Sectioned Research Articles

Mental health professionals’ beliefs and attitudes towards compulsory admission in Athens: a token of social stigma or good faith in psychiatry?—a cross-sectional study

BackgroundMental health professionals’ (MHPs) attitudes towards involuntary admissions have not received adequate attention in efforts to curb their rates. Thus, the present study set out to (i) explore MHP attitudes regarding involuntary hospitalisation, (ii) describe their perceived dangerousness of people with severe mental illness (SMI) and their trust in psychiatry, (iii) identify the predictors of attitudes towards compulsory admissions and (iv) gauge the contribution of perceived dangerousness versus trust in psychiatry to explaining them.MethodsA random sample of 300 mental health professionals working in public mental health services located in the Northern part of Athens and in the two psychiatric hospitals of Attica participated in the study. Respondents had to complete a self-reported instrument garnering information about participants’ attitudes towards involuntary hospitalisation (original scale), the perceived dangerousness of people with SMI (Perceived Dangerousness Scale) and their trust in psychiatry (based on the Attitudes to Mental Illness scale) as well as various socio-demographic and work-related variables.ResultsRespondents largely accepted involuntary hospitalisations, considering them to be beneficial (72.96%) and disagreeing with the view that they adversely influence the course of illness (54.85%). Nonetheless, they believe that people with SMI should be treated in the community (89.93%), that compulsory admission should be the last therapeutic resort (84.01%) and that people with SMI should not be placed in psychiatric hospitals against their will in order to be under surveillance (90.64%). However, they acknowledge that involuntary admission is often the only treatment options(61.19%). Concomitantly, they report moderate levels of perceived dangerousness and high levels of trust in psychiatry. Trust in psychiatry had the strongest positive association with acceptance of involuntary hospitalisation among mental health professionals whereas postgraduate studies and working in outpatient settings were linked to less favourable attitudes. Interestingly, perceived dangerousness did not yield an independent effect; rather, it weakened the association between trust in psychiatry and acceptance of involuntary admissions.ConclusionsMental health professionals hold complex attitudes towards involuntary hospitalisation, which are largely explained by their trust in psychiatry. Efforts to reduce the rates of involuntary admissions should address both them and their determinants.

Testing the Impact of a Law Enforcement-Operated Co-responder Program for Youths: A Quasi-Experimental Approach.

The authors examined whether use of a co-responder program reduced the likelihood of an involuntary commitment examination as the disposition of a police encounter with youths experiencing a mental health crisis and 1 year after the initial incident. Using a quasi-experimental design, the authors compared 206 incidents that involved the co-response program with 327 incidents that did not involve the program. Propensity score matching was used to balance groups on demographic and incident characteristics. The dependent variables included the disposition of the incident (deescalation or involuntary commitment examination), whether the youths experienced a later involuntary commitment examination within 1 year of the initial intervention, and time to the subsequent examination. Propensity score-weighted binary logistic regression and time-to-event analysis were used. The co-responder program was associated with a significantly lower likelihood of police officer-initiated involuntary commitment examinations and a lower likelihood of an involuntary commitment examination within 1 year. Eighty percent of the incidents that resulted in a co-response involving a police officer and a mental health professional were deescalated, allowing the youth to remain in the community with a safety plan, whereas 17% of incidents with a police-only response ended with crisis deescalation. These findings provide further support for the implementation of co-responder options that are available to police officers during encounters with children and adolescents experiencing a mental health crisis.

