Coercion In Psychiatry Research Articles

Mental health professionals' feelings and attitudes towards coercion

BackgroundDespite absence of clear evidence to assert that the use of coercion in psychiatry is practically and clinically helpful or effective, coercive measures are widely used. Current practices seem to be based on institutional cultures and decision-makers' attitudes towards coercion rather than led by recommendations issued from the scientific literature. Therefore, the main goal of our study was to describe mental health professionals' feelings and attitudes towards coercion and the professionals' characteristics associated with them. MethodMental health professionals working in the Department of Psychiatry of Lausanne University Hospital, Switzerland, were invited to participate to an online survey. A questionnaire explored participants' sociodemographic characteristics, professional background and current working context, and their feelings and attitudes towards coercion. Exploratory Structural Equation Modelling (ESEM) was used to determine the structure of mental health professionals' feelings and attitudes towards coercion and to estimate to which extent sociodemographic and professional characteristics could predict their underlying dimensions. Results130 mental health professionals completed the survey. Even if a large number considered coercion a violation of fundamental rights, an important percentage of them agreed that coercion was nevertheless indispensable in psychiatry and beneficial to the patients. ESEM revealed that professionals' feelings and attitudes towards coercion could be described by four main dimensions labelled “Internal pressure”, “Emotional impact”, “External pressure” and “Relational involvement”. The personal as well as the professional proximity with people suffering from mental disorders influences professionals' feeling and attitudes towards coercion. ConclusionsAs voices recommend the end of coercion in psychiatry and despite the lack of scientific evidence, many mental health professionals remain convinced that it is a requisite tool beneficial to the patients. Clinical approaches that enhance shared decision making and give the opportunity to patients and professionals to share their experience and feelings towards coercion and thus alleviate stress among them should be fostered and developed.

Informellt tvång mot patienter

Det har gjorts relativt omfattande forskning om formellt tvång mot patienter i psykiatrin, dvs. tvång som regleras av lagstiftningen. Däremot finns det inte lika mycket forskning om informellt tvång, speciellt inte ur ett personalperspektiv. Denna studie har utgått från tidigare forskning där man identifierat fem former av tvång i psykiatrin som personal använder; övertalning, utnyttjande av den personliga relationen, belöning, hot och formellt tvång. Syftet var att få personalens reflektioner över formerna för, och användningen av, informellt tvång gentemot patienter. 
 Vi genomförde fyra fokusgruppsintervjuer med kuratorer, psykologer och läkare där syftet var att skapa ett reflekterande samtal om informellt tvång. Dessa intervjuer analyserades med kvalitativ innehållsanalys. 
 Förutom de fem tidigare identifierade former av tvång i psykiatrin fann vi även tre andra former; att lura patienten, uppfostrande attityd samt användning av regler och rutiner. Deltagare beskrev även tvång från andra intressenter som anhöriga och andra myndigheter. När det gäller övriga reflektioner tolkades dessa som professionalitet och tvång, där deltagarna betonade betydelsen av personalens förhållningssätt till patienter, tydlig kommunikation, en individanpassad vård samt fungerande samarbete och samverkan. 
 Enligt deltagarna i studien användes informellt tvång ofta samtidigt som det fanns en tveksamhet till det. Det var främst hur man som personal bör utnyttja den personliga relationen till patienten samt hur patienten uppfattade informellt tvång där deltagarna hade väldigt skilda uppfattningar. De rapporterade svårigheter i att hantera det informella tvånget som anhöriga och andra myndigheter använder gentemot psykiatrins patienter eftersom det kunde hota patienternas återhämtning. En slutsats är att informellt tvång inte enbart bör ses från ett juridiskt och kliniskt perspektiv utan att också att viktiga etiska aspekter kring informellt tvång bör uppmärksammas.

Reduction of coercion in forensic psychiatry

In an article in Klinisk Sygepleje 04 / 2019 (Volume 33), Ellen Boldrup Tingleff mentioned her PhD thesis (1) about patients’ and relatives’ perceptions of situations associated with mechanical restraint (MR) in forensic psychiatry. Her conclusion is that patients and relatives demand de-escalation, inclusion and involvement of relatives, debriefing and a caring attitude from the staff, all for the purpose of reducing the number and duration of MR. In Denmark, as stated in the background, MR is still widespread in clinical psychiatric practice. In recent years, measures have been taken to reduce coercion in psychiatry in general and MR in particular. However, while the number of MRs has decreased, other forms of coercion, such as acute sedative medication and physical retention of patients, are on the increase (2). Further research in this important field of psychiatry might therefore concern implementation, focusing on staff’s attitude towards coercive measures and the implementation process of proposed measures, since the involvement of staff is crucial to the success of reducing coercion in several areas simultaneously.

