in many countries (Bulgaria, Czech Republic, Germany, Sweden….) If cross-national harmonization of best clinical practice is feasible is an open research question

26. Clinical guidelines re the use of coercive measures (ctd.) Method used in the EUNOMIA-project: Local expert groups in 11 countries worked out their recommendations in semi-structured group discussions. By use of a system of categories developed with a content-analytical method, these national documents were comparatively assessed, and integrated into a common clinical recommendation. Results: Legal and clinical pre-conditions for the use of e.g. mechanical restraint, specific instructions for the clinical behaviour of different professional groups, ethical issues, and procedural aspects of quality assurance were defined. Conclusions: Compared with established clinical guidelines, similarities concerning basic principles of clinical use appear to be higher than similarities concerning practical details.

27. Could coercive measures be minimized?

28. The Pennsylvania example Database: records of patients older than 18 years who were civilly committed to one of the nine state hospitals in the period 1990 to 2000. Results (presented data compare between 1990 and 2000): The rate of seclusion decreased from 4.2 to 0.3 episodes per 1,000 patient-days The average duration of seclusion decreased from 10.8 to 1.3 hours The rate of restraint decreased from 3.5 to 1.2 episodes per 1,000 patient-days The average duration of restraint decreased from 11.9 to 1.9 hours

29. Changes that influenced reduction in seclusion and restraint (I): Leadership: stimulated by several staff and user-representatives‘ activities some very important high-ranking health political activities were defined: seclusion and restraint were announced as representing “Treatment failure“, data collection and comparison across hospitals was improved, staff training programs were emphasized Independent (patient) advocates were assigned to each hospital Further state policy changes: e.g. definition of procedures for patient and staff debriefing sessions after the use of seclusion or restraint, orders for restraint and seclusion limited to no more than 60 minutes Implementation of psychiatric emergency response teams in each hospital

30. Changes that influenced reduction in seclusion and restraint (II): Decrease of unit size (from 36 to 32 beds) and improved patient-to-staff ratios (from 1 licensed psychiatric nurse and 3 psychiatric aides during the day and evening shifts (1990) to 2 licensed nurses and 4 psychiatric aides (2000)) Implementation of an incident management system containing 35 indicators (e.g. details of each forced medication): data aggregated on a monthly basis and shared with the hospitals as benchmarking, available at each ward as a report Second-generation antipsychotics Increase in the quantity and quality of active non-pharmacologic patient treatment

31. General Conclusions This presentation highlighted not only present main findings of recent research in this field, but also showed that coercion in mental health services is an important area for future clinical and research initiatives. Because of the linkages with legal, human rights, and ethical issues a huge number of individual (research) questions needs to be addressed in the future.

32. Thank you so much for your kind attention!