Involuntary Hospitalization: Does Social Work Education Prepare for Competency? A Systematic Review

Involuntary Hospitalization: Does Social Work Education Prepare for Competency? A Systematic Review

FISIOTERAPIA APLICADA NO PROCESSO CICATRICIAL DE CESÁREAS: REVISÃO DA LITERATURA

Physiotherapy plays an important role in the recovery process after a cesarean sec tion, where it works by promoting an adequate healing process, reducing all discomfort, aiming at elasticity, preventing a hypertrophic scar and mainly, improving the physical function of patients. It is important that physiotherapy is personalized according to individual needs and carried out as soon as possible, as early initiation of physiotherapy and adherence to the guidelines provided are essential for a successful recovery after a cesarean section. In this process, we can use massage and tissue mobilization techniques, where the application of gentle mas sages and mobilization techniques will help reduce tension in scar tissues, promoting blood circulation and helping to break down adhesions that may form during the process. of healing. In conjunction with manual therapies, we can use physical therapeutic resources, where the physiotherapist will work, for example, with low-intensity laser therapy, which can accelerate the healing process, reduce inflammation and alleviate discomfort in the area. of the incision. Other physical modalities, such as therapeutic ultrasound and electrotherapy, can also be applied to promote healing and reduce pain.

How ethical is the use of financial incentives to promote medication adherence among patients with serious mental illness? - a scoping review of the literature

Poor adherence to medication treatment in those with serious mental illness is common. Typical solutions and consequences in Western, formal psychiatric care settings often involve coercive measures such as involuntary hospital admissions and treatment, and out-patient commitments, with serious infringements on civil liberty. We examine the relatively unfamiliar, controversial and under-explored area of using financial incentive (FI) to enhance medication adherence in this population through a comprehensive scoping literature review, focusing on the ethical aspects of this practice. From nineteen qualified papers, we identified seven key themes of ethical “concerns,” and opposing arguments on whether FI is: (1) itself a form of coercion affecting autonomy; (2) leading to erosion of a proper consent process; (3) causing indirect and unintended harm; (4) worsening multiple levels of stigma related to mental illness; (5) associated with loss of intrinsic motivation of treatment; (6) associated with misuse of the fund itself; and (7) potentially leading to negative impact on therapeutic relationships. The ethics review shows a moderate receptivity to the use of FI in some specific and individualized circumstances; exceptions for those with poor insight and lacking treatment capacity are particularly relevant in order to avoid other forms of coercion. Additional highlights of the review include the optimal amount, duration, scope, and target population of the FI, and need for rigorous attention to psychoeducation, process, therapeutic relationships, stigma, and not lose sight of ultimately aiming to improve on patients’ insight, autonomy, quality of life and intrinsic motivation in this controversial approach.

Dark night of the soul: the lived experience and meaning of mental health crisis

ABSTRACT Objective Mental health crises are often described in terms of involuntary hospitalisation criteria or the presence or exacerbation of a psychiatric disorder that places people at risk of harm to themselves or others. However, there is limited research on the meaning of crisis from the perspective of people accessing crisis services. This paper reports on the subjective meaning of the construct of crisis that results in contact with crisis services. Method This phenomenological study used in-depth interviews with 31 people who accessed emergency departments (ED), crisis alternatives, and crisis phone lines. Findings The findings represent overlapping mental illness, life events/trauma, and existential explanations. Suicide featured strongly in accounts of crisis. However, the meaning of crisis was more complex and understood far beyond the risk of harm. The meaning of crisis was part of an ongoing rather than static narrative, often involving an initial adoption of clinical diagnosis with an eventual fuller understanding of crisis as part of the human condition. As such, participants viewed the crisis experience as meaningful and potentially transformative. Discussion Crisis was predominantly understood as part of the human condition, regardless of whether people have a psychiatric diagnosis, suicidality, or trauma. Suggestions are offered concerning the ways insights from participants can be translated into crisis care that speaks to the person’s own understanding.