Coercion in psychiatry: practical consequences of ethical aspects

Im Rahmen der rechtlichen und ethischen Voraussetzungen und Verfahren der Anwendung von Zwang in der Psychiatrie wird die Perspektive der Abwendung, also die Prävention zur Vermeidung von Zwang beleuchtet. Zwang ist ausschließlich bei Selbstbestimmungsunfähigkeit und unmittelbarer konkreter Lebensgefährdung zulässig. Praktische Schwierigkeiten bei der Feststellung dieser Kriterien werden kasuistisch illustriert. Verfahren zur Vermeidung von Zwang (Vorausverfügungen, vertrauensbildende Maßnahmen, Erkennung von Kontexteinflüssen, Sensibilisierung gegenüber Zwang) zielen ebenso wie die Präzisierung von Indikation und Kontrolle der Anwendung von Zwang und ein Einstellungswandel hin zur Entscheidungsassistenz darauf, die Respektierung des Selbstbestimmungsrechtes des psychisch Kranken zu stärken – und damit den Konflikt des Psychiaters zwischen Fürsorgepflicht und Respektierung des Selbstbestimmungsrechtes des Patienten in ein faires Gleichgewicht zu bringen.

Coercion in psychiatry: A cross-sectional study on staff views and emotions.

WHAT IS KNOWN ON THE SUBJECT?: Coercive interventions (CI) in emergency psychiatry face increasing criticism, as they can be an emotional, even traumatic event for all persons involved. They are thus considered the last resort. The use of coercive interventions differs widely with regard to type and frequency of measures across different countries and institutions. Individual staff characteristics, such as attitudes towards coercion, may play a vital role in the management of aggression. Little is known about the influence of emotions of staff members on CI, but they are likely to play an important role. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Most staff members surveyed had a rather critical view of coercion and considered it a "necessary evil." Staff members with the most work experience had a more critical view of coercion in comparison with less experienced staff. Nurses rated coercion more positively than did psychiatrists or psychologists. Emotions play an important role in decision-making processes. The current study systematically asked for accompanying emotions during the application of CI and looked for individual differences. A majority of the participants experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% stated that they felt a sense of power. Older staff members more often felt anger or guilt; women felt less power than men did. Nurses felt more desperation than other occupational groups. Staff members consider reflective interventions, such as team supervisions or post-seclusion/restraint debriefings with the patient, as important. Nevertheless, only half reported that these interventions are carried out routinely. Staff members believe that certain risk factors (including stress, low staffing, a fully occupied ward and the presence of particular staff members) enhance the probability of CI. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To reduce the use of coercive interventions, we recommend that psychiatric teams include highly experienced staff members as work experience has a positive effect on the attitudes towards coercive interventions. Structured post-seclusion/restraint debriefings and team supervisions are considered helpful by staff members and are relatively easy to implement on acute wards. Enhancing staff members' ability to reflect on their own attitudes, emotions and actions is likely to reduce coercive interventions. ABSTRACT: Introduction Little is known about staff attitudes towards coercive interventions (CI) and emotions accompanying these measures. Aim The current study assessed attitudes, views on reflective interventions and accompanying emotions of different occupational groups towards CI, as well as factors, that increase the probability of CI. Method Staff members (N=138) of a large psychiatric hospital in Germany were assessed using the Staff Attitude to Coercion Scale (SACS) and newly developed items assessing staff members' emotions and views on coercion. Results Experienced staff members were most critical of coercion. Nurses rated coercion significantly more positively than other staff. A majority experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% felt a sense of power. Nurses felt the most desperation. Participants strongly desired reflective measures such as post-seclusion/restraint debriefings with patients. According to staff members, stress on the wards and low staffing increases the probability of CI. Discussion The study assessed accompanying emotions during the application of CI. Attitudes towards coercion and emotions are associated with individual staff characteristics (e.g. profession, work experience). Implications The presence of experienced staff members may help prevent CI. Staff consider reflective interventions helpful in reducing CI.

Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of...

