INVOLUNTARY HOSPITALIZATION IN PSYCHIATRIC CARE - SOME STILL UNANSWERED QUESTIONS

INVOLUNTARY HOSPITALIZATION IN PSYCHIATRIC CARE - SOME STILL UNANSWERED QUESTIONS Georg Høyer, University of Tromsø, Norway

DOES COERCION WORK?

REPHRASING THE QUESTION: How is the outcome for those subjected to coercion compared to those who are not? Measured as…….? In the short or long run…?

ANOTHER WAY OF REPHRASING THE QUESTION What do we know about treatment outcome of mental disorders in general (without the use of coercion)? Does coercion change the outcome we have documented from none coercive treatment interventions?

Age, Gender, Cultural background, Education Housing, Social class, Employment Kind of problems, Severity of problems Environment, Standard of treatment fascilities and staff Information, Communication, Patient involvement Network, Relatives, Friends, Follow up Coercion (Perceived coercion, legal status, factual coercion) ……and more KIND OF TREATMENT HOW DOES COERCION EFFECT OUTCOME? TREATMENT OUTCOME COERCION IS ONLY ONE OF MANY THINGS, CIRCUMSTANCES AND EVENTS, IN ADDITION TO PATIENT AND STAFF CHARACTERISTICS, THAT MAY HAVE AN IMPACT ON OUTCOME

COMMON OUTCOME MEASURES USED IN COERCION RESEARCH • Symptoms (GAF, BPRS; HoNOS, PANSS, PTSD) • Use of inpatient services • Use of health- and social services • Treatment-compliance • Use of medication • Substance abuse • Violence and crime • Self-assessed mental health • Tratment satisfaction (whom?) • Insight • Social situation (work, housing, network) • Mortality

WITH TREATMENT WITHOUT TREATMENT HEALTHY TIME ILL

WITH TREATMENT WITHOUT TREATMENT HEALTHY TIME WEEKS YEARS ILL

COERCION AND OUTCOME:A LITTERATURE REVIEW • Search terms (separate or in combinations): • Coercion AND/OR mental health • Coercion AND outcome • Coercion AND/OR treatment • Involuntary treatment AND psychiatry • Involuntary treatment • Treatment refusal • Coerced treatment • Voluntary treatment • Coercion • Outcome assessment • Data bases: Medline, PsychINFO, Embase, Campbell • Other sources: Cohrane Library, References in key publications • Papers on involuntary hospitalization, mandated community treatment, and forced treatment were included, while dangerousness and violence as only outcomes were excluded

COERCION AND OUTCOME:A LITTERATURE REVIEW, cont. RESULTS:1350 papers, No restrictions regarding publication year Only papers from peer review journals were included When restricting the inclusion criteria to studies that included coercion as an independent variable and reported at least one outcome measure, the number of papers was reduced to: 121 In addition 2 Cohrane reviews on the effect of coercion were indentified

COERCION AND OUTCOME:A LITTERATURE REVIEW, cont. RESULTS: Only two RCT’s, both on mandated community treatment Conflicting evidence regarding outcome Two Cohrane reviews regarding the use of coercion:One on mandated outpatient treatment (2005, inconclusive) and one on the use of coercive measures (2000, inconclusive) Four review studies on coercion and in-patient treatment, And two review studies on mandated community treatment. All of them inconclusive and all of them underlining the low scientific quality of coercion studies

: “It is impossible to distinguish whether different findings reflect true variation in outcomes – e.g. because of differences in context, patient characteristics and treatment, or changes of views over time – or are due to methodological inconistence or both”. Katsakou C, Priebe S: Outcomes of involuntary hospital admission: a review. Acta Psychiatr Scand 2006; 114: 232-241 Take home message no I: We don’t know how coercion affects the outcome of psychiatric treatment

“Based on the generally low methodological level of research demonstrated in this important and sensitive field of mental health service provision, and because of the huge variety in the methodological aspects appearing in the studies assessed, a significant need to perform future methodologiclly-sound studies in routine care settings remains”. • Kallert TW, Glöckner, Schützwohl. Involunatry vs voluntary hospital admission. A systematic literature review on outcome diversity. Eur Arch Clin Neurosci 2008; 258: 195-209 WHY??? Basically because of low scientific quality

WHY the LOW SCIENTIFIC QUALITY??? Basically because research on coercion is difficult! • Coercion is hard to define and hard to measure • Selection biases • Outcome measures • Comparison groups

FORMAL (LEGAL) COERCION WHAT CONSTITUTES COERCION? PROCEDURES PHYSICAL (CONCRETE) COERCION PERCEIVED COERCION

UNCERTAIN CONCLUSIONS 1(Take half-way-home messages) Some likely conclusions based on the research litterature SYMPTOMS: Most, but not all, studies find no differences in improvement of symptoms. This seems to be the case both for professional assesments and self-rated improvement, and applies to both in-patient and out-patient settings ACCEPTANCE OF THE USE OF COERCION In most studies more than 50% of the patients accept the use of coercion in retrospect (range 33-75%). The acceptance increases over time (while perceived coercion remain constant)

UNCERTAIN CONCLUSIONS 2 More liekly conclusions to take half-way home based on the research litterature PERCEIVED COERCION. A consistant finding is the poor relationship between perceived coercion and legal status. Another consistant finding is that process inclusion (or exclusion) is the best predictor of perceived coercion. The U-shaped distribution of perceived coercion scores, indicates that perceived coercion tend to be an either-or phenomenon PATIENT SATISFACTION Roughly more than half of the committed patiens reprot being satisfied with the treatment (Range 39-81%)

REFERENCES AND SLIDES CAN BE FOUND AT: WWW.TVANGSFORSKNING.NO References are edited as follows: A: References on coercion by publication type 1. Review papers A. Inpatient treatment B. Mandated Community Treatment (Outpatient Commitment) 2. Randomized Controlled Trials on coercive interventions 3. Cohrane Reviews. Only two reviews address coercion (Kisely, Campbell & Preston, 2005 and Sailas & Fenton, 2000). Other reviews with relevance to coercion resaerch have been included, B: Complete reference list

INVOLUNTARY HOSPITALIZATION IN PSYCHIATRIC CARE - SOME STILL UNANSWERED QUESTIONS