‘No ability to choose freedom’: a qualitative study on people who use drugs’ experiences of compulsory isolation treatment

Background Extensive criminological literature has paid attention to the exacerbation of disadvantage due to compulsory treatment of drug use within vulnerable communities. However, understanding how compulsivity shapes users’ narrative framework and meaning construction of lives is still limited. Methods Based on an ethnography conducted at a Compulsory Isolation Treatment Center (CITC) in Central China, we collect in-depth interview data about how trainees who were convicted as drug dependents experienced and interpreted compulsory treatment in the context of life history. Our coding and case analysis of data illustrate four representative narratives on rehabilitation and reveal different ways of meaning-giving between each other. Results Our finding shows that the experience of incarcerated detoxification did not relieve the social disadvantages of people who use drugs. Instead, it was perceived as a negative encounter that intensified discrimination, deeply ingrained in social identity and constantly resurfaced in everyday life. Specifically, harmful experiences are generated by the punitive management of CITC, which underlines obedience between instructors (police officers) and trainees and encourages mutual distrust among peers. The crippling of interpersonal relationships prevents participants from developing social connections or restoring social skills. We also find trainees’ diverse coping strategies to the punitive institutions, ranging from showing physical weakness for board shelter catering to the standard of conduct for an early release to deciphering the intricacies of power relations in CITC. However, these temporary strategies cannot balance their permanent estrangement from public life and thus make them descend into the invisible confines of societal imprisonment. Implications Our ethnographic descriptions reveal the deliberated production of punishment and isolation in the process of compulsory isolation treatment and explicate the potential proximity between political correctives and drug treatment. We, thus, promote abolishing the compulsory isolation model in China, which stems not only from the inefficiency of the treatment at the medical level but also from the political motivations behind the institution and the superficiality of its moral reshaping.

The Royal College of Psychiatrists should become British, not Royal.

The royal charter of the Royal College of Psychiatrists is generally taken to enhance its status. However, the concept of a hereditary monarchy is intellectually indefensible and the realities of the British monarchy exacerbate inequalities in the UK. The connection is particularly problematic for psychiatrists because of their role in the compulsory detention and treatment of patients. The Royal affiliation can only serve to emphasise the power inequalities in society associated with these activities. College members should feel free to discuss whether this situation should continue or whether we should be British rather than Royal.

Involuntary Psychiatric Commitments Among Non-Western Immigrants During the Muhammad Cartoon Controversy in Denmark.

Persons deemed a danger to themselves, others, or gravely disabled may receive involuntary psychiatric commitment if family, other residents, law enforcement, or clinicians initiate this process. On September 30, 2005, a Danish newspaper published cartoons depicting the Prophet Muhammad. This publication led to the worst foreign policy crisis in Denmark since World War II. Whereas protests within Denmark against the cartoon remained peaceful, this cartoon controversy-including the attacks on four Danish embassies outside of Denmark-may have reduced societal tolerance for threatening or deviant behavior among non-Western immigrants. We applied Box-Jenkins interrupted time-series methods to test whether this cartoon controversy coincided with greater than expected counts of new involuntary psychiatric commitments among non-Western immigrants. The analytic period spans 48 quarters from January 1995 to December 2006. Findings support the hypothesis in that new involuntary psychiatric commitments rose 43% during the controversy (p <.01). Changes in help-seeking overall for mental health services do not appear to account for this rise in new involuntary commitments. Population-wide controversies may lower societal tolerance for behavior deemed deviant-and in this case, specifically among non-Western immigrants.

Developing and testing Advance Choice Document implementation resources for Black African and Caribbean people with experience of compulsory psychiatric admission

BackgroundAdvance Choice Documents (ACDs) have been recommended for use in England and Wales based on evidence from trials that show that they can reduce involuntary hospitalisation, which disproportionately affects Black African and Caribbean people. Our aim was therefore to develop and test ACD implementation resources and processes for Black people who have previously been involuntarily hospitalised and the people that support them.MethodsResource co-production workshops were held to inform the development of the ACD template and two types of training for all stakeholders, comprising a Recovery College course and simulation training. An ACD facilitator then used the ACD template developed through the workshops to create personalised ACDs with service users and mental health staff over a series of meetings. Interviews were then conducted with service user and staff participants and analysed to document their experience of the process and opinions on ACDs. Other implementation strategies were also employed alongside to support and optimise the creation of ACDs.ResultsNine ACDs were completed and were largely reported as appropriate, acceptable, and feasible to service users and staff. Both reported it being an empowering process that encouraged hope for better future treatment and therefore better wellbeing. Uncertainty was also expressed about the confidence people had that ACDs would be adhered to/honoured, primarily due to staff workload. The information provision training and the skills training were generally considered to be informative by trainees.ConclusionsThe project has developed an ACD creation resource that was reported as agreeable to all stakeholders; however, the generalisability of the findings is limited due to the small sample size. The project also highlights the importance of staff and ACD facilitator capacity and good therapeutic relationships in ACD completion. Further research is needed to determine the adjustments needed for large scale use, including for those under age 18 and those under the care of forensic mental health services; and how to include carers/supporters more in the process.

