[Mental healthcare in South Tyrol]. / Psychiatrische Versorgung in Südtirol.

Mental healthcare in South Tyrol, as everywhere in Italy, is still characterized by Law 180, which came into force in 1978 under the leadership of Franco Basaglia and Bruno Orsini. The Ministry of Health subsequently set a target number of beds of 10/100,000 inhabitants. Unlike in other parts of Italy, private clinics play a minimal role in South Tyrol. The "Psychiatric Services" are part of the state healthcare system responsible for all citizens and are also responsible for compulsory outpatient care. According to the concept of community care, also due to the small number of inpatient beds, a great deal of care is provided on an outpatient basis. Coercive measures can only be used in the case of an illness requiring urgent treatment that the patient refuses, without recourse to endangering circumstances (self-endangerment or danger to a third party). Inpatient hospitalization is only possible if treatment also takes place and the principle of "outpatient before inpatient" also applies in this context, i.e., coercive treatment can only take place as an inpatient if it cannot be carried out as an outpatient. Forensic psychiatry has very few places and mentally ill offenders are often in prison or occupy beds in general psychiatric wards. Compared to Germany there are fewer beds available but staffing levels are better, particularly for nursing. In relation to the number of inhabitants, compulsory treatment is more frequent than in Germany, whereas involuntary hospitalization and physical restraint are much rarer (only possible in Italy by court order).

[Psychiatry without coercion-Exclude the coercion or the patients?] / Psychiatrie ohne Zwang ­ den Zwang ausschließen oder Patient:innen?

BACKGROUND: With reference to the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD), a fundamental change in psychiatric care in Germany was proposed in 2019 by Zinkler and von Peter, supported by a legal perspective from Kammeier, which has since led to controversial debates. Essentially, the aim is not only to reduce coercion in psychiatry to a minimum, but also to fundamentally exclude it in a psychiatry that only provides care. The function as an agent of social control is to be returned from psychiatry to state institutions. Psychiatric hospitals will only admit patients with their consent; patients who refuse therapy will not be admitted regardless of their capacity for self-determination and will remain untreated or, if they have committed a criminal offence or threaten to commit a criminal offence, they will be taken into custody or imprisoned in accordance with the legal regulations applicable to all people. There they will receive psychiatric care if they so wish. AIM OF THE PAPER: The paper outlines the background of this concept, including international sources, traces the discussion in German specialist literature and takes a critical look at it. RESULTS: The criticism is primarily directed against the fact that responsibility for a relevant proportion of psychiatric patients would be handed over to the police and judiciary and that, as a result, two realities of care would be established that would considerably differ in terms of quality. CONCLUSION: Arguments are put forward in favor of retaining the function of social control and considerations are suggested as to how caring coercion can be largely minimized.

The internment of patients undergoing treatment for alcohol addiction as a result of a specific interpretation of legal provisions by some judicial authorities. / Internowanie pacjentów leczacych sie odwykowo jako skutek okreslonej wykladni przepisów prawa przez niektóre organy wymiaru sprawiedliwosci.

In the Polish legal system, each medical procedure requires patient's consent. Exemptions from the obligation to obtain such a consent are limited by the legislator to exceptional situations, i.e., when the delay caused by the procedure for obtaining consent would pose a threat to patient's life, serious injury, or serious health impairment. Undergoing addiction treatment is also voluntary. Exceptions to this principle are stipulated by a legal act. People who abuse alcohol and therefore break down family life, demoralize minors, avoid the obligation to meet the needs of their families, or systematically disturb peace or public order, may be obliged to undergo addiction treatment in an inpatient or outpatient treatment centre on condition that they are addicted to alcohol. A patient who fails to report to the medical entity designated by the court to execute the decision on the obligation to undertake addiction treatment may be brought to this entity by the police. In the context of the obligation to obtain a consent for treatment by a person against whom a court decision containing an obligation in this respect has been issued, there are discrepancies in the application of law provisions. In some medical entities, this results in the forced continuation of addiction treatment by a given patient in hospital, as discharge from the hospital depends on a court order issued in this regard, not on the consent of the patient himself/herself. In other medical entities, patients are not admitted for treatment due to the lack of such a consent, despite the court's obligation in this respect. The article confirms that a specific practice of applying the law, which downgrades the role of the patient's consent in the therapeutic process, has negative consequences for the effectiveness of the therapy.

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018.

INTRODUCTION: Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018. METHOD: We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender. RESULTS: Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%). CONCLUSION: Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

The History of Territorial Psychiatric Hospitals in Russia.

