How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study.

BACKGROUND: The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication. METHODS: The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document. RESULTS: Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times. CONCLUSION: The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study.

BACKGROUND: Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment. AIMS: To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment. METHOD: A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission. RESULTS: A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement. CONCLUSIONS: Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

Coerced hospital admission and symptom change--a prospective observational multi-centre study.

INTRODUCTION: Coerced admission to psychiatric hospitals, defined by legal status or patient's subjective experience, is common. Evidence on clinical outcomes however is limited. This study aimed to assess symptom change over a three month period following coerced admission and identify patient characteristics associated with outcomes. METHOD: At study sites in 11 European countries consecutive legally involuntary patients and patients with a legally voluntary admission who however felt coerced, were recruited and assessed by independent researchers within the first week after admission. Symptoms were assessed on the Brief Psychiatric Rating Scale. Patients were re-assessed after one and three months. RESULTS: The total sample consisted of 2326 legally coerced patients and 764 patients with a legally voluntary admission who felt coerced. Symptom levels significantly improved over time. In a multivariable analysis, higher baseline symptoms, being unemployed, living alone, repeated hospitalisation, being legally a voluntary patient but feeling coerced, and being initially less satisfied with treatment were all associated with less symptom improvement after one month and, other than initial treatment satisfaction, also after three months. The diagnostic group was not linked with outcomes. DISCUSSION: On average patients show significant but limited symptom improvements after coerced hospital admission, possibly reflecting the severity of the underlying illnesses. Social factors, but not the psychiatric diagnosis, appear important predictors of outcomes. Legally voluntary patients who feel coerced may have a poorer prognosis than legally involuntary patients and deserve attention in research and clinical practice.

Globalisation and mental disorders. Overview with relation to depression.

BACKGROUND: Globalisation is the process by which traditional boundaries of cultures are changing. Industrialisation, urbanisation and influence of the media are influencing idioms of distress across cultures. AIMS: To discuss the role of globalisation, using the epidemiology, diagnosis, clinical presentation and treatment of depression across various cultures as an example. METHOD: Recent studies focusing on transcultural aspects of depression were reviewed and summarised. RESULTS: Cultural, social and religious mores account for variations in the presentation of depression across cultures. Somatic symptoms are common presenting features throughout the world and may serve as cultural idioms of distress, but psychological symptoms can usually be found when probed. Feelings of guilt and suicide rates vary across cultures and depression may be underdiagnosed. CONCLUSIONS: Training packages could enhance clinicians'cultural competency in multicultural settings. However, globalisation is likely to influence idioms of distress and pathways to care in ways that are difficult to predict.

Prevalence of bulimic behaviours and eating attitudes in schoolgirls from Trinidad and Barbados.

We investigated eating attitudes and the prevalence of bulimic disorders in a group of 362 schoolgirls from the islands of Trinidad and Barbados using key questions from the Bulimia Investigatory Test, Edinburgh (BITE) and additional questions for the exploration of eating attitudes and dieting practices. A random sample of 92 girls were interviewed using the DSM-III-R Bulimia Diagnostic Interview. Only three subjects (0.8%) scored over the cut-off point on the BITE. None of the interviewees was diagnosed as having bulimia nervosa. Two hundred and forty-five girls (67.7%) reported being terrified of becoming fat and fat-fear was associated with higher Body Mass Index, dieting and exercising for losing weight. Girls of African origin were found to have a more unusual eating pattern and more concerns about their eating habits. The prevalence of bulimic disorders in Caribbean schoolgirls is still very low, but they are a population at increasing risk since they share the western ideals of slimness and engage in dieting behaviours.