Erich Flammer

Subjective Distress After Seclusion or Mechanical Restraint: One-Year Follow-Up of a Randomized Controlled Study

OBJECTIVE Patients who participated in a randomized controlled trial comparing subjective distress and traumatic impact after seclusion or mechanical restraint were interviewed about the coercive measure about one year later. METHODS Between May and December 2006, patients were interviewed about one year after experiencing seclusion or mechanical restraint as an inpatient. Items from the Coercion Experience Scale (CES) were used in the original and the follow-up studies to assess distress on a 5-point scale, with higher scores indicating greater distress. Patients were also asked about subjective feelings about the coercive measure and completed the Impact of Event Scale-Revised (IES-R) to assess symptoms of posttraumatic stress disorder (PTSD). RESULTS Sixty (59%) of the 102 patients in the original sample were included for follow-up. Although the original study found no differences between patients who experienced seclusion or mechanical restraint, the follow-up study found significantly higher mean scores for CES items among patients who had experienced mechanical restraint (2.5 and 3.7, respectively, p<.001). IES-R scores did not differ significantly. IES-R scores for two patients who experienced mechanical restraint and one who experienced seclusion indicated probable PTSD. Patients reported experiencing a wide range of negative feelings during the measure, most frequently helplessness, tension, fear, and rage. However, 58% reported some positive effects. Contact with staff was most helpful in alleviating distress during the coercive measure. CONCLUSIONS Contrary to the original study, the follow-up study suggested that seclusion might be a less restrictive alternative for most patients. The incidence of PTSD seemed lower than expected.

Similarities and differences in borderline personality disorder and schizophrenia with voice hearing.

Abstract The aim of the study was to identify psychopathological similarities and differences in borderline personality disorder (BPD) and schizophrenia. We compared 23 female patients with a BPD and 21 female patients with schizophrenia according to auditory verbal hallucinations (AVHs), dissociation, childhood trauma, and additional psychotic symptoms. The character of AVH was similar with regard to commenting voices, location, and foreign voices. Major differences were found in the prevalence of negative symptoms, bizarre delusions, and formal thought disorder. These characteristics were more frequent in schizophrenia and negatively correlated with childhood traumatization. A history of childhood traumatization and dissociative symptoms was significantly more frequent in BPD. AVHs in BPD and schizophrenia are not distinguishable in terms of the historically grown criteria in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision for diagnosing schizophrenia. Other symptoms such as delusions, negative symptoms, formal thought disorder, and dissociative psychopathology could help to differentiate between both groups.

Ward safety perceived by ward managers in Britain, Germany and Switzerland: identifying factors that improve ability to deal with violence.

Little is known about how safe nurses feel on psychiatric wards across different European countries. This paper is aim to evaluate how ward safety is perceived by ward managers in Great Britain, Germany and Switzerland. We replicated a Swiss questionnaire study in Germany and Britain, which asked ward managers on adult psychiatric wards to give details about their ward including data on the management of aggression, staffing levels, staff training, standards and type of restraint used, alarm devices, treatment and management of aggression and the existence and perceived efficacy of standards (protocols, guidelines). The British sample had by far the highest staffing levels per psychiatric bed, followed by Switzerland and Germany. The British ward managers by far perceived violence and aggression least as a problem on their wards, followed by Germany and then Switzerland. British ward managers are most satisfied with risk management and current practice dealing with violence. German managers were most likely to use fixation and most likely to have specific documentation for coercive measures. Swiss wards were most likely to use non-specific bedrooms for seclusion and carry alarm devices. British wards were far more likely to have protocols and training for the treatment and management of violence, followed by Switzerland and Germany. British ward managers by far perceived violence and aggression to be a small problem on their wards compared with Swiss and German ward managers. This was associated with the availability of control and restraint teams, regular training, clear protocols and a lesser degree risk assessments, but not staffing levels.

Impact of the temporaneous lack of legal basis for involuntary treatment on the frequency of aggressive incidents, seclusion and restraint among patients with chronic schizophrenic disorders

OBJECTIVE In the German federal state Baden-Wuerttemberg involuntary medication of detained psychiatric inpatients was unlawful during eight months from July 2012 until February 2013 due to a decision of the Federal Constitutional Court except for emergency situations. We examined whether aggressive incidents and mechanical coercive measures such as seclusion and restraint increased. METHODS Routine data of 2.644 cases with schizophrenic and manic disorders in seven psychiatric hospitals were analysed by a pooled cross-section analysis as well as by a longitudinal analysis for the relevant time period and the corresponding period of the preceding year. RESULTS The number of mechanical coercive measures and of aggressive incidents increased significantly by over 40 % in the cross-sectional analysis. In the longitudinal analysis which included only patients with admissions in both periods, the increase of both aggressive incidents and coercive measures was over 100 %. Effects on the duration of measures were insignificant. CONCLUSION The temporaneous impossibility to apply involuntary medication was associated with a significant increase of aggressive incidents, seclusion, and mechanical restraint.

Basisdokumentation in der klinischen Praxis: Wie zuverlässig sind BADO-Daten?