The establishment of district psychiatric hospitals in the Russian Empire in the second half of the 19th-early 20th century is one of the most important stages in the development of domestic psychiatry. In fact, it was the first experience in the design and construction of psychiatric hospitals as large specialized autonomous complexes aimed not only at isolation of patients, but also at therapy of their condition. The idea of building such institutions was suggested by reality itself: city houses for the mentally ill under the jurisdiction of provincial and then zemstvo authorities were overcrowded, but there was a lack of specialized doctors, since psychiatry in Russia in the first half of the 19th century was only beginning to gain scientific prestige. In a sense, the development of Russian psychiatry and the evolution of the project of district hospitals for the mentally ill pushed each other: leading psychiatrists of their time took a most enthusiastic part in the development of the project, and the hospitals established through their efforts provided enormous practical material for studying mental diseases and methods of their therapy.

New injectable antiretroviral therapy for HIV facilitates novel treatment pathways for persons without capacity to consent to medical treatment.

OBJECTIVE: The development of new injectable antiretroviral therapy facilitates treatment for Human immunodeficiency virus (HIV) positive individuals who lack capacity to consent, posing a safety risk to both themselves and the wider community. We consider pathways to enforce treatment and propose an algorithm to determine the most appropriate legal instrument for application. CONCLUSION: Legislative safeguards in mental health and guardianship legislation provide oversight and protection for those who suffer from illness and require coercive treatment. These frameworks have utility in the treatment of HIV patients who lack capacity to consent to treatment.

Impact of language proficiency on mental health service use, treatment and outcomes: "Lost in Translation".

BACKGROUND: Mastery of a language is bound to place of origin; low language proficiency is thus related to migration and cultural differences, all of which influence access to mental health care, treatment and outcomes. Switzerland, being multilingual, allows the disentangling of language proficiency from migration and, to some extent, culture. This study uses propensity score matching to explore how language proficiency relates to help-seeking behaviour, service use, treatment and outcomes in patients with mental health disorders. METHODS: We used the first admission of patients admitted to and discharged from an academic psychiatric hospital in Switzerland between January 1st, 2013 and December 31st, 2019, with an observation period of one-year post-discharge (until December 31st, 2020). We paired 2101 patients with low language proficiency to 2101 language proficient patients, balancing baseline sociodemographic and clinical characteristics using propensity score matching. RESULTS: Patients with low language proficiency had a higher probability of compulsory admission (OR: 1.79, 99%CI: 1.60-2.02); which remained after adjustment for confounders (OR: 1.51; 99%CI: 1.21-1.89). Whilst in treatment, they had higher rates of compulsory medication (OR: 1.73, 99%CI: 1.16-2.59) and seclusion/restraint (OR: 1.87, 99%CI: 1.25-2.79). Furthermore, patients initially admitted voluntarily had a higher probability of being compulsorily retained (OR: 1.74, 99%CI: 1.24-2.46). Both groups showed similar clinical improvement rates and service use parameters. CONCLUSIONS: Our results demonstrate that low language proficiency constitutes a risk factor for coercive measures throughout hospitalisation. The results demonstrate the need for an increase in language sensitivity in psychiatric care.

Mandatory treatment for methamphetamine use in Australia.

BACKGROUND: In 2016, following a flurry of government inquiries and taskforces including calls for mandatory treatment regimes, the Australian community nominated methamphetamine as the drug most likely to be associated as a problem substance. Mandatory treatment for alcohol and other drug problems in Australia consists of broadly two mechanisms compelling a person into treatment: involuntary treatment or civil commitment regimes; and coercive treatment regimes, usually associated with the criminal justice system. This paper aims to provide a review of the evidence for mandatory treatment regimes for people who use methamphetamines. METHODS: Using a narrative review methodology, a comprehensive literature and citation search was conducted. Five hundred two search results were obtained resulting in 41 papers that had cited works of interest. RESULTS: Small, but robust results were found with coercive treatment programs in the criminal justice system. The evidence of these programs specifically with methamphetamine use disorders is even less promising. Systematic reviews of mandatory drug treatment regimes have consistently demonstrated limited, if any, benefit for civil commitment programs. Despite the growing popular enthusiasm for mandatory drug treatment programs, significant clinical and ethical challenges arise including determining decision making capacity in people with substance use disorders, the impact of self determination and motivation in drug treatment, current treatment effectiveness, cost effectiveness and unintended treatment harms associated with mandatory programs. CONCLUSION: The challenge for legislators, service providers and clinicians when considering mandatory treatment for methamphetamines is to proportionately balance the issue of human rights with effectiveness, safety, range and accessibility of both existing and novel mandatory treatment approaches.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

BACKGROUND: Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. AIMS: To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. METHOD: Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. RESULTS: A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. CONCLUSIONS: Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

"It's not a life of war and conflict": experienced therapists' views on negotiating a therapeutic alliance in involuntary treatment.