Compulsory treatment at home: an interview study exploring the experiences of an early group of patients, relatives and mental-health workers

BackgroundWhen introduced in 2020, the Netherlands’ Compulsory Mental Healthcare Act included provisions for compulsory community treatment (CCT) and compulsory treatment in patients’ homes (CTH). Although CCT has been incorporated into mental health care in many countries, its effectiveness is debated. We know of no other countries in which CTH has been adopted.The aim of this study is to evaluate how an early group of participants experienced CTH. They were drawn from three stakeholder groups: patients, relatives and mental-health workers.MethodsIn total, 17 open interviews were conducted with six patients, five relatives and six mental-health workers. All had experience with CTH. Thematic analysis was used to analyze the interviews.ResultsFive themes were identified: 1). Reasons for applying for a court order with options for CTH. The reasons included preventing harm, avoiding hospitalization, and providing a safety net. 2.) Participants’ experiences with CTH in practice. The four most noteworthy experiences were related to the process of applying for a court order; compulsory home visits and the compulsory use of medication; the involvement of relatives during treatment; and the influence of CTH on the relationship between patients and relatives. 3.) The advantages and disadvantages of CTH. The most important advantages were avoiding hospitalization; improving medication adherence; facilitating easy access to care; early signaling of deterioration; early intervention; and regained autonomy. The most important disadvantages were restricted autonomy; fewer options for monitoring compared to hospitalization; and problems regarding control of patient behavior. 4.) Participants’ preferences. All preferred CTH to hospitalization. 5.) Participants’ suggestions for improving CTH. These included the need not only to provide patients with better information, but also to improve the involvement of relatives during treatment.ConclusionThe interviewees found that CTH might help to avoid hospitalization by providing stakeholders with more options for arranging effective care at home. Although this suggests that initial experiences of CTH under the new Dutch mental health law were positive, it is still uncertain whether CTH as currently implemented really differs from CCT.

Understanding Involuntary Hospitalization Applications Submitted to an Urban Police Department.

To improve understanding of the application process for temporary involuntary hospitalization (Section 12 of the Massachusetts General Laws) in Boston, the authors focused on cases involving the Boston Police Department (PD) and the information shared about the individuals involved. A retrospective analysis was conducted on all Section 12 applications submitted to the Boston PD by external clinicians from July 14, 2021, to June 30, 2022. The authors analyzed 488 applications processed by the Boston PD's Street Outreach Unit, examining demographic information, reasons for requests, information provided by petitioners, and the status of the applications (completed vs. not). The analysis revealed racial disparities: 41% of involuntary hospitalization applications were for individuals identified as Black or African American, but this racial group represents only 23% of Boston's population. Racial-ethnic data were based on police perceptions, and 21% of cases lacked race-ethnicity data. Seventy-six percent of applications were submitted without a direct clinical examination by petitioners, who did not justify the omission. The Boston PD completed 70% of the requested involuntary hospitalization orders. This study identified substantial racial disparities in Section 12 applications, which disproportionately involved Black or African American individuals. The frequent absence of direct clinical examinations before application submissions and the lack of justification indicated a need for regulatory oversight and enhanced petitioner training. Incomplete demographic data underscored the need for improved data collection and reporting practices. These findings highlight the need for reforms to ensure equitable, transparent, and best practice-aligned involuntary hospitalization processes.

