Compulsory Care Research Articles

Patient Experiences of Patient-Initiated Brief Admission in Psychiatric Care: A Systematic Review.

Patient-initiated brief admission (PIBA) is an innovative psychiatric care intervention that gives patients the autonomy to initiate a short admission (approximately 1-3 days) to psychiatric inpatient care. This intervention is structured around a mutual agreement between the patient and their care provider that outlines the specific structure and content of their care. Unlike regular psychiatric admissions, healthcare professionals do not review the patient's decision for admission during PIBA. Similar interventions have been developed globally to reduce the need for long inpatient admissions and compulsory care by enhancing patient autonomy, promoting active participation in care, and empowering patients to recognise early signs of mental health deterioration. The objective of this systematic review was to explore the experiences of PIBA among individuals with mental health disorders. A systematic review was conducted using qualitative articles sourced from the PubMed, CINAHL, and PsycINFO databases. A total of thirteen original articles were included in the review, encompassing 186 patients. Research demonstrates that PIBA significantly impacts patients' care experiences in various ways. Access to PIBA gives patients the opportunity to take a break from daily stressors, which has proven significant in interrupting the cycle of worsening symptoms and negative thoughts. Furthermore, when the care environment is characterised by trust and respect, patients experience an increased sense of freedom, which contributes to a more effective recovery process. PIBA provides patients with a sense of safety and offers the possibility of a more functional daily life. Healthcare professionals'attitude and care provision also significantly influences patients' experiences. Central to a positive patient experience are a warm reception, attentiveness, and active listening. PIBA can not only change patients' perceptions of healthcare but, more importantly, fosters a transformative view of themselves as active participants in their own well-being. Knowledgeable healthcare professionals are crucial for the successful implementation of this intervention. By offering dignity and warmth alongside safety, PIBA addresses a critical gap in patient mental health care.

Mental healthcare in South Tyrol

Mental healthcare in South Tyrol, as everywhere in Italy, is still characterized by Law 180, which came into force in 1978 under the leadership of Franco Basaglia and Bruno Orsini. The Ministry of Health subsequently set atarget number of beds of 10/100,000 inhabitants. Unlike in other parts of Italy, private clinics play aminimal role in South Tyrol. The "Psychiatric Services" are part of the state healthcare system responsible for all citizens and are also responsible for compulsory outpatient care. According to the concept of community care, also due to the small number of inpatient beds, agreat deal of care is provided on an outpatient basis. Coercive measures can only be used in the case of an illness requiring urgent treatment that the patient refuses, without recourse to endangering circumstances (self-endangerment or danger to a third party). Inpatient hospitalization is only possible if treatment also takes place and the principle of "outpatient before inpatient" also applies in this context, i.e., coercive treatment can only take place as an inpatient if it cannot be carried out as an outpatient. Forensic psychiatry has very few places and mentally ill offenders are often in prison or occupy beds in general psychiatric wards. Compared to Germany there are fewer beds available but staffing levels are better, particularly for nursing. In relation to the number of inhabitants, compulsory treatment is more frequent than in Germany, whereas involuntary hospitalization and physical restraint are much rarer (only possible in Italy by court order).

Using and Measuring Motivational Interviewing in a New Setting: Experiences From a Project Highlighting Relationship-Building Skills in the Process of Recruiting New Staff

Relationship-building skills, with empathy and empathic abilities as crucial ingredients, are described as central in human service professions. These professions usually require training on relationship-building skills. However, in many professional groups, with support or care functions, rather than functions specifically oriented towards treatment, the level of education and training required varies. Empathic skills are central in the concept of Motivational Interviewing (MI). It has been suggested that for the ethical reason that treatment staff should not harm clients, workplaces should assess staff members’ empathic skills and ability to refrain from harmful behaviours, and these capabilities should be investigated when recruiting new staff. In accordance with this suggestion, the residential homes at the Swedish National Board of Institutional Care (SiS), which provides compulsory care for young people, initiated a project to develop and trial a work test based on the concept of MI. The aim of the article is to, based on 59 interviews with stakeholders in the SiS-project, add to the discussion on the balancing act required in evidence-based practise of maintaining psychometric stringency versus making contextual and situational adjustments. Focus is on exploring the possibilities for using and interpreting measures of MI in a new setting as well as the possibilities for assessing relationship-building skills in the recruitment process. The results suggest that tinkering is often necessary when using standardised measures for complex skills like relationship building. The study proposes that a nuanced understanding of the method, measurement, and organisational context is essential even with well-established methods.

