Abstract
BackgroundCoercive measures are among the most controversial interventions in psychiatry. There is a large discrepancy between the sheer number of high-quality guidelines and the small number of scientifically accompanied initiatives to promote and evaluate their implementation into clinical routine. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry.MethodsThe study presented examines whether coercive measures on psychiatric wards can be reduced by means of an operationalized implementation of the guidelines “Prevention of coercion: prevention and therapy of aggressive behavior in adults”. Out of a set of 12 interventions offered, wards are free to choose three interventions they want to implement. The primary outcome is the number of coercive measures per bed and month/year. Secondary outcomes are cumulative duration of coercive measures per bed and month/year. The most important control variable is the number of aggressive incidents. We plan to recruit 52 wards in Germany. Wards treating both voluntary and compulsorily admitted patients will be included. A 1:1 stratified randomized controlled trial will be conducted stratified by the amount of coercive measures and implemented aspects of the guidelines. In addition to the control group analysis, a waiting list design allows a pre-post analysis for all participating wards of the waiting list group. A parallel qualitative study will examine factors related to successful implementation and to successful reduction of coercion as well as relevant barriers.DiscussionWe are planning a nationwide study on the implementation of evidence- and consensus-based guidelines in psychiatric hospitals. This study intends to promote the transfer of expert knowledge as well as results from clinical trials into clinical routine with the potential to change supply structures in mental health sector.Clinical Trial Registration www.isrctn.com, identifier ISRCTN71467851.
Highlights
Whether and under what circumstances the use of coercion in psychiatric treatment is justified is one of the oldest and most controversially discussed questions in psychiatry
Wards are randomized in a 1:1 ratio to either an intervention or a control condition, stratified by the amount of coercive measures per bed and month/year and the implemented aspects of the guidelines to matched pairs
A waiting-list control design allows for a pre-post analysis for participating wards of the waiting list group. This design allows for analyzing if observer effects already lead to a reduction of coercive measures between the baseline and the start of the intervention as well as for assessing potential spill-over effects in the control group during the waiting time
Summary
Whether and under what circumstances the use of coercion in psychiatric treatment is justified is one of the oldest and most controversially discussed questions in psychiatry. The subject has been classified as highly relevant by the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and is the subject of numerous statements [5] Against this background, the Clinical Practice Guidelines “Prevention of coercion: prevention and therapy of aggressive behavior in adults” [6] was published in 2018. A comprehensive research of the scientific evidence as well as a structured consensus-finding process involving all relevant experts was incorporated into the recommendations These guidelines define aggressive behavior as an interactive process. Aggressive behavior in psychiatric institutions results from the interaction of individual experience and behavior on the part of patients, relatives and employees, situational characteristics and an escalation component This means that aggressive escalations as well as coercive measures by psychiatric institutions can be modified. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry
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