BACKGROUND: Working alliances are considered to be essential to treatment, and they represent a robust predictor of positive treatment outcomes. In a working alliance, a patient and therapist agree upon treatment decisions, which can raise a series of challenges when patients are in involuntary treatment. The aim of this study was to research how therapists experience negotiating a working alliance with patients with serious mental illnesses who are subjected to coercive treatment. METHODS: Using a qualitative approach, we conducted 10 semi-structured interviews with experienced therapists in a Norwegian mental health care setting. Transcripts were analysed using a team-based thematic analysis method. RESULTS: Two interrelated major themes and five sub-themes were identified: (1) between coercion and care; (a) the ease of coercion, (b) the paradox of autonomy, and (c) the coercion as care; and (2) imperative treatment and interpersonal dilemmas; (a) this is happening between us and (b) when we do not meet in the middle. CONCLUSION: We conclude that the therapists exhibited a will to consider their patients' goals and methods, but only when they were in agreement, and they ultimately made treatment decisions themselves. Further, patient autonomy seems to come second in therapist assessments of needs for care; consequently, we question to what degree the working alliance as a defined concept of mutual agreement is present in the involuntary treatment we investigated.

Surveying the Geneva impasse: Coercive care and human rights.

The United Nations human rights system has in recent years been divided on the question as to whether coercive care interventions, including coercive psychiatric care, can ever be justified under UN human rights standards. Some within the UN human rights community hold that coercive care can comply with human rights standards, provided that the coercive intervention is a necessary and proportionate means to achieve certain approved aims, and that appropriate legal safeguards are in place. Others have held that coercive care is never justified. Disagreement over this issue has produced an impasse in the UN human rights system. We survey the impasse with particular attention to the legal arguments that inform the divergent positions. In doing so we introduce a distinction among a variety of different 'abolitionist' positions regarding coercive care, and draw a distinction between 'non-consensual' and 'coercive' treatment. We conclude with three proposals for moving beyond the current impasse.

[Voluntariness in Outpatient Psychotherapy with Children and Adolescents]. / Über die Freiwilligkeit in der ambulanten Kinder- und Jugendlichenpsychotherapie.

Voluntariness in Outpatient Psychotherapy with Children and Adolescents Voluntariness is no selective construct in psychotherapy with children and adolescents. Generally psychotherapy is utilized under external pressure, at least partially. At any rate it is crucial to painstakingly analyze the motivation for change and possible obstacles to motivation. On that basis different strategies to foster motivation for change can be applied. Problems regarding the efficiency of voluntary or involuntary utilization of outpatient psychotherapy for children and adolescents should be subjects to further research.

Two Sides of the Same Coin: A Case Report of First-Episode Catatonic Syndrome in a High-Functioning Autism Patient.

Background: Catatonic phenomena such as stupor, mutism, stereotypy, echolalia, echopraxia, affective flattening, psychomotor deficits, and social withdrawal are characteristic symptoms of both schizophrenia and autism spectrum disorders (ASD), suggesting overlapping pathophysiological similarities such as altered glutamatergic and dopaminergic synaptic transmission and common genetic mutations. In daily clinical practice, ASD can be masked by manifest catatonic or psychotic symptoms and represent a diagnostic challenge, especially in patients with unknown or empty medical history. Unclear diagnosis is one of the main factors for delayed treatment. However, we are still missing diagnostic recommendations when dealing with ASD patients suffering from catatonic syndrome. Case presentation: A 31-year-old male patient without history of psychiatric disease presented with a severe catatonic syndrome and was admitted to our closed psychiatric ward. After the treatment with high-dose lorazepam and intramuscular olanzapine, catatonic symptoms largely remitted, but autistic traits persisted. Following a detailed anamnesis and a thorough neuropsychological testing, we diagnosed the patient with high-functioning autism and catatonic schizophrenia. The patient was discharged in a remitted state with long-acting injectable olanzapine. Conclusion: This case represents an example of diagnostic and therapeutic challenges of catatonic schizophrenia in high-functioning autism due to clinical and neurobiological overlaps of these conditions. We discuss clinical features together with pathophysiological concepts of both conditions. Furthermore, we tackle social and legal hurdles in Germany that naturally arise in these patients. Finally, we present diagnostic "red flags" that can be used to rationally select and conduct current recommended diagnostic assessments if there is a suspicion of ASD in patients with catatonic syndrome in order to provide them with the most appropriate treatment.

Reduced Frequency of Cases with Seclusion Is Associated with "Opening the Doors" of a Psychiatric Intensive Care Unit.

