Discussing studies on how to reduce coercion in Psychiatry

1. Discussing studies on howtoreducecoercion in Psychiatry Prof. Dr. C.L. Mulder Norway May 21

2. Topics • CompulsoryAdmissions • Epidemiology • Criteria • Effects • Prevention • Future studies • Inpatientcoercion

3. Epidemiology of involuntary admissions

4. Portugal: 6/100.000 Decision psychiatrist + judge + advocate Finland: 218/100.000 Decision by medical doctor only Compulsory admissions in Europe (Salize et al. 2004)

5. Italy/Portugal: 15/100.000 Higher numbers in countries with more beds Higher poverty, lower numbers Austria 282/100.000 Compulsory admission in Europe (Rains et al. in press)

6. Emergency Compulsory Admissions Alternating Patterns in Rotterdam: 1924 – 2005(Wierdsma et al., Hist Psychiatry 2008) Mentoringpsychiatry Regionalpsychiatry Socialpsychiatry Custodialpsychiatry Antipsychiatry

7. Coercion in the Netherlands (absolute numbers)

8. Criteria for commitment specified by statutes, laws or acts in various European countries(Salize et al. 2004)

9. Association between commitment criteria and number of involuntary admissions (Dressing et al. 2005) • In countries using only dangerousness criteria men were more frequently committed then women • No association between commitment criteria and total number of involuntary admissions • In countries that have a legal representative (advocate) the number of involuntary admissions was lower

10. PsychiatricBeds in Europe NL Germ Eurostat, 2017

11. PsychiatricBeds 2009 – 2014(per 100.000 inhabitants) Eurostat, 2017

12. The standard in Europe

13. Reduction of beds paralel to increase of involuntary admissions in UK Keown et al. BMJ 2011

14. Subgroups at risk for Involuntary Admission

19. Conclusion Largedifferences in (subgroups) of involuntaryadmissionrateswithin and betweenEuropeancountries

20. Future research • Learnfromcountrieswith low numbers? • In depth studies of differences in • Mental Health Laws • Populations at risk anddangerousnesscriteria • Socioculturalandeconomical factors • Attitudes frompatients, significant others, clinicians, politicians, andpolice

21. Future research • In depth studies of differences in: • Mental Health Laws • Populations at risk anddangerous criteria • Sociocultural, politicalandeconomical factors • Opinionsfrompatients, significant others, clinicians, politicians, andpoliceaboutcoercion

22. Future research • Comparecountries in Europe (numbers per 100.000), e.g.: • Norway (2016): 150 Declining • Denmark (2017): 58 Declining • Netherlands (2015): 115 Rising

23. Future research • Data bases needed: • Data of patients • Demographic • Psychiatric • Dangerousness • Data on mental health laws • Data on mental health system

24. Dangerousness Criteria

25. Netherlands Mental Health Law • Law forInvoluntaryadmission: • disorder causesdanger, • lessrestrictivealternativenotavialable, • patient does notexplicitly state thathe want to beadmitted • CommunityTreatment Order Available • Patient has to complywithpre-setconditions • Ifnot: involuntaryadmission

26. Changes in Dangerousness Criteria for EIA 1997-2005 in patients with psychotic disorders > 18 years (Mulder et al. IJLP 2008) *: p<0.01

27. Effects of Compulsory Admissions

28. Effects of involuntary admissions(Baars, Mulder et al. Psychiatr Serv 2010)

29. Changes in HoNOS scores after involuntary admission in ACT patients(Kortrijk, Mulder et al. SPPE, 2010)

30. Changes in motivation after involuntary admission in ACT patients (Kortrijk, Mulder et al. SPPE, 2010)

32. Prevention of compulsoryadmissions

34. Metaanalysiseffects of interventionsaimed at reduction of involuntaryadmissions

42. Opinions of patients and carers • Borum et al. (1999): 306 clients were interviewed about beliefs regarding CCT. They think that CCT leads to better adherence to treatment: 83 % believed patients under CCT are more likely to take their medication, 76.5 believed they were more likely to stay out of hospital and 82% thought people under CCT were more likely to stick to their appointments • Gibbs et al. (2005): interviewed 42 clients who had experience with CCT and they were generally supportive, especially if the alternative was admission • Mullen et al. (2006): interviewed 27 relatives of clients they were generally in favour of using CCT, experiencing a positive influence on their relatives, themselves, family relationships and relations with clinical staff

43. Clinicians’ opinionsabout CTO 62% in favor of CTO’s 78.8% of the psychiatrists and 84.8% of the other mental health professionals preferred CCT 60% of psychiatrists preferred to work in a system with CCT 83% of the participating psychiatrists and 67% of the other professionals were in favour of working with CCT • O’Reilly et al. (2000, Canada) • Romans et al. (2004) • Manning et al. (2011, England) • Coyle (2013, England)

44. New Mental Health Law Netherlands 2020 • Criteria (unchanged): psychiatric disorder causingdanger, no other options available • Making itpossibletouseoutpatientinvoluntary treatment in thepatients’ home • Unique ’’experiment’’

45. Leverage and coercion

47. Discussion • Do we believethatCTO’s do not have any effect? • Are CTO’sanunwanted ‘’alternative’’ forgoodqualitycommunity care? • How to proceedwith studies onCTO’s? • More studies onleverage?

49. Money for Medication?

50. Results Primary outcome MPR > 80%