Involuntary psychiatric hospitalisation - differences and similarities between patients detained under the mental health act and according to the legal guardianship legislation.

BACKGROUND: Involuntary psychiatric hospitalisation occurs under different legal premises. According to German law, detention under the Mental Health Act (MHA) is possible in cases of imminent danger of self-harm or harm to others, while detention according to the legal guardianship legislation (LGL) serves to prevent self-harm if there is considerable but not necessarily imminent danger. This study aims to compare clinical, sociodemographic and environmental socioeconomic differences and similarities between patients hospitalised under either the MHA or LGL. METHODS: We conducted a retrospective health records analysis of all involuntarily hospitalised cases in the four psychiatric hospitals of the city of Cologne, Germany, in 2011. Of the 1,773 cases, 87.3% were detained under the MHA of the federal state of North Rhine-Westphalia and 6.4% were hospitalised according to the federal LGL. Another 6.3% of the cases were originally admitted under the MHA, but the legal basis of detention was converted to LGL during the inpatient psychiatric stay (MHA→LGL cases). We compared sociodemographic, clinical, systemic and environmental socioeconomic (ESED) variables of the three groups by means of descriptive statistics. We also trained and tested a machine learning-based algorithm to predict class membership of the involuntary modes of psychiatric inpatient care. RESULTS: Cases with an admission under the premises of LGL lived less often on their own, and they were more often retired compared to MHA cases. They more often had received previous outpatient or inpatient treatment than MHA cases, they were more often diagnosed with a psychotic disorder and they lived in neighbourhoods that were on average more socially advantaged. MHA→LGL cases were on average older and more often retired than MHA cases. More often, they had a main diagnosis of an organic mental disorder compared to both MHA and LGL cases. Also, they less often received previous psychiatric inpatient treatment compared to LGL cases. The reason for detention (self-harm or harm to others) did not differ between the three groups. The proportion of LGL and MHA cases differed between the four hospitals. Effect sizes were mostly small and the balanced accuracy of the Random Forest was low. CONCLUSION: We found some plausible differences in patient characteristics depending on the legal foundation of the involuntary psychiatric hospitalisation. The differences relate to clinical, sociodemographic and socioeconomical issues. However, the low effect sizes and the limited accuracy of the machine learning models indicate that the investigated variables do not sufficiently explain the respective choice of the legal framework. In addition, we found some indication for possibly different interpretation and handling of the premises of the law in practice. Our findings pose the need for further research in this field.

[Effects of a Motivational Intervention on the Effectiveness and Sustainability of Sports and Exercise Therapy in Inpatient Psychiatric Care]. / Effekte einer motivationalen Intervention auf die Wirksamkeit und Nachhaltigkeit der Sport- und Bewegungstherapie in der stationären psychiatrischen Versorgung.

OBJECTIVE: Reinforcement and sustainability of sports and exercise therapy in inpatient depression treatment. METHODS: Randomized controlled study with 3 measurement times: t0 admission to the study, t1 after four weeks, t2 two months after discharge. 96 inpatients with depressive disorders (ICD-10 F32, F33) were randomly assigned to an intervention group (IG) or a control group (KG). In addition to sports and exercise therapy (KG), the IG received an educational and motivational session on the importance of sports and exercise, as well as a motivational final discussion. RESULTS: Endurance performance and physical fitness improved more significantly in the IG than in the CG over the 3 measurement times. The motivational final discussion was rated as more helpful. DISCUSSION: The intervention was well accepted by the patients and partially increased the effects of sports and exercise therapy. Not only psychological aspects of depression treatment were influenced, but also measurable physical effects. CONCLUSION: The practical and time-efficient motivational intervention in inpatient psychiatric care can complement sports and exercise therapy for depressive patients.

[Social Determinants of Mental Health among Refugees in Germany - The Influence of Postmigratory Social Isolation and Resources on Psychopathology and Utilization Behavior]. / Soziale Determinanten für die psychische Gesundheit von Geflüchteten in Deutschland ­ Der Einfluss postmigratorischer sozialer Isolation und Ressourcen auf Psychopathologie und Inanspruchnahmeverhalten.

The mental health of refugees is influenced by a variety of pre-, peri- and postmigratory factors. It remains largely unclear how social determinants influence the utilization of psychiatric-psychotherapeutic treatment. We applied a questionnaire survey to 189 refugees from a clinical sample in a psychiatric hospital and from a control sample, which was not in treatment. The influence of social factors on psychopathology and utilization of care was analyzed by means of a CHAID algorithm. The total sample was highly stressed (54% PTSD and 41.4% depression symptoms). Patients were more severely affected in all psychometric scales as well as in traumatization and they were less able to draw on resources such as a social network or residence permit. The strongest predictor for psychotherapeutic-psychiatric treatment was social isolation in the living environment. For patients, the lack of a work permit was the strongest predictor of depression symptoms. The results point to the importance of postmigratory social determinants for the mental health of refugees. In particular, stable social relationships, together with formal factors such as work permit and residence title, should help to reduce mental distress and the need for psychiatric treatment.

