Abstract
Intensive outpatient models of need-adapted psychiatric care have been shown to reduce the length of hospital stays and to improve retention in care for people with severe mental illnesses. In contrast, evidence regarding the impact of such models on involuntary hospital treatment and other coercive measures in inpatient settings is still sparse, although these represent important indicators of the patients' wellbeing. In Germany, intensive models of care still have not been routinely implemented, and their effectiveness within the German psychiatric system is only studied in a few pioneering regions. An innovative model of flexible, assertive, need-adapted care established in Berlin, Germany, in 2014, treating unselected 14% of the catchment area's patients, was evaluated on the basis of routine clinical data. Records of n = 302 patients diagnosed with severe mental disorders, who had been hospitalized at least once during a 4-year-observational period, were analyzed in a retrospective individual mirror-image design, comparing the 2 years before and after inclusion in the model project regarding the time spent in hospital, the number and duration of involuntary hospital treatments and the use of direct coercive interventions like restraint or isolation. After inclusion to the project, patients spent significantly less time in hospital. Among patients treated on acute wards and patients with a diagnosis of psychosis, the number of patients subjected to provisional detention due to acute endangerment of self or others decreased significantly, as did the time spent under involuntary hospital treatment. The number of patients subjected to mechanical restraint, but not to isolation, on the ward decreased significantly, while the total number of coercive interventions remained unchanged. Findings suggest some potential of intensive models of need-adapted care to reduce coercive interventions in psychiatry. However, results must be substantiated by evidence from randomized-controlled trials and longer observation periods.
Highlights
Many efforts have been made in the past years, the use of coercive measures like involuntary hospital treatment, seclusion, mechanical restraint and forced medication in psychiatric inpatient setting still belongs to everyday practice
The subgroup of patients with a diagnosis of psychosis benefited from the effects of the model project, indicating that one of its main goals, i.e., providing alternatives to hospital admissions for patients with SMI, could be attained
Many Intensive Case Management (ICM)/assertive community treatment (ACT) models such as the integrated care model of the University of Hamburg already focus their resources on this patient subgroup in order to provide assertive treatment to a population which exhibits high rates of treatment drop-out, comorbid disorders and lower treatment adherence [20]
Summary
Many efforts have been made in the past years, the use of coercive measures like involuntary hospital treatment, seclusion, mechanical restraint and forced medication in psychiatric inpatient setting still belongs to everyday practice. The experience of coercion has been shown to be linked to a wide range of negative consequences, from higher rates of subsequent involuntary admissions, deterioration of the therapeutic relationship, lower use of outpatient resources to the development of post-traumatic symptoms [1,2,3]. It negatively influences private relationships and future professional perspectives [4]. They often include multiple strategies, e.g., staff training, use of advance directives and crisis plans, modification of ward environments, early evaluation and identification of risk situations, or changes in ward routines [6, 7]
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