OBJECTIVES To assess the quality of data recorded using a modified version of the German Psychiatric Basic Documentation (BADO) and to use this assessment as the basis for the development of a short version of the BADO. METHODS BADO codings of a random sample of 200 admitted cases in 2007 were compared to information retrieved from computer-based records for the same patients. RESULTS In general, the quality of data recorded using the BADO was good, particularly in terms of the accuracy and the completeness of the data. However, a comparative analysis of the data suggests that ambiguities in the coding of particular BADO items might reduce their sensitivity and precision. CONCLUSIONS Data recorded using the BADO is fit for the purposes of quality management and, with some limitations, for research applications. The short version of the BADO developed using the results of the evaluation, significantly enhances its user-friendliness and increases the reliability of the coded data.

Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review.

BackgroundThe United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) aims at stimulating profound changes and social development in many areas of the society. We wanted to examine the impact of the convention on mental health care research up to now by a systematic review.MethodsWe searched relevant electronic databases for empirical studies from the area of mental health which focused directly on the content of the UN-CRPD.ResultsOne thousand six hundred ten articles were screened, 36 of which fulfilled the inclusion criteria and came from 22 different countries. 25 studies (69 %) are related to persons with intellectual disabilities, only 11 to other mental disorders. Study designs were quantitative and qualitative as well. Issues were realisation of the UN-CRPD, implementation and financing, development of instruments, and attitudes towards the UN-CRPD.ConclusionsIn contrast to possible wide-reaching consequences for the organisation of mental health care, theoretical debates prevail as of yet and empirical research is still scarce. Research on the UN-CRPD is more advanced for intellectual disabilities and provides good suggestions for relevant research aspects in major mental disorders.

Involuntary Medication, Seclusion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013

Background Involuntary medication in psychiatric treatment of inpatients is highly controversial. While laws regulating involuntary medication have been changed in Germany, no data have been available to date on how often involuntary medication is actually applied. Recently, our hospital group introduced specific routine documentation of legal status and application of involuntary medication in the patients’ electronic records, which allows the assessment of the frequency of involuntary medication. Method For the year 2014, we extracted aggregated data from the electronic database on age, sex, psychiatric diagnosis, legal status during admission, kind of coercive measure (mechanical restraint, seclusion, and involuntary medication) applied, and the number and duration of seclusion and restraint episodes for seven study sites. Results A total of 1,514 (9.6%) of 15,832 admissions were involuntary. At least one coercive measure was applied in 976 (6.2%) admissions. Seclusion was applied in 579 (3.7%) admissions, mechanical restraint was applied in 529 (3.3%) admissions, and involuntary medication was applied in 78 (0.5%) admissions. Two-thirds of involuntary medications were applied in cases of emergency; the remainder was applied after a formal decision by a judge. In 55 (70.5%) of the admissions with involuntary medication, at least one other coercive measure (seclusion, restraint, or both) was applied as well. Conclusion Involuntary medication is rarely applied and less frequent than seclusion or mechanical restraint, possibly as a consequence of recent legal restrictions.

Ratings of coercive interventions by inpatients and staff in Germany.

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Skills-based medication training program for patients with schizophrenic disorders: a rater-blind randomized controlled trial.

Background The long-term course of schizophrenia is often characterized by relapses, induced by poor medication adherence. Early nonadherence after discharge is frequent. Objective To evaluate a skills-based inpatient training program for medication intake. Methods We developed a manual-based inpatient medication training program to be carried out by nurses and focusing on practical skills enabling autonomous intake of medication. Medication adherence was measured by three different methods: pill count, determination of serum levels, and self-assessment by the patient. The raters were blinded. Results Four weeks after discharge, 98% of the patients in the intervention group (N=52) were rated as adherent by pill count versus 76% in the control group (N=50; P<0.01). By measurement of serum level, 88.5% versus 70% were adherent (P<0.05). Conclusion The inpatient medication training program carried out by nurses seems to be an effective intervention for enhancing medication adherence after hospital discharge.

Das Fallregister für Zwangsmaßnahmen nach dem baden-württembergischen Psychisch-Kranken-Hilfe-Gesetz: Konzeption und erste Auswertungen

BACKGROUND In the federal state of Baden-Wuerttemberg, collecting data on coercive measures in psychiatric hospitals and supplying this data to a central register has been mandatory since 2015, so that statewide comprehensive data is available. This first full survey of the use of coercive measures in German psychiatric hospitals presents data of the year 2016 and allows comparisons with previous smaller samples. METHODS We analyzed the register data. The analysis is based on data provided by 32 facilities with 108,863 treated cases. RESULTS 10.7 % of admissions were involuntary at least at parts of their stay. 7,321 (6.7 %) cases were affected by any kind of freedom-restrictive measures (5.3 % mechanical restraint, 4.5 % seclusion). 674 cases (0.6 %) were affected by forced medication either as an emergency or after a judges decision. The mean cumulative duration of freedom-restrictive measures was 45.9 hrs per admission. Time in seclusion or restraint accounted on 0.5 % of total time in hospital. CONCLUSION In comparison to previous studies in smaller samples, the use of coercive measures has considerably decreased in patients with delirium and dementia (ICD-10 F0). Coercive medication is rarely used.