Determinants of compulsory hospitalisation at admission and in the course of inpatient treatment in people with mental disorders-a retrospective analysis of health records of the four psychiatric hospitals of the city of Cologne.

BACKGROUND: We aimed to identify differences in predictors of involuntary psychiatric hospitalisation depending on whether the inpatient stay was involuntary right from the beginning since admission or changed from voluntary to involuntary in the course of in-patient treatment. METHODS: We conducted an analysis of 1,773 mental health records of all cases treated under the Mental Health Act in the city of Cologne in the year 2011. 79.4% cases were admitted involuntarily and 20.6% were initially admitted on their own will and were detained later during the course of in-patient stay. We compared the clinical, sociodemographic, socioeconomic and environmental socioeconomic data (ESED) of the two groups. Finally, we employed two different machine learning decision-tree algorithms, Chi-squared Automatic Interaction Detection (CHAID) and Random Forest. RESULTS: Most of the investigated variables did not differ and those with significant differences showed consistently low effect sizes. In the CHAID analysis, the first node split was determined by the hospital the patient was treated at. The diagnosis of a psychotic disorder, an affective disorder, age, and previous outpatient treatment as well as the purchasing power per 100 inhabitants in the living area of the patients also played a role in the model. In the Random Forest, age and the treating hospital had the highest impact on the accuracy and decrease in Gini of the model. However, both models achieved a poor balanced accuracy. Overall, the decision-tree analyses did not yield a solid, causally interpretable prediction model. CONCLUSION: Cases with detention at admission and cases with detention in the course of in-patient treatment were largely similar in respect to the investigated variables. Our findings give no indication for possible differential preventive measures against coercion for the two subgroups. There is no need or rationale to differentiate the two subgroups in future studies.

[Cologne Questionnaire on Attitudes Towards Coercive Measures (KEZ)]. / Der KEZ ­ Kölner Fragebogen zu Einstellungen zu Zwangsmaßnahmen.

OBJECTIVE: To develop a psychometric instrument for the assessment of the attitude of psychiatric staff towards the use of coercion. METHODS: Based on a literature search, interviews (37 open questions) were carried out by representatives each of doctors and nurses. A first version was developed, all doctors and nurses in a psychiatric clinic were asked to answer the questionnaire anonymously. RESULTS: 226 employees took part (response rate 32.3 %). A test-theoretical analysis led to a 39 item set with a high consistency of the overall scale (Cronbach's α =0 .904) and three factors: 1) Acceptance of coercive measures without questioning (Cronbach's α = 0.797); 2) Meaningfulness and legitimation of coercive measures (Cronbach's α = 0.812); and 3) Security and order through coercive measures (Cronbach's α = 0.791). CONCLUSIONS: With the KEZ an instrument is available that holistically presents the various aspects of the attitudes of psychiatric staff to the use of coercion.

[Opening up an acute psychiatric ward as a complex intervention]. / Öffnung einer psychiatrischen Akutstation als komplexe Intervention.

BACKGROUND: An open-door policy may help to reduce conflicts, aggression and containment measures in inpatient psychiatric care. OBJECTIVE: A complex intervention was performed including opening the doors of an acute psychiatric ward. The aim was to deescalate conflicts and reduce containment measures. METHODS: Along with opening of the doors, several other measures were taken including intensive training of staff in deescalating techniques and nonviolent communication, review and liberalization of rules of the ward, opening of a time-out room and access to a secure garden. RESULTS: The open-door policy proved to be feasible and was permanently established. Thereafter, incidents involving aggression decreased but containment measures did not. Overall, the staff appreciated the new concept but considered the opening of the doors to be of minor importance. CONCLUSION: The opening of a closed psychiatric ward should be understood as part of a complex, autonomy focused intervention. Other aspects such as sufficient numbers of well-trained staff and structural architectural features of the ward are possibly more important than opening of the doors.

A retrospective analysis of determinants of involuntary psychiatric in-patient treatment.

BACKGROUND: The purpose of our study was to identify predictors of a high risk of involuntary psychiatric in-patient treatment. METHODS: We carried out a detailed analysis of the 1773 mental health records of all the persons treated as in-patients under the PsychKG NRW (Mental Health Act for the state of North Rhine-Westphalia, Germany) in a metropolitan region of Germany (the City of Cologne) in 2011. 3991 mental health records of voluntary in-patients from the same hospitals served as a control group. We extracted medical, sociodemographic and socioeconomic data from these records. Apart from descriptive statistics, we used a prediction model employing chi-squared automatic interaction detection (CHAID). RESULTS: Among involuntary patients, organic mental disorders (ICD10: F0) and schizophrenia and other psychotic disorders (ICD10: F2) were overrepresented. Patients treated as in-patients against their will were on average older, they were more often retired and had a migratory background. The Exhaustive CHAID analysis confirmed the main diagnosis to be the strongest predictor of involuntary in-patient psychiatric treatment. Other predictors were the absence of outpatient treatment prior to admission, admission outside of regular service hours and migratory background. The highest risk of involuntary treatment was associated with patients with organic mental disorders (ICD 10: F0) who were married or widowed and patients with non-organic psychotic disorders (ICD10: F2) or mental retardation (ICD10: F7) in combination with a migratory background. Also, referrals from general hospitals were frequently encountered. CONCLUSIONS: We identified modifiable risk factors for involuntary psychiatric in-patient treatment. This implies that preventive measures may be feasible and should be implemented to reduce the rate of involuntary psychiatric in-patient treatment. This may include efforts to establish crisis resolution teams to improve out-patient treatment, train general hospital staff in deescalation techniques, and develop special programs for patients with a migratory background.