BACKGROUND: Implementing an open door policy is a complex intervention comprising changes in therapeutic stance, team processes, and a change from locked to open doors. Recent studies show that it can lead to a reduction of seclusion and forced medication, but the role of the physical change of door status is still unclear. AIMS: The aims of this study is to examine the transition from closed to predominantly open doors on a psychiatric intensive care unit (PICU) and its associations with the frequency of seclusion and forced medication. METHOD: A PICU at the Department of Adult Psychiatry, University of Basel, Switzerland, implemented evidence-based strategies for operating an open door policy within the context of acute psychiatry and participated in a hospital-wide implementation of an open door policy before changing door status. 131 inpatient cases hospitalized on this PICU were examined regarding the frequency of seclusion and forced medication using explorative analyses over a time span of 32 weeks (16 weeks after implementation of the new treatment concept but before door opening, 16 weeks after door opening). RESULTS: Following door status change, the PICU was completely open on 51% of the days and partly open on 23% of the days. The mean number of open hours per day was 12.8 ± 3.9 h. The frequency of forced medication did not change, and the frequency of seclusion decreased significantly [χ2 (1, N = 131) = 4.73, p = 0.036]. CONCLUSION: This pilot study underlines the potential of a change of door status to attain a reduction in safety measures in the first 4 months.

Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years.

BACKGROUND: Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication. METHOD: In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models. RESULTS: In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; ηp2=0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; ηp2=0.70; odds ratio: 0.90). CONCLUSION: This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

Pregnant substance abusers in voluntary and coercive treatment in Norway: Therapists' reflections on change processes and attachment experiences.

AIMS AND OBJECTIVES: To explore therapists' discourses on treatment processes, when working with pregnant substance abusers in voluntary and coercive treatment, and looking for the clinical implications of these discourses. BACKGROUND: Treatment of substance use disorder faces many challenges. One is pregnancy and motherhood, which are vulnerable and complex processes. The literature emphasises lack of optimal and knowledge-based treatment for this group. DESIGN: The study follows a Foucauldian inspired discourse analysis. METHOD: Forty therapists from four different residential units in Norway, offering both voluntary and coercive treatment of pregnant women with substance use disorders, were interviewed in focus groups. The semi-structured interview schedule focused on exploring how therapists' discourses on change processes and relationship experiences informed their clinical practice. RESULTS: How to start "healthy" attachment processes between the pregnant woman and the unborn child was the dominant discourse among the therapists. Another important theme was coercion, and whether that as a contextual frame was negative or positive in creating attachment between mother and child. Other discourses were varieties of understanding attachment when the mothers had difficulties with substance abuse, the mothers' own attachment histories, and social and cultural challenges. CONCLUSION: Systematic work with attachment issues between the pregnant woman and her unborn child was the dominant perspective of nearly all the therapists. The contextual factors in the lives of the women were less prioritised, even though they are of decisive importance for the relationship between mother and child. RELEVANCE TO CLINICAL PRACTICE: Treatment professionals need to focus more on the discursive dilemmas encountered in the relation between substance use disorders and the unborn child.

Regaining ownership and restoring belongingness: impact of family group conferences in coercive psychiatry.

AIM: This study examined the impact of family group conferences on coercive treatment in adult psychiatry. BACKGROUND: Coercive treatment in psychiatry infringes the fundamental rights of clients, including the right to control their lives. A promising intervention is the family group conferences, which has the potential to prevent crises through the integration of the expertise of informal and professional networks. DESIGN: A responsive evaluation, including qualitative and quantitative methods, was deployed to study the process leading up to the FGC, the proceedings and the impact of the conference. METHOD: From 2013-2015, 41 family group conferences were studied in three regions in the Netherlands. The impact of every conference was examined with scales (ranging from 0-10) during interviews with attendees (clients, family members, friends, mental health professionals and family group conferences coordinators) who reflected on three outcome measures: belongingness, ownership and coercion. RESULTS: After the family group conferences, respondents indicated a slight reduction in their experience of coercive treatment. They also mentioned an increase in ownership and belongingness. CONCLUSION: Family group conferences seems a promising intervention to reduce coercion in psychiatry. It helps to regain ownership and restores belongingness. If mental health professionals take a more active role in the pursuit of a family group conferences and reinforce the plans with their expertise, they can strengthen the impact even further.

Ethics of Coercive Treatment and Misuse of Psychiatry.

The author discusses a pragmatic approach to decisions about coercive treatment that is based on four principles from principle-based ethics: respect for autonomy, nonmaleficence, beneficence, and justice. This approach can reconcile psychiatry's perspective with the U.N. Convention on the Rights of Persons With Disabilities. Coercive treatment can be justified only when a patient's capacity to consent is substantially impaired and severe danger to health or life cannot be prevented by less intrusive means. In this case, withholding treatment can violate the principle of justice. In the case of danger to others, social exclusion and loss of freedom can be seen as harming psychosocial health, which can justify coercive treatment. Considerable efforts are required to support patients' informed decisions and avoid allowing others to make substitute decisions. Mental disorder alone without impaired capacity does not justify involuntary treatment, which can be considered a misuse of psychiatry. Involuntary detention without treatment can be justified for short periods for assessment and to offer treatment options.