Thomas W. Kallert

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)

Involuntary vs. voluntary hospital admission. A systematic literature review on outcome diversity.

This article systematically reviews the literature on the outcome of acute hospitalization for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily. Inclusion and exclusion criteria qualified 41 out of 3,227 references found in Medline and PSYNDEXplus literature searches for this review. The authors independently rated these articles on six pre-defined indicators of research quality, carried out statistical comparisons ex-post facto where not reported, and computed for each adequate result the effect size index d for the comparison of means, and the Phi- or contingency coefficient for cross-tabulated data. Methodological quality of the studies, coming mostly from North American and European countries, showed significant variation and was higher concerning service-related than clinical or subjective outcomes. Main deficits appeared in sample size estimation, lack of clear follow-up time-points, and the absence of standardized instruments used to assess clinical outcomes. Length of stay, readmission risk, and risk of involuntary readmission were at least equal or greater for involuntary patients. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. Further, involuntary patients demonstrated lower levels of social functioning, and equal levels of general psychopathology and treatment compliance; they were more dissatisfied with treatment and more frequently felt that hospitalization was not justified. Future methodologically-sound studies exploring this topic should focus on patient populations not represented here. Further research should also clarify if the legal admission status is sufficiently valid for differentiating the outcome of acute hospitalization.

Factors influencing subjective quality of life in patients with schizophrenia and other mental disorders: a pooled analysis.

Subjective quality of life (SQOL) is an important outcome in the treatment of patients with schizophrenia. However, there is only limited evidence on factors influencing SQOL, and little is known about whether the same factors influence SQOL in patients with schizophrenia and other mental disorders. This study aimed to identify the factors associated with SQOL and test whether these factors are equally important in schizophrenia and other disorders. For this we used a pooled data set obtained from 16 studies that had used either the Lancashire Quality of Life Profile or the Manchester Short Assessment of Quality of Life for assessing SQOL. The sample comprised 3936 patients with schizophrenia, mood disorders, and neurotic disorders. After controlling for confounding factors, within-subject clustering, and heterogeneity of findings across studies in linear mixed models, patients with schizophrenia had more favourable SQOL scores than those with mood and neurotic disorders. In all diagnostic groups, older patients, those in employment, and those with lower symptom scores had higher SQOL scores. Whilst the strength of the association between age and SQOL did not differ across diagnostic groups, symptom levels were more strongly associated with SQOL in neurotic than in mood disorders and schizophrenia. The association of employment and SQOL was stronger in mood and neurotic disorders than in schizophrenia. The findings may inform the use and interpretation of SQOL data for patients with schizophrenia.

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.

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.

A comparison of psychiatric day hospitals in five European countries: implications of their diversity for day hospital research.

Abstract.Objective:As the use of “day hospitals” increases, conceptual models of these services are changing dramatically across Europe. Therefore, the need arises for mental health services research to assess this process cross-nationally in a standardised and systematic way. Such research approaches should seek to maximise the generalisability of results from high-quality (e. g. randomised controlled) single- or multi-site trials assessing specific models of day hospital care.Method:Using a self-developed structured questionnaire, the European Day Hospital Evaluation (EDEN) study group carried out national surveys of the characteristics of day hospitals for general psychiatric patients in Germany, England, Poland, the Slovak Republic and the Czech Republic, during the period 2001–2002.Results:Response rates varied from 52 to 91%. Findings show that day hospitals have no consistent profile of structural and procedural features. Similarities across countries focus on three main issues: on average, consideration of concepts oriented toward providing acute treatment are equivalent; disorders associated with disabled functioning in everyday life, high risk of somatic complications, and need for behaviour control are excluded to a comparable degree; and some core therapeutic activities are consistent with the main approaches of social psychiatry. Identified according to self-rated conceptions and extended with data from individual hospital’s statistics on the clientele in 2000, three clusters of limited selectivity subdivide the services. One category focuses mainly on rehabilitative tasks; two categories are oriented toward providing acute treatment as an alternative to inpatient care, but combine this either with rehabilitative tasks or with equal additional functions of shortening inpatient treatment and providing psychotherapy. The distribution of services across these three clusters varies significantly in the five European countries.Conclusion:Future day hospital studies should always clarify the type of services being assessed. To fully consider the impact of their results, the current national and international health policy environment of these services should be taken into account. Such surveys require enhanced methodology, however, in order to identify clear, distinct categories of services characterised by overlapping programme functions, and to increase the generalisability of valid results from single- or multi-site trials.

Needs for care of chronic schizophrenic patients in long-term community treatment.

Abstract.Background:Specific problems of long-term community care of chronic schizophrenic patients are an under-researched area interesting for the provision of regional mental health care.Methods:This study focuses on a 4 1/2-year prospective assessment of normative needs for care in a cohort (initially N = 115) living in the Dresden care region (Germany). At six time-points, normative needs for care were assessed with the Needs for Care Assessment (NFCAS).Results:The total number of problems did not change significantly over the study period. The average number of met needs was lower at the longer-term follow-up assessments,due particularly to a decrease in the social section. This trend is also demonstrated for the average number of unmet needs. In contrast, the mean number of “unmeetable needs” increased. Consistently, 70–80% of the patients exhibit problems in positive psychotic and negative symptoms, household affairs and recreational activities. Communication, occupation and recreational activities constitute a trio of social needs not met for nearly one-third of the patients disabled in these respects. Logistic analyses of regression could not identify a predictive model for the total needs development within the 4 1/2-year community treatment.Conclusion:The rather stable pattern of needs for care seems to define clear long-lasting tasks for community mental health services. For chronic schizophrenic patients, services should especially focus on social skills training and psychoeducational approaches. Due to a wide range of possible factors of influence, however, planning long-term context-dependent processes of care in the community lacks a clear evidence base.

