Lars Kjellin

Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries

Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions. (Psychiatric Services 61: 1012-1017, 2010)

Family Burden and Relatives' Participation in Psychiatric Care: Are the Patient's Diagnosis and the Relation to the Patient of Importance?

Background: Studies that differentiate among diagnoses have detected divergent results in the experience of family burden. Aim: This study aimed to investigate differences in family burden and participation in care between relatives from subgroups of psychoses, affective disorders and ‘other diagnoses’, and between different subgroups of relatives. Method: In a Swedish longitudinal study performed in 1986, 1991 and 1997, 455 close relatives of both committed and voluntarily admitted patients were interviewed concerning different aspects of their burden, need for support and participation in the actual care situation. Results: Relatives showed burdens in several of the aspects measured. In only one aspect of the investigated burden items was a difference found between different diagnostic subgroups. The relatives of patients with affective disorder more often had to give up leisure time. However, spouses showed more burdens and more often experienced sufficient participation in the patients treatment than other subgroups while siblings more seldom experienced burdens and more seldom felt that their own needs for support had been met by the psychiatric services. Within each diagnostic subgroup there were differences between subgroups of relatives. Conclusion: Being a close relative, and living together with a severely mentally ill person in an acute situation, is one factor of importance for experiencing burden and participation in care, contradicting the conventional wisdom which differentiates between diagnoses.

Coerced Hospital Admission and Symptom Change—A Prospective Observational Multi-Centre Study

Introduction Coerced admission to psychiatric hospitals, defined by legal status or patients 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.

Coercion in psychiatric care – patients’ and relatives’ experiences from four swedish psychiatric services

The aim of this study was to explore possible regional differences in the use of coercion in psychiatric care as experienced by patients and relatives. At four psychiatric care settings in different parts of Sweden, 138 committed and 144 voluntarily admitted patients were interviewed at admission using the Nordic Admission Interview. At discharge or, if the care episode was still ongoing, after 3 weeks of care, a follow-up patient interview and an interview with 162 relatives of these patients took place. In one of the centers, where involuntarily admitted patients were treated without locking the doors of the wards, the patients reported less coercion at admission than in the other three centers. Regarding the patients’ reports of the use of coercive measures, personal treatment and outcome of care, and concerning the relatives’ experiences, few differences were found between centers among committed and voluntarily admitted patients, respectively. Coercion in psychiatric care, as reported by patients and relatives, was not always legally based, and many of the patients reported they felt violated during the admission process. Only a minority of patients and relatives reported participation in treatment and care planning, as regulated by law. Still, a majority of both committed and voluntarily admitted patients reported they had been well treated by the personnel at admission as well as during the stay at the ward, and that they had been improved in their mental health after the psychiatric care episode.

Patient characteristics and symptoms associated with perceived coercion during hospital treatment

Fiorillo A, Giacco D, De Rosa C, Kallert T, Katsakou C, Onchev G, Raboch J, Mastrogianni A, Del Vecchio V, Luciano M, Catapano F, Dembinskas A, Nawka P, Kiejna A, Torres‐Gonzales F, Kjellin L, Maj M, Priebe S. Patient characteristics and symptoms associated with perceived coercion during hospital treatment.

Explicit versus implicit social cognition testing in autism spectrum disorder

Although autism spectrum disorder is defined by reciprocal social-communication impairments, several studies have found no evidence for altered social cognition test performance. This study examined explicit (i.e. prompted) and implicit (i.e. spontaneous) variants of social cognition testing in autism spectrum disorder. A sample of 19 adolescents with autism spectrum disorder and 19 carefully matched typically developing controls completed the Dewey Story Test. ‘Explicit’ (multiple-choice answering format) and ‘implicit’ (free interview) measures of social cognition were obtained. Autism spectrum disorder participants did not differ from controls regarding explicit social cognition performance. However, the autism spectrum disorder group performed more poorly than controls on implicit social cognition performance in terms of spontaneous perspective taking and social awareness. Findings suggest that social cognition alterations in autism spectrum disorder are primarily implicit in nature and that an apparent absence of social cognition difficulties on certain tests using rather explicit testing formats does not necessarily mean social cognition typicality in autism spectrum disorder.

