Do compulsory mental health patients have a right to receive a second opinion on their treatment under Australian mental health legislation?

We reviewed Australian mental health legislation to determine what obligations it places on psychiatrists to facilitate second opinions for compulsory patients who request them. Only four jurisdictions-Australian Capital Territory, Queensland, Victoria, and Western Australia-have legislated for 'patient-initiated' second opinions. Within these four regimes, there is variation in important aspects of the second opinion process, and there is a general absence of direction given to the second opinion providers. Based on research showing the variability of second opinion provision under New Zealand mental health legislation, we argue that this absence is likely to result in significant variation in the quality and depth of second opinions provided in Australia. We argue that New South Wales, the Northern Territory, South Australia, and Tasmania should consider formal provision for patient-initiated second opinions in their mental health legislation. We believe that such legislation ought to be aware of the barriers patients may face in accessing second opinions, and avoid exacerbating these barriers as Queensland's legislation appears to. Also, we argue that research on current practice in Australia should be conducted to better understand the effects of legislation on second opinions, and to help determine what amounts to best practice.

Rethinking the place of compulsory community mental health treatment in Aotearoa New Zealand: Implications of an assemblage theory approach.

Many countries with developed mental health systems permit compulsory treatment for mental illness in community settings. Research has challenged practices associated with the increased use of compulsory community treatment due to non-compliance with human rights and lack of therapeutic efficacy. In the cultural context of Aotearoa New Zealand, this paper introduces a study of the medico-legal process for making compulsory community treatment orders. Drawing on assemblage theory, our analysis critically unpacks the idea of being heard in the event of a court hearing. We illustrate how relations in-between participants, place, and things, become territorialised in ways that reproduce orders. We suggest reterritorialisation of these relations is vital to becoming heard. Rethinking the role of compulsory community treatment orders has implications for mental health law reform. This reform provides a rare opportunity to support services in avoiding compulsory treatment in practice.

[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study.

BACKGROUND: Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. AIMS: To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. METHOD: PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. RESULTS: Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. CONCLUSIONS: Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Compulsory treatment in Portuguese-speaking countries: An analysis and comparison of the legal framework.

BACKGROUND: Compulsory treatment involves the hospital admission of individuals with mental disorders in appropriate facilities through judicial decisions. However, limited information is available regarding the similarities and differences in compulsory treatment legislation in Portuguese-speaking countries. AIMS: To analyse the commonalities and differences in compulsory treatment legislation in Portuguese-speaking countries, where Portuguese is the primary official language, including Angola, Brazil, Cape Verde, East Timor, Guinea-Bissau, Mozambique, Portugal, and São Tomé and Príncipe. METHODS: A comparative analysis of the specific legislation on compulsory treatment in Portuguese-speaking countries was conducted. National development plans were analysed in countries lacking legislation. A purposive sampling of mental health professionals was contacted to gather information on the countries under study. RESULTS: Among the eight Portuguese-speaking countries examined, specific legislation regarding compulsory treatment was found only in Brazil, Cape Verde, and Portugal. These countries, with the lowest poverty rates, exhibited a notable degree of homogeneity in the criteria supporting compulsory treatment, ensuring the protection of individual rights. In contrast, in Angola, East Timor, Guinea-Bissau, Mozambique, and São Tomé and Príncipe, compulsory treatment primarily relies on mental health development plans, resulting in significant variations in the presented criteria. CONCLUSIONS: The significant disparities in compulsory treatment policies among Portuguese-speaking countries, with only Brazil, Cape Verde, and Portugal having specific legislation, underscore the need for a collective effort to establish more consistent procedures and safeguard individual rights.

Crime and victimization outcomes following civil rights limits to the use of compulsory treatment.

Community treatment orders (CTOs) have been associated with reduced crime/victimization-risk. Australia's ratification of the U.N. Convention on the Rights of Persons with Disabilities (CRPD) enabled patient-rights-advocacy to limit CTO-assignment to persons lacking decision-making-capacity. This effort was accompanied by a 15% reduction in CTO-utilization. Has this change affected crime/victimization-involvements of patients with schizophrenia-diagnoses? In Victoria Australia, the study considers crime/victimization-involvement among three patient-groups recruited with the same sampling-algorithm in the decade before (2000-2009, N = 14,711) and after (2010-2019, N = 10,702) CRPD-ratification. Each group is its own-control. Each group's positive-outcome across decades would be "no increase" in crime/victimization-involvement or in the ratio of the group's incident-rates to the State's. Following CRPD-ratification, first-hospitalized-patients with at least one CTO-assignment doubled their involvement in major crime-perpetrations (from 13% to 27%), non-CTO-hospitalized-patients almost doubled (from 10% to 18%), and 11% of outpatients were involved when none were before. Overall, a third (34%) were victimized-by-major-crime up from 28%, with 25% of outpatients experiencing victimization when none had before. Increases were most evident in major-crimes, led by assaults/abductions. Capacity-constraints on compulsory-treatment are associated with increases in crime/victimization-involvement, a transfer of responsibility for patients with schizophrenia-diagnoses from the mental-health-system to the criminal-justice-system, validation of dangerousness stereotypes, and growing negative family impact.

Nasogastric tube feeding under restraint: understanding the impact and improving care.

BACKGROUND: Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement. AIMS: To examine the impact of this intervention on people with lived experience, carers and staff. METHOD: People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed. RESULTS: Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored. CONCLUSION: This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

Psychometric properties of the Italian version of the staff attitude to coercion scale: an exploratory factor analysis.