Humane treatment versus means of control: coercive measures in Norwegian high-security psychiatry, 1895-1978.

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway - Kriminalasylet (Criminal Asylum) and Reitgjerdet - during the period 1895-1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

Measures to Avoid Coercion in Psychiatry and Their Efficacy.

Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry. This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content. Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%. Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.

Ograniczenie autonomii jednostki, a może ochrona konstytucyjnych praw i wolności człowieka? Normatywne aspekty stosowania „przymusu bezpośredniego” w psychiatrii

The publication is concentrated on the use of direct coercion in psychiatry. I tried to answer on the question whether using direct coercion always leads to the limitation of individual autonomy, whether provides the protection of constitutional law and human freedom. Unraveling above background would be impossible without refer to the human rights which is a source of basic laws and freedom. The reference to limitation of individual autonomy was based on Bioethical Convention. Situation and requirements became closer which explain and can create a foundation for using a direct coercion. In this article, circumstances were intorduced in which in compliance with law, using direct coercion is acceptable as well as rules and the course. The relationship was noticed between its application and required agreement of individual to grand the health care.

Patients’ attitudes towards and acceptance of coercion in psychiatry

Coercive interventions for psychiatric patients are controversial. Research on different preventive measures has increased over the last years. The present study examined patients’ attitudes towards and understanding of previously experienced coercive measures as well as their preferences related to coercive measures and possible alternatives. In total, 213 patients who had experienced coercion and 51 patient controls (patients staying voluntarily on a closed ward with no coercive treatment) from three acute wards were examined via expert interviews and questionnaires in the framework of a naturalistic trial. Assessments included a new self-developed questionnaire as well as instruments measuring psychopathology. Patients who had experienced coercion differed from controls in both symptoms and insight into their illness. As expected, “noninvasive measures” (e.g., the use of a “soft room,” observation in seclusion) were better accepted by patients than “invasive measures” (e.g., mechanical restraint, forced medication). Forced medication and mechanical restraint were less well accepted than involuntary hospitalization, seclusion, or video surveillance. The retrospective understanding of coercive measures increased over the course of treatment. In addition, patients rated a number of options for reducing coercion on the wards, particularly music or exercises. A large subgroup indicated they would like to discuss future admissions with the staff.

Does the use of psychotropic medication go up during focused efforts to bring coercion and restraint down?

IntroductionAntipsychotic or anxiolytic medicine is widely used in agitated patients in risk of coercion. However this medication is also known to contribute to cardio-vascular disease and reduced life expectancy. Department of Psychiatry in Aabenraa, Denmark participates in a nation-wide Danish project supporting efforts to reduce coercion and restraint. Our hypothesis is that reduction of coercion might lead to unwanted increase in doses of psychotropic medication.ObjectiveTo document the use of psychotropic medication during the project period, in order to learn more about the impact of interventions to reduce coercion and restraint on psychopharmacological treatment.AimTo compare type and doses of psychotropic prescriptions during the project period with the time before implementation.MethodsCohort study of patients in risk of agitation and coercion admitted to the wards during first quarter of 2013 and 2016. Eligible patients were diagnosed as having organic mental disorders, substance abuse, psychotic disorders, mania, bipolar affective disease or personality disorders (ICD-10: F0x, F1x, F2x, F30-31, F60). Primary outcome is the exposure to antipsychotic medication measured as defined daily doses, and secondary outcomes are exposure to benzodiazepines, polypharmacy and compliance with guidelines on agitated patients.ResultsData collection is carried out during autumn of 2016, and the results will be presented at the congress.ConclusionsResults from this study will contribute to our understanding of the implications of the initiative to reduce restraint and coercion in psychiatry. The results will also sharpen our awareness of possible inexpedient practice.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Regaining ownership and restoring belongingness: impact of family group conferences in coercive psychiatry.

This study examined the impact of family group conferences on coercive treatment in adult psychiatry. Coercive treatment in psychiatry infringes the fundamental rights of clients, including the right to control their lives. A promising intervention is the family group conferences, which has the potential to prevent crises through the integration of the expertise of informal and professional networks. A responsive evaluation, including qualitative and quantitative methods, was deployed to study the process leading up to the FGC, the proceedings and the impact of the conference. From 2013-2015, 41 family group conferences were studied in three regions in the Netherlands. The impact of every conference was examined with scales (ranging from 0-10) during interviews with attendees (clients, family members, friends, mental health professionals and family group conferences coordinators) who reflected on three outcome measures: belongingness, ownership and coercion. After the family group conferences, respondents indicated a slight reduction in their experience of coercive treatment. They also mentioned an increase in ownership and belongingness. Family group conferences seems a promising intervention to reduce coercion in psychiatry. It helps to regain ownership and restores belongingness. If mental health professionals take a more active role in the pursuit of a family group conferences and reinforce the plans with their expertise, they can strengthen the impact even further.