[Psychiatric and Psychotherapeutic Care of Refugees by Reference of a Large Psychiatric Care Hospital in Western Germany]. / Psychiatrisch-psychotherapeutische Versorgung von Geflüchteten am Beispiel eines großen psychiatrischen Versorgungskrankenhauses im Rheinland.

Medical and psychological care of refugees is among the most important current challenges in German health politics. Work with patients from this heterogeneous group who have often faced severe stress before, during and after their migration is currently based on a thin data foundation. Based on introductory information on current knowledge concerning psychiatric morbidity of refugees this article presents the psychiatric care of refugees at LVR Clinics Cologne - a psychiatric specialty hospital situated in North Rhine-Westphalia, Germany. A sample of 239 cases of refugee patients who were referred to in- and outpatient departments of the LVR Clinics Cologne between April 2015 and March 2016 are evaluated in respect of diagnoses, admission modalities and socio-demographic variables. The majority of principal diagnoses (40.2%) belong to the group of stress-related and somatoform disorders (F4 in ICD-10). Mood disorders (F3 in ICD-10) represented 31.0%, followed by mental and behavioral disorders due to psychoactive substance use (F1 in ICD-10) with 15.1%. Posttraumatic Stress Disorder (PTSD) was the most prevalent diagnose (13.0%). Among the 29 countries of the patients' origin Afghanistan (10,0%), Serbia (9.6%) and Kosovo (8.8%) were the most abundant. The diagnoses and the high rate of acute psychiatric events reflect the massive psychological pressure of the patients. The important role of interpreters and mediators specialized in language and integration in the treatment process is emphasized.

[Mentally Ill Parents in Psychiatric Hospitals]. / Psychisch kranke Eltern in stationärer Behandlung.

BACKGROUND: Offsprings of psychiatric patients are burdened and they are at risk of developing a mental disorder themselves. METHODS: All admissions in a psychiatric hospital within a period of 6 months were screened for parenthood of underaged children. They were given standardized questionnaires for child behavior (SDQ), parenting behavior and subjective need for help in parenting. RESULTS: 21.5 % (N = 439) of the patients had underaged children, 194 patients participated in the study. They considered their children as having more psychological/behavioral problems than a control group (N = 97). Patients with personality or affective disorders and patients with a high level of psychiatric comorbidity rated their children most problematic. Although patients did not differ from controls in the evaluation of their parenting style, they expressed a higher need for help in parenting. CONCLUSION: Parenting and education issues need to be considered in the treatment of mentally ill patients. Effective support could be a relief for families and help to prevent mental disorders in offsprings.

Trans-Sector Integrated Treatment in Psychosis and Addiction.

BACKGROUND: Patients with psychosis often develop comorbid addiction, with a lifetime prevalence of ca. 50%. Dual diagnoses are considered hard to treat. Long-term integrated treatment programs might improve such patients' outcomes, at least to a moderate extent, but they have not yet been adequately studied or implemented in Germany to date. METHODS: 100 dual diagnosis patients participated in a single-center, randomized, controlled trial under standard hospital treatment conditions. They were randomly allotted to two groups. Patients in the intervention group were admitted to a specialized open hospital ward, where they were given integrated treatment, including disorder-specific group therapy. Their treatment was continued with further disorder-specific group therapy in the outpatient setting. Patients in the control group were admitted to an open general psychiatric ward and received treatment as usual, but no disorder-specific treatment either during their hospitalization or in the subsequent outpatient phase. Follow-up examinations were performed three, six, and twelve months after inclusion. The primary outcome was defined as the changes in substance use and abstinence motivation. The secondary outcome consisted of the patients' satisfaction with treatment and with life in general, retention rate, psychopathology, rehospitalizations, and global level of functioning. RESULTS: The patients in the intervention group developed higher abstinence motivation than those in the control group (p = 0.009) and transiently reduced their substance use to a greater extent (p = 0.039 at three months). They were also more satisfied with their treatment (group effect: p = 0.011). Their global level of functioning and their retention rate were also higher, but these differences did not reach statistical significance. CONCLUSION: Low-threshold, motivational, integrated treatment programs with psycho-educative and behavioral therapeutic elements may be helpful in the treatment of dual diagnosis patients and should be more extensively implemented as part of standard hospital treatment. Larger-scale, methodologically more complex studies will be needed to identify subgroups of patients that respond to such treatments in different ways.