Temporal patterns and individual characteristics of compulsory treatment orders for mental disorders in Scotland from 2007 to 2020.

Compulsory mental health treatment has increased globally. In Scotland, compulsory treatment for >28 days is permitted under hospital- and community-based compulsory treatment orders. Community-based compulsory treatment has not been shown to lead to improved outcomes, and scrutiny of their use is needed. To describe the trend, duration and demographic characteristics of compulsory treatment orders in Scotland over a 14-year period. We conducted a retrospective analysis of order use in Scotland from 1 January 2007 to 31 December 2020, focusing on the (a) number and demographic characteristics of those treated, (b) duration, (c) extensions beyond the 6-month review point and (d) characteristics of new versus continued orders. The number of individuals on a community-based order increased by 118% (571 v. 1243) from 2007 to 2020, compared with a 16% increase (1316 v. 1532) for hospital-based orders. Of orders starting in 2007, 57.3% were extended, compared with 43.7% in 2020. The median duration was 6 months for first-time orders and 9 months for subsequent orders, which were longest for males (median 11 months); those of African, Caribbean or Black (median 11 months), Asian (median 11 months) and mixed ethnicity (median 10 months); and individuals from the most deprived communities (median 10 months). There has been a marked rise of community-based compulsory treatment orders in Scotland. If existing trends continue, there will be more people receiving care under community-based orders than hospital-based orders, fundamentally changing the nature of involuntary treatment. Further work needs to explore associations between demographic and diagnostic characteristics on order duration.

Key changes across valley floors in mountain areas affected by different levels of human impact: a case study of the Ochotnica river catchment in the Polish Carpathians

The goal of this paper was to present knowledge on changes in the morphodynamic structure of the Ochotnica River (Polish Carpathians) and transformations within its active river zone since the end of the 19th century. The study used a set of archival and contemporary cartographic materials and the results of three-fold field mapping of the morphodynamic structure of the riverbed. Direct and indirect human interference with the natural environment of the catchment and the fluvial system was taken into account in the analysis. Analysis of changes in the morphodynamic structure of the Ochotnica and its active river zone since the end of the 19th century indicated significant changes in the development trend of the riverbed. The contemporary structure of the Ochotnica is more complex than in the 1980s. There has been a fragmentation of the riverbed into sections with different morphodynamic sections. The proportion of erosive sections has increased, which explains the reduced in the width of the active river zone of the Ochotnica. The average width of the active river zone of the river between 1861 and 2022 has changed from 80 m to 18 m. Human impact has been identified as the main reason for the changes in the morphodynamic structure of the riverbed and its active river zone. Currently, only the unregulated sect ion is characterised by free lateral migration of the riverbed and the widest active river zone (∼ 28 m).

Involuntary commitment and medical education on mental health diseases across Europe

Abstract Background Psychiatric diseases are projected to become one of the greatest contributors to the global burden of disease by 2030, already presenting as one of the principal causes of DALYs lost in Europe. Given the particular nature of psychiatric disorders, national legislatures have been enacted by each European country regarding the possibility of involuntary psychiatric treatment. As practical implementations vary greatly from country to country, we wish to analyse how different attitudes to involuntary treatment affect health outcomes, so as to propose a uniform guideline for European medical practitioners. We also wish to analyse whether medical education targeted at communication with psychiatric patients has an effect on involuntary treatment rates and general mental well-being. Methods We conducted a systematic review on PubMed to identify studies pertaining to how legislature on involuntary commitment varies between European countries, as well as to what extent it is utilised. We also looked at the extent of medical education on psychiatric diseases. Results Preliminary results show that involuntary hospitalisation rates vary greatly within Europe, with certain countries being almost 20 times more likely to utilise such measures than others, notwithstanding similar mental illness prevalence. Results do not seem correlated to legislation types. Conclusions Given the vastly different use of involuntary commitment, a more standardised European approach should be implemented, especially in sight of the growing prevalence and burden of disease of psychiatric illnesses. Furthermore, an often-overlooked aspect of medical education is how to understand and communicate effectively with patients dealing with mental diseases: we advocate for continuous education, regardless of medical specialty. Key messages • Involuntary hospitalisation rates vary greatly across Europe, but the effects of this phenomenon have been poorly studied. We propose a more unified approach to maximise the efficacy of such a law. • We advocate for a more thorough education of health professionals on mental illnesses, regardless of medical specialty, in sight of the growing prevalence of such diseases.