Challenges for unaccompanied asylum-seeking minors in Swedish compulsory institutional care

This qualitative thematic study aimed to examine the placement of unaccompanied asylum-seeking minors in compulsory institutional care in Sweden, to expand knowledge regarding their care and treatment. The dataset comprised official documents and anonymized journal documents from personnel detailing the experiences of twenty-five unaccompanied asylum-seeking minors in compulsory institutional care organized by the Swedish National Board of Institutional Care in 2015. The study identified three main themes: traumatic life events and mental health, alignment between needs, goals, and treatment, and language difficulties. The findings revealed a high prevalence of severe traumatic experiences among the asylum-seeking minors, with half having endured significant psychological and physical trauma. Mental health issues were inconsistently addressed, and prior traumas were often overlooked in care planning. The majority exhibited various mental health problems, underscoring the need for tailored interventions. The study highlights challenges in aligning unaccompanied asylum-seeking minors' individual needs, treatment goals, and provided care. Language barriers emerged as a critical concern, impeding effective communication and treatment. Approximately 80% of the asylum-seeking minors experienced difficulties in understanding and expressing themselves in Swedish. The limited use of professional interpreters further exacerbated this issue. The study underscores the need for targeted interventions to better support unaccompanied asylum-seeking minors within compulsory institutional settings.

Professionals’ account-making of institutional care for youths. Intertwined discretionary spaces and blurred collaborative practice

ABSTRACT In this article, the account-making of social workers and institutional care staff on locked institutional care for youth is analysed, based on empirical material consisting of 10 interviews with 25 members of the two professions. The study departs from a Swedish context where locked institutional care for youth is mainly provided for individuals who are in compulsory care due to criminality, drug abuse, or other socially destructive behaviour. The analytical framework draws on account theory and Emerson’s concept of institutional care as a ‘last resort’. The results show that both social workers and staff use similar justifications and excuses, relating to organizational resources and rules and to assessments and decisions made by the other professional group; but also, that different layers of accounts overlap between professionals’ account-making stories and can change as care proceeds. The results are discussed in relation to the pooled discretion that is exercised when different professional groups are involved in care decisions, and the organizationally specialized care setting resulting in intertwined discretionary spaces and blurred practice, with consequences for the quality of care and challenges in holding professionals accountable.

Blurring the Lines Between Victimhood and Responsibilization? Sex as Behavioral Problems in Court Decisions on Compulsory Care of Young People

Formal social control of girls has historically focused on disciplining their sexual behavior, and studies show this is still present. This article analyses how authorities describe and give meaning to young people’s sexual behavior when assessing their need of compulsory care. The results show that in the few cases when boys’ sexual behavior is highlighted, it concerns sexual delinquency. The assessments of girls’ sexual behavior largely regards situations where they are exposed to others’ sexual transgressions, risking to victim-blame girls. This is discussed in relation to gendered understandings of sexual behavior and supposed gaps in legislation.

Geographical variation in compulsory mental health care: cause for concern and source of causal inference

