Patient characteristics and symptoms associated with perceived coercion during hospital treatment.

OBJECTIVE: Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, their perceived coercion should be reduced as far as possible. There is however limited evidence on patient characteristics associated with perceived coercion during hospital treatment. This study aimed to identify i) sociodemographic and clinical characteristics associated with perceived coercion at admission and ii) changes in symptoms and global functioning associated with changes in perceived coercion over time. METHOD: Three thousand and ninety three in-patients who were involuntarily admitted or felt coerced to hospital treatment despite a legally voluntary admission were recruited in the European evaluation of coercion in psychiatry and harmonization of best clinical practice - EUNOMIA project in 11 European countries. Perceived coercion, global functioning and symptoms were assessed after admission and at a 3-month follow-up. RESULTS: Involuntary admission, female gender, poorer global functioning and more positive symptoms were associated with higher levels of perceived coercion at admission. Perceived coercion significantly decreased over time, and the improvements in global functioning and positive symptoms were associated with reduction in perceived coercion. CONCLUSION: Female patients perceive more coercion in psychiatric hospital treatment. Effective treatment for positive symptoms and improving patients' global functioning may lead to a reduction in perceived coercion.

How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study.

Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients' rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.

Ethical benefits and costs of coercion in short-term inpatient psychiatric care.

OBJECTIVE: The study examined the outcome of psychiatric inpatient care in terms of patients' reports of ethical benefits, which were defined as fulfillment of the ethical principles of beneficence and autonomy, and ethical costs, which were defined as any violation of those principles. METHODS: A consecutive sample of 84 committed patients and a random sample of 84 voluntarily admitted patients in psychiatric care in two Swedish counties were studied. The patients were assessed twice by a psychiatrist, at admission and at discharge or after three weeks of care. They were also interviewed by a clinical psychologist at discharge or after three weeks. Four aspects of the ethical benefits or costs of their care were examined--whether they reported improvement in mental health, being treated with respect, not being violated as a person, and not being exposed to measures against their will (aside from commitment). RESULTS: The great majority of all patients reported improvement as a result of the psychiatric care. A third of the committed patients and more than half of the voluntarily admitted patients experienced ethical benefits only, without ethical costs. Twenty-three percent of the committed patients and 13 percent of the voluntary patients experienced ethical costs only, without ethical benefits. Some of the patients who experienced ethical costs only were also rated by a psychiatrist as not improved. CONCLUSIONS: Few patients had no measurable benefits of care. For committed as well as voluntary patients, an association was found between perceived respect for autonomy and self-reported improvement in mental health.

Compulsory psychiatric care in Sweden 1979-1993. Prevalence of committed patients, discharge rates and area variation.

The prevalence of committed patients in mental health care from seven different inventories between 1979 and 1993 and rates of discharge from compulsory psychiatric care during 1984, 1988 and between 1 July 1992 and 30 June 1993 were studied by using statistics from the Swedish National Board of Health and Welfare. Changes over time and area variation in prevalence and discharge rates were analysed in relation to mental commitment law reform, urbanization, number of psychiatric beds and locus of short-term psychiatric care. The prevalence of committed patients in psychiatric in-patient care and the discharge rates from compulsory psychiatric care rapidly decreased during the periods studied. Legal reforms in 1983 and 1992, which led to a strengthened legal influence on compulsory care procedures, were followed by further reductions in the use of compulsory psychiatric care. The reductions were found not only among patients with psychotic conditions, but also among patients given other diagnoses. The proportion of committed patients in relation to the total number of in-patients increased during the latter half of the 1980s. Area variations in the 26 counties (or corresponding health administrative areas) were significant and increased after the new legislation in 1992. The three large city areas had higher psychiatric bed rates and also higher compulsory care rates than other areas in the country. In the counties outside the large city areas, no connection was found between number of beds and prevalence of committed patients, and no relation was found between locus of care and rates of compulsory psychiatric care.

Medical and social paternalism. Regulation of and attitudes towards compulsory psychiatric care.

In Sweden, recommendations and reforms in psychiatric care have increasingly stressed respect for patient autonomy and justice with less emphasis on medical and social paternalism. This is the official policy. But what are the attitudes of the people involved in or affected by compulsory psychiatric care? To answer this question, the attitudes of committed and voluntarily admitted patients, their relatives, psychiatric staff, health and welfare personnel of primary care and a sample of the general public were studied in 2 Swedish counties. Strong support for medical and social paternalism was reported, and according to most of the people asked, doctors, not legal authorities, should decide about commitment. These attitudes are discordant with the recent legislative changes in Sweden.