Quality of Longer Term Mental Health Facilities in Europe: Validation of the Quality Indicator for Rehabilitative Care against Service Users’ Views

Background The Quality Indicator for Rehabilitative Care (QuIRC) is a staff rated, international toolkit that assesses care in longer term hospital and community based mental health facilities. The QuIRC was developed from review of the international literature, an international Delphi exercise with over 400 service users, practitioners, carers and advocates from ten European countries at different stages of deinstitutionalisation, and review of the care standards in these countries. It can be completed in under an hour by the facility manager and has robust content validity, acceptability and inter-rater reliability. In this study, we investigated the internal validity of the QuIRC. Our aim was to identify the QuIRC domains of care that independently predicted better service user experiences of care. Method At least 20 units providing longer term care for adults with severe mental illness were recruited in each of ten European countries. Service users completed standardised measures of their experiences of care, quality of life, autonomy and the unit’s therapeutic milieu. Unit managers completed the QuIRC. Multilevel modelling allowed analysis of associations between service user ratings as dependent variables with unit QuIRC domain ratings as independent variables. Results 1750/2495 (70%) users and the managers of 213 units from across ten European countries participated. QuIRC ratings were positively associated with service users’ autonomy and experiences of care. Associations between QuIRC ratings and service users’ ratings of their quality of life and the unit’s therapeutic milieu were explained by service user characteristics (age, diagnosis and functioning). A hypothetical 10% increase in QuIRC rating resulted in a clinically meaningful improvement in autonomy. Conclusions Ratings of the quality of longer term mental health facilities made by service managers were positively associated with service users’ autonomy and experiences of care. Interventions that improve quality of care in these settings may promote service users’ autonomy.

Friends and symptom dimensions in patients with psychosis: a pooled analysis.

Background Having friends is associated with more favourable clinical outcomes and a higher quality of life in mental disorders. Patients with schizophrenia have fewer friends than other mentally ill patients. No large scale studies have evaluated so far what symptom dimensions of schizophrenia are associated with the lack of friendships. Methods Data from four multi-centre studies on outpatients with schizophrenia and related disorders (ICD F20-29) were included in a pooled analysis (N = 1396). We established whether patients had close friends and contact with friends by using the equivalent items on friendships of the Manchester Short Assessment of Quality of Life or of the Lancashire Quality of Life Profile. Symptoms were measured by the Brief Psychiatric Rating Scale or by the identical items included in the Positive and Negative Syndrome Scale. Results Seven hundred and sixty-nine patients (55.1%) had seen a friend in the previous week and 917 (65.7%) had someone they regarded as a close friend. Low levels of negative symptoms and hostility were significantly associated with having a close friend and contact with a friend. Overall, almost twice as many patients with absent or mild negative symptoms had met a friend in the last week, compared with those with moderate negative symptoms. Conclusions Higher levels of negative symptoms and hostility are specifically associated with the lack of friendships in patients with psychotic disorders. These findings suggest the importance of developing effective treatments for negative symptoms and hostility in order to improve the probability of patients with schizophrenia to have friends.

The prevalence of depressive symptomatology in the german elderly population and the impact of methodical aspects on the identified prevalence

OBJECTIVES The issue of whether depression increases or decreases with age remains unclear. Methodical aspects play an important role in the research on depression in the elderly. METHODS In a representative survey of the German general population aged 50 years and older (n = 1.156) depressive symptomatology was assessed using the CES-D and the PHQ-2, generalized anxiety (GA) was assessed using the GAD-7. RESULTS According the CES-D 15.9 % and according to the PHQ-2 9.6 % of the population under study are classified as depressed. Prevalence rates increase with increasing age, but only few age groups show significant differences. The CES-D reveals higher prevalence rates than the PHQ-2. Nevertheless depending on the age group 3.6-7.8 % of the sample exclusively identified by the PHQ-2, and 9.0-14.9 % of the sample are exclusively identified by the CES-D. 4.8 (50-59 yrs.) to 10.3 % (80+ yrs.) report a moderate symptomatology of GA. GA is highly comorbid with depressive symptomatology. CONCLUSIONS The prevalence rates in our study are consistent with previous findings of other studies. Moreover our study underpins the importance of methodical aspects for the prevalence rates identified.AbstractThe Prevalence of Depressive Symptomatologyin the German Elderly Population and the Impactof Methodical Aspects on the Identified Prevalence ! Objectives The issue of whether depression increases or de-creaseswith ageremains unclear. Methodicalaspectsplayanim-portant role in the research on depression in the elderly.Methods In a representative surveyof the German general pop-ulationaged50yearsandolder(n=1.156)depressivesymptoma-tology was assessed using the CES-D and the PHQ-2, generalizedanxiety (GA) was assessed using the GAD-7.Results According the CES-D 15.9% and according to the PHQ-29.6% of the population under study are classified as depressed.Prevalence rates increase with increasing age, but only few agegroups show significant differences. The CES-D reveals higherprevalence rates than the PHQ-2. Nevertheless depending on theage group 3.6–7.8% of the sample exclusively identified by thePHQ-2, and 9.0–14.9% of the sample are exclusively identifiedby the CES-D. 4.8 (50–59 yrs.) to 10.3% (80+ yrs.) report a mod-eratesymptomatologyof GA. GA ishighlycomorbidwith depres-sive symptomatology.Conclusions The prevalence rates in our study are consistentwith previous findings of other studies. Moreover our study un-derpins the importance of methodical aspects for the prevalencerates identified.