Improving the rights of people with mental disorders in the Republic of Croatia

Abstract The mental health care system in the Republic of Croatia, despite the ongoing reform, is still based on hospital treatment. Hospitalizations due to mental disorders are in first place according to the length of stay. According to the annual report of the Ombudsman in the Republic of Croatia, 2% of hospitalizations due to mental disorders are involuntary hospitalization. Coercive measures and deprivation of business capacity are also often used. In order to reduce the number of coercive measures, involuntary hospitalizations and deprivation of professional capacity, it is necessary to increase mental health literacy and knowledge about human rights and the rights of persons with mental disorders, both among mental health experts and among patients and their families, as well as the general public. In order to increase knowledge and skills related to the rights of people with mental disorders, the Croatian Institute of Public Health, has been conducting WHO Quality Rights workshops in Croatian counties since 2019. The two-day workshops include all stakeholders: local politicians and decision-makers, associations of people with mental disorders and their families, employees in the mental health care system with the involvement of the media. So far, the training has been conducted in five major Croatian counties. The Quality Rights e-training platform has been translated into Croatian and the link to access the training is available online. In order to ensure the sustainability of the program and expand knowledge and skills, obtaining a certificate of completed Quality Right training became a requirement for passing the specialist exam in public health and in psychiatry. In five years of implementation of the program, the number of coercive measures in psychiatric hospitals decreased by 58%. Respect for human rights is a prerequisite for improving the mental health care system and the mental health. of both patients and the entire population. Key messages • Respect for human rights is necessary for the mental health of the population. • Knowledge and skills about the rights of patients with mental disorders reduce the rate of coercive measures.

Use and perceptions of involuntary civil commitment among post-overdose outreach staff in Massachusetts, United States: A mixed-methods study.

Involuntary civil commitment (ICC) is a legal process by which people are compulsorily admitted to substance use treatment. This study explored views about and promotion of ICC procedures for substance use disorders among public health-public safety post-overdose outreach programs and their outreach team members in Massachusetts, USA. In this mixed-methods study, survey data were collected from post-overdose outreach programs in 2019, and semi-structured interviews were conducted with outreach team members in 2019 and 2020. Massachusetts, USA. We received 138 survey responses and conducted 38 interviews with post-overdose outreach team members (law enforcement officers, recovery coaches, social workers and harm reductionists) who were majority male (57%) and white (66%). We used the survey instrument to categorize programs as more (discussed ICC at 50% or more of outreach encounters) or less ICC focused (discussed ICC at less than 50% of outreach encounters) and to identify program characteristics that corresponded with each categorization. Semi-structured interviews explored staff perceptions of ICC effectiveness. Among 138 programs, 36% (n = 50) discussed ICC at 50% or more of outreach encounters. Discussing ICC at a majority of visits was positively associated with abstinence-only program philosophies (36% v. 6%, P < 0.001) and collaborating with drug courts (60% v. 30%, P < 0.001), but negatively associated with naloxone distribution (48% v. 75%, P < 0.001) and referring to syringe service programs (26% v. 65%, P < 0.001). Qualitative interviews identified three themes: 1) some programs viewed ICC as a first line tool to engage overdose survivors in treatment; 2) other programs considered ICC a last resort, skeptical of its benefits and concerned about potential harms; 3) families commonly initiated discussions about ICC, reportedly out of desperation. Promotion of involuntary civil commitment (ICC) appears to vary widely across post-overdose outreach programs in Massachusetts, USA, with approaches ranging from seeing it as a first step to treatment to being a tool of last resort. Demand for ICC among family members may relate to inadequate access to voluntary treatment. Family interest in ICC appears to be driven by inadequate availability of treatment and other services. ICC at post-overdose outreach visits should be limited, if used at all.