IntroductionCompulsory mental health care remains a controversial practice. The many difficulties in performing Randomised Controlled Trials (RCT) on the topic means there is limited evidence to support its effectiveness. For ethical and legal reasons, compulsory mental health care should only be used when necessary. Yet, geographical variations, which can indicate both overuse and underuse, have been observed. In the funded research project “Controversies in Psychiatry” we intend to use this variation as a source of knowledge production. We propose that this naturally occurring variation mimics randomisation, and can therefore permit causal inference from registry data.ObjectivesWe will estimate the causal effect of compulsory inpatient mental health care on a range of outcomes, including injuries, self-harm, and all-cause mortality; violent crime; employment vs benefit allowance; rehospitalisation and outpatient commitment.MethodsObserved variation in register data on all episodes of compulsory inpatient mental health care in Norway between 2015-2016 (N ≈ 300 000), will serve as a source of as-random variation. Provider-preference for compulsion usage will be used as an instrumental variable (IV).ResultsOutcomes will be observed from 2017-2025. If assumptions underlying IV-analysis do not hold, the project will still provide important and complete descriptive data on long-term outcomes for a whole population.ConclusionsGeographical variation is a cause for concern if people are treated differently depending on area of residence. But it also presents an opportunity to use differences in service provider’s preference for using compulsory care as an instrumental variable to estimate the causal effect of compulsory care on multiple short and long-term outcomes. This approach can help resolve controversies that are difficult or even impossible to investigate through RCTs. After presenting the project plan we invite to a discussion of the feasibility of using an instrument variable approach to explore if relatively low versus high rates of compulsory care produce favorable outcomes for patients.Disclosure of InterestNone Declared

Challenges that early career psychiatrists can face on compulsory treatment

AbstractThe delivery of mental health care worldwide often involves compulsory treatment, a practice encountered by early career psychiatrists from the outset of their training. Despite its prevalence, little research has explored the challenges faced by trainees and early career psychiatrists when compelled to administer treatment without patient’s consent. This presentation will synthesize research data and offer personal reflections on the author’s experiences.Challenges that early career psychiatrists can face regarding compulsory treatment can be categorized into personal, professional, and institutional. Personal challenges encompass the emotional stress associated with applying coercive measures, coping with negative emotions, and managing service users’ attitudes toward treatment without consent. There is also concern that compulsory treatment may elevate the risk of emotional burnout. Professional challenges involve the administrative burden associated with organizing compulsory treatment, often exacerbated by the formalization of the process as a bureaucratic procedure in many European countries. Additionally, dealing with legal processes, including interactions with lawyers and courts, can pose significant difficulties, even though it is clearly done to protect the rights of the persons receiving care. Institutional challenges encompass the overall policy of providing compulsory psychiatric care in the psychiatrist’s home country and the specific practices of coercive measures in a given treatment facility. Furthermore, the lack of dedicated time for ethics of coercion during training is a common issue.In the current landscape of mental health care, early career psychiatrists must undergo training to handle coercive measures. While these measures are sometimes unavoidable, ethical principles must guide their administration. Additionally, access to supervision/mentoring is crucial for early career professionals facing challenging cases.Disclosure of InterestNone Declared

Handling the desire to die– evaluation of an elective course for medical students

BackgroundThe desire to die can occur in palliative care patients with a prevalence of up to 22%. Not every desire to die is accompanied by a pressure to act, but usually by a burden that can arise from various factors. To address this burden appropriately, health care workers should be trained. Based on an evaluated course on handling the desire to die, an elective course for medical students was developed and evaluated. In order to identify the impact of the elective course’s content, a comparison of attitudes towards assisted dying with two other participant groups was conducted. Therefore, three questions from the evaluation of the elective course were used.MethodOnline evaluation of the elective and questions addressing attitude were assessed using a five-point Likert scale. The specific outcome-based assessment was determined using the Comparative Self-Assessment Gain. The main participant group (group 1) were students who took the elective. The additional survey on attitudes towards assisted dying included undergraduate medical students who had taken compulsory palliative care courses (group 2) and physicians who had taken an introductory course in intensive care or emergency medicine (group 3).ResultsGroup 1 (n = 13, response rate rr = 86.7%) was very satisfied with the blended learning format (100%) and the course itself (100%). They were able to deepen their knowledge (81.0%) and train skills (71.2%) through the course. In the additional surveys, there were 37 students in group 2 (rr = 66.1%) and 258 physicians in group 3 (rr = 73.6%). Willingness to assist with or accompany the various options for assisted dying varied according to the type of assistance. Among the participants, it can be summarised that the highest willingness was shown by the students of group 2 followed by the physicians of group 3 and the students of group 1.ConclusionsA course on handling the desire to die of palliative patients can deepen knowledge and train communication skills and thus support self-confidence. Dealing with the background of the desire to die, knowledge about assisted dying, but also one’s own attitudes and responsibilities can influence the attitude towards assisted dying.