Krizna stanja i primjena mjera prisile u psihijatriji

The article deals with phenomena of aggression and violence in humans with special attention to mental illnesses. Crisis and violent behaviour do not occur only in psychiatry. It can happen in any context or circumstance, and any person could either fall victim or be the perpetrator. Knowledge of multicausality and complexity as well as of individual environmental and situational factors that can lead to violent behaviour has little power of prediction. Statistical indicators can conceal false positive and false negative results, whereby the error of assessment can dramatically increase the risk of some behaviour or lead to an unjustified suspension of human rights of freedom. The use of coercion in psychiatry is necessary only in exceptional situations where dangerous behaviour directly threatens the life and health of the person or the environment or property. Positive legislation, in particular the Law on the Protection of Persons with Mental Disabilities (Narodne novine 76/2014) and the Ordinance on the Types and Methods of Enforcement of Coercion to a Person with Serious Mental Disorders (Narodne novine 16/2015) further protects the rights of the mentally ill and prescribes the type and mode of coercion as well as procedures for handling. Professional psychiatric societies have provided additional guidelines and treatment strategies. The paper emphasizes the need for better conditions, infrastructure and human resources, with continuous improvement and evaluation of the quality of work in psychiatry. In conclusion, the standards and ethical issues of society and a broad spectrum of activities are being discussed, from destigmatization, through better access to services to standards of living and social inclusion, which can indirectly lead to a significant reduction of violence in society.

Coercion in psychiatry: the importance of extramural factors

Background: Mechanical restraints and forced procedures in psychiatric wards are of major concern in Denmark and there is a desire to reduce these procedures to a minimum. So far, focus has primarily been on identifying and changing internal (intramural) factors when seeking to reduce coercion.Aim: To identify possible external (extramural) factors that may increase the risk of coercion during admission to a closed psychiatric ward.Method: Using a retrospective case-controlled design, 235 patients admitted to a closed ward during 2011–2013 were randomly selected. Coercion comprised belt restraint, physical restraint, and forced medication. The data source was the electronic patient records, which include statutory information on all forced measures. Multiple logistic regression analyses were applied to calculate the risk (odds ratio, OR (95% confidence interval)) of forced measures being used.Results: Out of the 235 patients, 66 (28%) were subject to coercion. The time of forced procedures was predominately during the first hours after admission. The risk of forced measures being applied was significantly higher if patients were involuntarily admitted (OR = 6.4 (3.4–11.9)), or were acutely intoxicated by substances at the time of admission (OR = 3.7 (1.7–8.2)).Conclusion: Extramural factors should be included when mental health authorities plan efforts to reduce coercion during admission to psychiatric wards. A reduced threshold for admission and improved integrated effort between mental health services and treatment for substance abuse could improve the course of disease for this group of patients and reduce the need for involuntary admissions and subsequently coercion.

National data on coercion in psychiatry from Wales

A lack of adequate and accurate data in relation to coercion means that there is little information to guide benchmarking and service planning. The aim of this study was to collate and analyse data for restrictive physical interventions (RPIs) across Wales. All health boards in Wales were asked to provide information on restrictive physical interventions across all specialties. Information requested allowed calculations per 100 admissions and per 100 occupied bed days per month, which reduce bias attributed to levels of admissions and occupancy. Full data sets were obtained for 2013 from all health boards. There was a wide level of variation between health boards. Uniform data gathering is required. Benchmarking may be a useful tool to develop strategies to reduce regional variations.