Risk and protective factors for disturbed eating in adolescent girls : aspects of perfectionism and attitudes to eating and weight

The aim of this study was to longitudinally examine the role of personal standards, self-evaluation, perceived benefits of thinness and attitudes to eating and weight in the development of healthy versus disturbed eating in adolescent girls. In a longitudinal study, girls who participated in two assessments, four to five years apart, were divided into three groups according to the attitudes to eating that they manifested at the second evaluation: those with disturbed eating patterns (DE-group, n = 49), those with intermediate concerns about eating (IE-group, n = 260) and those with healthy eating attitudes (HE-group, n = 120). Variables concerning attitudes to eating and weight and physical self-evaluation emerged as risk factors, whereas personal standards or self-evaluation in general did not. Protective factors were a low BMI, healthy eating attitudes, an accepting attitude towards body size and a positive self-evaluation, particularly with regard to physical and psychological characteristics. The results of this study contribute to the understanding of early risk and protective factors for eating disturbances in girls.

Relatives of psychiatric inpatients--do physical violence and suicide attempts of patients influence family burden and participation in care?

A common concern of psychiatric patients’ relatives is that patients might be a danger to themselves or others. The aim of this study was to investigate family burden and relatives’ participation in care in relation to physical violence towards others and suicide attempts by psychiatric inpatients before admission. Information concerning violence and suicide attempts by the patients prior to admission was collected from the medical records of 155 acutely voluntarily and involuntarily admitted psychiatric inpatients. Relatives were interviewed a month after admission, using a semi-structured questionnaire. Violence towards other persons and suicide attempts were recorded in 16% and 17% of the cases, respectively. There were no differences between relatives of patients who had been violent and other relatives regarding burden and participation in care. Relatives of patients with suicide attempts more often stated they had been prevented from having own company, worried about suicide attempts by the patient, had mental health problems of their own, and had own need for care and support. It was concluded that violence of acutely admitted psychiatric patients, targeted at other people, was not associated with burden of family, but the results corroborate the need for psychiatric services to involve and support relatives of psychiatric patients with suicidal behaviour.

Accumulated coercion and short-term outcome of inpatient psychiatric care

BackgroundThe knowledge of the impact of coercion on psychiatric treatment outcome is limited. Multiple measures of coercion have been recommended. The aim of the study was to examine the impact of accumulated coercive incidents on short-term outcome of inpatient psychiatric careMethods233 involuntarily and voluntarily admitted patients were interviewed within five days of admission and at discharge or after maximum three weeks of care. Coercion was measured as number of coercive incidents, i.e. subjectively reported and in the medical files recorded coercive incidents, including legal status and perceived coercion at admission, and recorded and reported coercive measures during treatment. Outcome was measured both as subjective improvement of mental health and as improvement in professionally assessed functioning according to GAF. Logistic regression analyses were performed with patient characteristics and coercive incidents as independent and the two outcome measures as dependent variablesResultsNumber of coercive incidents did not predict subjective or assessed improvement. Patients having other diagnoses than psychoses or mood disorders were less likely to be subjectively improved, while a low GAF at admission predicted an improvement in GAF scoresConclusionThe results indicate that subjectively and professionally assessed mental health short-term outcome of acute psychiatric hospitalisation are not predicted by the amount of subjectively and recorded coercive incidents. Further studies are needed to examine the short- and long-term effects of coercive interventions in psychiatric care.

Compulsory psychiatric care in Sweden : development 1979-2002 and area variation

As in many other countries, the Swedish legislation on compulsory psychiatric care has been revised several times during the last four decades. Great regional differences within the country in the use of compulsory psychiatric care have been reported. The aims of this study were to describe the development of compulsory psychiatric care in Sweden 1979-2002, and to analyse differences between two groups of counties, one group with high and one with low civil commitment rates, in terms of psychiatric care structure, resources and processes. Data on civil commitments and forensic psychiatric care in Sweden 1979-2002 were collected from public statistics. At least one responsible person in leading position (administrative manager or chief psychiatrist) in each of the included counties was interviewed. The total number of involuntarily hospitalised patients decreased about 80% between censuses in 1979 and 2002, but the rates of forensic patients were unchanged. No clear-cut differences were found in the analyses of structure, resources and processes of psychiatric services between counties with high and counties with low levels of compulsory care. The equality before the law may be questioned. The importance of leadership is emphasised for future analyses.