Reimagining citizenship: Exploring the intersection of ecofeminism and republicanism through political care and compulsory care service

Reimagining citizenship: Exploring the intersection of ecofeminism and republicanism through political care and compulsory care service

Feasibility and results of a pilot online survey to examine prevalence of gambling and problem gambling among Swedish substance abuse inpatients in compulsory care

Feasibility and results of a pilot online survey to examine prevalence of gambling and problem gambling among Swedish substance abuse inpatients in compulsory care

Conditions for the provision of psychiatric care under compulsion: civil law aspect

The article is devoted to the issues of compulsory psychiatric care and ensuring the legitimate rights and interests of a person suffering from mental disorders and subjected to compulsory medical measures. It is noted that the level of a person’s mental health is determined by the influence of many factors – social, biological and psychological. The analysis of current legislation and specialised literature are allowed the author to argue that the issue of mental health of people, the population as a whole, is relevant today also because humanity is faced with various stress factors which can negatively affect human health, and in particular, mental health, worsen the moral and psychological climate in the family due to illness or death of loved ones, devastating natural disasters with a huge number of victims, military conflicts, military operations, including in Ukraine, which entail huge human losses and cause suffering for many.
 The author is substantiated the conclusion that compulsory psychiatric care is possible and necessary on the following grounds: the presence (assumption) of an acute mental illness or exacerbation of a chronic mental illness requiring inpatient treatment; danger of a mentally ill person to others or to himself/herself (psychomotor agitation with a tendency to aggressive actions, systematic delusional syndromes if they determine the patient’s socially dangerous behaviour, depressive states with suicidal tendencies, epileptic status, manic and hypomanic states that cause violations of public order or aggressive behaviour towards others, etc. etc.); inpatient examination (labour, military, forensic psychiatric).

The diversity of legal relations within the compulsory health insurance system

The adoption and subsequent implementation of Law No. 1585 dated 27.02.1998, concerning compulsory health care insurance, have generated a series of legal relationships that were previously unfamiliar to the healthcare system of the Republic of Moldova. Given that every legal relationship follows a certain course – it is initiated, may undergo modifications and/or suspensions, and eventually concludes – the legal relationships arising from the compulsory medical insurance system follow the same logical trajectory. However, it is essential to mention that within the com-pulsory medical insurance system, there exists a diversity of legal relationships which, both structurally and in terms of content, can be entirely distinct. This article addresses this diversity of legal relationships, which simultaneously form an integral part of medical legal relationships but only encompass those individuals directly involved in the compulsory health care insurance system: the insured, the insured persons, the insurer, and, correspondingly, the providers and suppliers of services and goods within this intricate social framework.

Is compulsory care ethically justified for patients with borderline personality disorder?

Patients with borderline personality disorder (BPD) are overrepresented in compulsory inpatient care for suicide-protective reasons. Still, much evidence indicates negative effects of such care, including increased suicide risk. Clinical guidelines are contradictory, leaving clinicians with difficult ethical dilemmas when deciding on compulsory care. In this study, we analyse the arguments most commonly used in favour of compulsory care of BPD patients, to find out in what situations such care is ethically justified. The aim is to guide clinicians when deciding on compulsory care for BPD patients and reduce the use of potentially harmful care. The arguments analysed are (a) the patients lack decision competence, (b) the patients lack authenticity, (c) compulsory care saves the patient from suicide, (d) compulsory care safeguards against litigation, complaints, or doctor's anxiety, (e) compulsory care is a practical solution in emergencies, and (f) it is better for the caregiver to ‘err on the safe side’. We conclude that compulsory care is not ethically justified in most cases unless the clinician has probable reason to believe that the patient lacks decision capacity by suffering from a severe mental co-morbidity and stands to benefit from such care.