Coercion and trust in psychiatry: the ultimate contradiction

Purpose– The purpose of this paper is to present a focused viewpoint of coercion in psychiatry from the perspective of a survivor and activist.Design/methodology/approach– This paper takes elements from and builds on three recent conference and seminar presentations presented in France and the UK in 2014: International Congress on Clinical Ethics Consultation 2014, Paris: Comité Européen Droit Ethique et Psychiatrie, June 2014, Perpignan and Royal College of Psychiatrists’ Annual Congress, London 2014.Findings– Coercion in psychiatry runs counter to the highest human rights standards, rules out genuine care and profoundly undermines trust.Research limitations/implications– Additional research from a user and survivor experience would offer a different and more grounded perspective of how coercion is actually exerted and experienced through, for instance, a narrative approach.Originality/value– The paper is proposed from the viewpoint of a survivor of psychiatry and human rights activist. It is a contribution towards a more user/survivor oriented discourse in this area.

Gender differences in coerced patients with schizophrenia.

BackgroundDespite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied.Methods291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed.ResultsWhen compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men.ConclusionsResults of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Mechanische Bewegungseinschränkungen: Die klinische Praxis an einer psychiatrischen Universitätsklinik

Public opinion on psychiatric medicine is still dominated by images of repression; in particular, the aspects of involuntary admissions, restraint, isolation, or involuntary administration of medication contribute significantly to public prejudice. Furthermore, violations of individual privacy rights and the use of coercion in psychiatry is an ethical challenge. The aim of this study was to describe the "practice of mechanical restraint" at a university hospital in Austria. In this study, all admissions to the closed ward at the Department of Psychiatry of the University Clinic of Innsbruck between July and December 2009 were assessed through retrospective data analysis. 529 admissions were identified during the study period. In 148 admitted patients mechanical restraint was arranged at least once. Mechanical restraint was used most frequently and over the longest period of time in patients of the ICD diagnosis group F0. In most cases, "self- harm" had been the reason for restraint. Fourteen percent of the restraints were due to a "danger to others". In patients with "danger to others", a 5 point fixation was used significantly more often than in patients without danger to others, where a restriction by bedrail and/or abdominal belt was most common. A comparison of these data with those of other centers is limited due to diverse documentation systems. A unified approach in terms of an effective quality management would be desirable in this regard.

Impact of Psychiatrists’ Qualifications on the Rate of Compulsory Admissions

Despite efforts to reduce coercion in psychiatry, involuntary hospitalizations remain frequent, representing more than half of all admissions in some European regions. Since October 2006, only certified psychiatrists are authorized to require a compulsory admission to our facility, while before all physicians were, including residents. The aim of the present study is to assess the impact of this change of procedure on the proportion compulsory admissions. All medical records of patients admitted respectively 4 months before and 4 month after the implementation of the procedure were retrospectively analyzed. This search retrieved a total of 2,227 hospitalizations for 1,584 patients. The overall proportions of compulsory and voluntary admissions were 63.9 % and 36.1 % respectively. The average length of stay was 32 days (SD ± 64.4). During the study period, 25 % of patients experienced two hospitalizations or more. The most frequent patients' diagnoses were affective disorders (30 %), psychotic disorders (18.4 %) and substance abuse disorders (15.7 %). Compared with the period before October 2006, patients hospitalized from October 2006 up were less likely to be hospitalized on a compulsory basis (OR = 0.745, 95 % CI: 0.596-0.930). Factors associated with involuntary admission were young age (20 years or less), female gender, a diagnosis of psychotic disorder and being hospitalized for the first time. Our results strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions.

P-603 - Relatives' views on hospital treatment predict patients' clinical and social outcomes

Relatives' involvement in the delivery and evaluation of psychiatric treatments has been recently emphasized by mental health policies. However, few data are available so far on relationship between relatives' evaluation of psychiatric treatments and patients' outcomes. A multicentre prospective study was carried out in eight European countries, as part of the “European evaluation of coercion in psychiatry and harmonization of best clinical practice (EUNOMIA)” study. In each centre, all legally involuntarily admitted patients and voluntarily admitted patients who reported high levels of coercion (i.e. a score higher than 3 at the Mac Arthur Scale for Perceived Coercion) were asked to participate in the study. Patients were evaluated at the admission and at three months. Relatives were assessed one month after admission. Five hundred and 78 patients and their relatives were recruited. Relatives' views of patients' hospital treatment were globally positive. In the multivariate linear regression analysis, relatives' views were associated with better objective patients' outcomes at three months from admission, when controlling for patients' and relatives' age and gender, diagnosis and country. Relatives of inpatients assess treatment rather positively and their appraisal is associated with clinical outcomes. Further studies should evaluate what are the best strategies to involve relatives in evaluation of mental health care.