The Forgotten Feminist

Kate Millett (1934–2017) is best known for her text Sexual Politics (1970). Despite her sudden rise to popularity in the women’s liberation movement, she was quickly dismissed and forgotten, even while continuing to produce new works. Victoria Hesford and Sheila Jeffreys have, respectively, examined the role of homophobia and shifts in feminist theory on Millett’s cataclysmic rise and fall. Expanding on these accounts, the article addresses how sanist discourse pathologized Millett’s bisexuality and polyamory as symptomatic of mental illness to delegitimize her critiques of heteronormative patriarchal psychiatry. It draws a connection between Millett’s public outing in 1970, her first involuntary psychiatric hospitalization in 1973, and the unfavourable and problematic literary responses to her memoirs Flying in 1974 and The Loony-Bin Trip in 1990. Relying on Maria Rovito’s Madwoman theory, the article argues literary critics participate in the silencing and pathologization of Millett by continuing to frame her as mentally ill, instead of as a survivor of psychiatric abuse. It seeks to demonstrate that Madwoman theory is an ethical feminist disability methodology for literary criticism that restores Millett’s voice by unveiling the intersections of heteronormative monosexism and sanism that functions to silence queer Madwomen through epistemic violence and social death.

Cochrane meta-analysis fuels invalid skepticism about compulsory community treatment effectiveness

BackgroundQuantitative research on non-randomized-samples, focused on statute-mandated-outcomes, has found positive results favoring compulsory-community-treatment (CCT) in jurisdictions fully supporting its implementation. In contrast, three randomized-studies “failed-to-find” a difference between randomly-assigned-CCT and control-groups–each study repeatedly summarized in revisions of a Cochrane-meta-analysis reporting this failure. Considering the potential health and safety threats to people with severe-mental-illness and those with whom they interact, there is a critical need for this investigation to resolve these conflicting results. MethodUsing data and procedural-descriptions from the involved-studies, this validity-focused-analysis addressed six questions. Two external-validity focused-questions addressing generalizability of study findings: 1. Did the Cochrane-meta-analysis select studies focused on the CCT-target population? 2. Assuming valid population focus did the Cochrane meta-analysis enroll individuals from among this population fitting the CCT criteria? Four internal-validity-questions: 1. Did the study-designs address the intervention's purpose? 2. Were the outcome-criteria used in the selected-studies valid-indicators of the intervention's intended-outcomes? 3. Were the studies reviewed in the Cochrane-meta-analysis, controlled-trials? And 4. Were the prescribed-Cochrane-Database-statistical-procedures appropriate for evaluating the reviewed-randomized-trials? ResultsFocused on completing randomized-investigations, two outpatient-commitment and one CTO-study failed to validly represent the CCT-population, failed to enroll qualifying-subjects, conflated their primary outcome-measure with a required-intervention-procedure, failed to control for post-randomization experiences directly related to their primary-outcome-measure, and conflated the study conditions. Two trials continuously misrepresented themselves as “randomized-controlled-trials”. All relied on univariate-contrasts in evaluating their outcomes, while without post-randomization-control the studies required multivariate-controls for contrasting the outcomes of their intervention-groups. The Cochrane-review, while listing the short-comings of these studies, placing an over-emphasis on prescriptive-methodology, without addressing study substantive-validity, has yielded spurious-conclusions suborning an invalid political-narrative regarding CCT-effectiveness. ConclusionsThe “failure-to-find” results from the Cochrane-reviewed-studies can be attributed to research shortcomings rather than intervention-ineffectiveness. The Cochrane-review has promoted undue controversy and skepticism re the use of CCT, a potentially lifesaving-procedure.

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).