“A Lonely Road to Walk Along” – The Experiences of Being a Next of Kin to a Woman in Need of Compulsory Psychiatric Inpatient Care

It is seldom that it is only the patient who is affected when someone is admitted to compulsory psychiatric inpatient care, the next of kin is usually also impacted. The aim was to describe the lived experiences of being a next of kin to a woman in need of compulsory psychiatric inpatient care. Ten next of kin were interviewed and the material was analyzed with a Reflective Lifeworld Research approach. The results show loneliness and feelings that their existence has collapsed. An emotional duality is described in the realization that the care is needed but they are devastated that the woman is there. A trust exists, but it changes when the next of kin are no longer a part of the care process.

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project.

Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.

A multilevel Bayesian Markov Chain Monte Carlo Poisson modelling of factors associated with components of antenatal care offered to pregnant women in Nigeria

BackgroundThe most recent WHO guideline on antenatal care (ANC) utilization reaffirmed the necessary and compulsory care and services a pregnant woman should receive to maximize the importance and gains of ANC. While most studies focused on the time of initiation and number of ANC contacts, emphasis was rarely placed on the components of ANC offered to women. This study assessed how complete the components of ANC received by pregnant women are as a proxy for the quality of ANC services offered in Nigeria. We also assessed the clustering of the components and state-level differentials and inequalities in the components of ANC received in Nigeria.MethodsWe used nationally representative cross-sectional data from the 2018 Nigeria Demographic Health Survey. We analysed the data of 11,867 women who had at least one ANC contact during the most recent pregnancy within five years preceding the survey. The assessed components were tetanus injection, blood pressure, urine test, blood test, iron supplement, malaria intermittent preventive treatment in pregnancy (IPTp), and told about danger signs. Others are intestinal parasite drugs (IPD)intermittent and HIV/PMTCT counsel. Descriptive statistics, bivariable and multivariable multilevel Bayesian Monte Carlo Poisson models were used.ResultsIn all, 94% had blood pressure measured, 91% received tetanus injection, had iron supplement-89%, blood test-87%, urine test-86%, IPTp-24%, danger signs-80%, HIV/PMTC-82% and IPD-22%. The overall prevalence of receiving all 9 components was 5% and highest in Ogun (24%) and lowest in Kebbi state (0.1%). The earlier the initiation of ANC, the higher the number of contacts, and the higher the quality of ANC received. Respondents with higher education have a 4% (adjusted incidence risk ratio (aIRR): 1.04, 95% credible interval (CrI): 1.01–1.09) higher risk of receiving more components of ANC relative to those with no education. The risk of receiving more ANC components was 5% (aIRRR: 1.05, 95% CI: 1.01–1.10) higher among pregnant women aged 40 to 49 years than those aged 15 to 19 years. Women who decide their healthcare utilization alone had a 2% higher risk of getting more components than those whose spouses are the only decision taker of healthcare use. Other significant factors were household wealth status, spouse education, ethnicity, place of ANC, and skill of ANC provider. Pregnant women who had their blood pressure measured were very likely to have blood and urine tests, tetanus injections, iron supplements, and HIV talks.ConclusionsOnly one in every 20 pregnant women received all the 9 ANC components with wide disparities and inequalities across the background characteristics and the States of residence in Nigeria. There is a need to ensure that all pregnant women receive adequate components. Stakeholders should increase supplies, train, and create awareness among ANC providers and pregnant women in particular.

A Critical Appraisal of Compliance with the Compulsory Treatment and Care for Victims of Gunshot Act 2017

Aim: The practice of demanding police report before gunshot injury victims receive medical care in Nigeria has led to needless loss of life in several instances. The practice stems from the (mis)application of the Robbery and Firearms (Special provision) Act 1984. Thus, the Compulsory Treatment and Care for Victims of Gunshot Act 2017 was enacted to mandate expedite medical treatment for gunshot victims without demand for police report.
 Methods: Adopting the doctrinal research methodology, this paper assessed the legacy of the Robbery and Firearms Act on the treatment of gunshot injury victims. It equally examined medical practitioners’ level of compliance with the provisions of the Compulsory Treatment and Care for Victims of Gunshot Act 2017 and the legal implication of non-compliance, while highlighting remedial options available under the law.
 Results: The study found that despite the provisions of the Compulsory Treatment and Care for Victims of Gunshot Act 2017, gunshot victims are still haunted by the ghost of the Robbery and Firearms (Special Provision) Act. Medical practitioners are still uneasy about the treatment of gunshot casualties without police reports due to apprehension about police harassment.
 Conclusion: This paper concludes that the lack of publicity about the current realities of the law and lack of coordination between medical practitioners, police officers and other key stakeholders is responsible for non-compliance with the Act.
 Recommendation: The study therefore recommends the need for enforcement of professional and penal sanctions against erring medical practitioners who fail to provide expedite medical treatment for gunshot injury victims.

Cognitive impairment in adults under compulsory psychiatric care: association with psychotic symptoms and high-dose antipsychotics

Background There is limited evidence on the association between cognitive function, psychotic symptoms and doses of antipsychotics in adults under compulsory psychiatric care. Aims We assessed (a) the degree of cognitive impairment in adults involuntarily hospitalised for compulsory psychiatric care and (b) correlation of Montreal Cognitive Assessment (MoCA) score with psychotic symptoms, polypharmacy and prescription of high-dose antipsychotics. Method This was a nationwide, cross-sectional study, conducted at the only referral state hospital for compulsory psychiatric care in Cyprus (December 2016–February 2018). Τhe MoCA was applied for the assessment of cognitive functioning. The Positive and Negative Syndrome Scale (PANSS) was applied for the assessment of psychotic symptoms. Results The sample comprised 187 men and 116 women. The mean MoCA score was 22.09 (reported scale range (RSR): 3–30); the mean PANSS general symptoms subscale score was 49.60 (RSR = 41–162). The participants who reported positive psychiatric history (mean 21.71, s.d. 5.37), non-adherence to pharmacotherapy (mean 21.32, s.d. 5.56) and prescription of high-dose antipsychotics (with medication prescribed as needed: mean 21.31, s.d. 5.70; without medication prescribed as needed: mean 20.71, s.d. 5.78) had lower mean MoCA scores compared with those who reported negative psychiatric history (mean 23.42, s.d. 4.51; P = 0.017), adherence to pharmacotherapy (mean 23.10, s.d. 6.61; P = 0.003) and no prescription of high-dose antipsychotics (with medication prescribed as needed: mean 22.56, s.d. 4.90; without medication prescribed as needed: mean 22.60 s.d. 4.94; P = 0.045–0.005), respectively. Mean MoCA score was mildly and inversely associated with total PANSS score (r = −0.15, P = 0.03), PANSS general (r = −0.18, P = 0.002) and PANSS negative (r = −0.16, P = 0.005) symptoms subscales, respectively. Conclusions Our findings support the evaluation of cognitive functioning in adults under compulsory psychiatric care via the MoCA tool, with focus on those prescribed high-dose antipsychotics, with positive mental health history and non-adherence to pharmacotherapy.

Legal Minors Who Inject: Differences in Socio-Demographics and Treatment Needs Compared to Adults in a Swedish National Sample of People with Injecting Drug Use

Background Injection drug use among legal minors is under-researched. Although the population may be small in absolute terms, treatment needs may be greater than for those who began injecting as adults. Such knowledge may help tailor services more effectively. Previous research tends to use selective samples or focuses solely on medical indicators. The present study uses a larger sample drawn from national register data in Sweden over a 9-year period (2013–2021) to analyze differences in medical and social treatment needs between people who began injecting as legal minors and their older counterparts. Method Data on first-time visitors to needle and syringe programmes (n = 8225, mean age 37.6, 26% women) were used. Historical socio-demographics and presenting treatment needs were compared between those with a debut injecting age under 18, and those who began injecting as adults. Results The prevalence of injecting before 18 years was 29%. This group had more negative social circumstances, such as leaving school early, worse health, and greater service consumption, compared to those who began injecting as adults. In particular, they had been subjected to a greater level of control measures, such as arrest and compulsory care. Conclusions The present study shows that there are important health and social differences between those who inject prior to 18 and those who begin injecting as adults. This raises important questions for both child protection services and harm reduction approaches for legal minors who inject, who still qualify as ‘children’ in a legal and policy sense.