Aims: The current study aimed to validate the Italian version of the Staff Attitude to Coercion Scale (SACS), which assesses mental health care staff's attitudes to the use of coercion in treatment. Methods: The original English version of the SACS was translated into Italian, according to the back-translation procedure. Subsequently, it was empirically validated by performing an exploratory factor analysis on a sample of 217 mental health professionals (Mean = 43.40 years, SD = 11.06) recruited form Italian general hospital (acute) psychiatric wards (GHPWs), with at least 1 year of work experience (i.e., inclusion criteria). Results: Results confirmed the three-factor solution of the original version for the Italian version of the SACS, though three items loaded on different factors, compared to the original. The three extracted factors, explained 41% of total variance, and were labeled similarly to the original scale and according to their respective item content, i.e., Factor 1 "Coercion as offending" (items: 3, 13, 14, and 15), Factor 2 "Coercion as care and security" (items: 1, 2, 4, 5, 7, 8, and 9), and Factor 3 "Coercion as treatment" (items: 6, 10, 11, and 12). The internal consistency of the three-factor model of the Italian version of the SACS was assessed through Cronbach's α and yielded acceptable indexes, ranging from 0.64 to 0.77. Conclusion: The present findings suggest that the Italian version of the SACS is a valid and reliable tool that can be used to assess healthcare professionals' attitudes toward coercion.

Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors.

BACKGROUND: A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN. METHODS: In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics. RESULTS: IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these. CONCLUSIONS: High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.

Retention rate in methadone maintenance treatment and factors associated among referred patients from the compulsory residential centers compared to voluntary patients.

Introduction: Compulsory treatment has decades of history in Iran; both before and after the Islamic Revolution, but there are many debates regarding its efficacy and effectiveness. Retention Rate is one of the best indices to estimate the efficacy of treatment. This study will compare Retention Rate among people referred from compulsory treatment centers and volunteer participants. Methods: This was a retrospective (historical) cohort study that has been conducted among people who were taking methadone maintenance treatment (MMT). The study sample was selected from the MMT centers that admit both referral patients from compulsory centers and voluntary patients. All newly admitted patients from March 2017 to March 2018 were enrolled and followed up until March 2019. Results: A total of 105 participants were recruited for the study. All were males with a mean age of 36.6 ± 7.9 years. Fifty-six percent of individuals were referred from compulsory residential centers. The total one-year retention rate of participants in this study was 15.84%. The one-year retention rate for the patients referred from compulsory residential centers and the non-referred patients was 12.28 and 20.45%, respectively (value of p = 0.128). Among the other studied factors, only marital status was significantly associated with MMT retention (p = 0.023). Conclusion: Although the average treatment adherence time for non-referred patients was about 60 days higher than those referred from compulsory residential centers, this study found no significant differences in retention days and a one-year retention rate. Further studies with larger sample sizes and longer follow-ups are needed to explore the efficacy of compulsory treatment methods in Iran.

[Compulsory community treatment orders (CTOs): recent research and future directions].

SUMMARY: Compulsory community treatment orders (CTOs) are controversial because the right to refuse treatment is overridden, even when patients may not be acutely unwell. Scrutiny of outcomes associated with CTOs is therefore required. This editorial provides an overview of the evidence for CTOs. It also discusses recent papers reporting outcomes associated with CTOs and makes recommendations for researchers and clinicians to consider.

Human rights promotion and the 'Geneva impasse' in mental healthcare: scoping review.

BACKGROUND: The World Psychiatric Association recently emphasised that the protection of human rights in mental healthcare was a 'central concern'. This paper examines recent literature on human rights and mental healthcare. AIMS: To (a) outline how international human rights law distinguishes between the protection and promotion of human rights; and (b) explore the literature on promoting human rights in mental healthcare which avoids what has been termed the 'Geneva impasse' between those who argue that compulsory care and treatment can never comply with human rights law and those who argue that they can if certain conditions are met. METHOD: The following doctrinal methodology was used: (a) identification and detailed analysis of international human rights conventions and commentaries; (b) identification of key literature on human rights and mental healthcare; and (c) critical analysis of key issues emerging from the literature. RESULTS: Much of the literature on human rights and mental healthcare focuses on whether restrictions on compulsory care are required to meet the requirements of United Nations Conventions. There is an emerging literature identifying measures to promote the right to the enjoyment of the highest attainable standard of mental health. CONCLUSIONS: There has been a focus on protecting the rights to liberty and equality before the law for mental health patients. The nascent literature on promoting human rights in mental healthcare could mark a way forward beyond the 'Geneva impasse' that has dominated public debate in recent years.

The role of 'micro-decisions' in involuntary admissions decision-making for inpatient psychiatric care in general hospitals in South Africa.

While the ethics of involuntary admission for psychiatric inpatient care is widely contested, the practice is legally permissible across most jurisdictions. In many countries, laws governing the use of involuntary admission set out core criteria under which involuntary admission is permitted; these parameters broadly related to either risk of harm to self or others, need for treatment, or both. In South Africa, the use of involuntary admission is governed by the Mental Health Care Act no. 17 of 2002 (MHCA 2002), which sets out clear criteria to direct mental healthcare practitioners' decision-making and delineates a process by which decision-making should occur. However, recent research suggests that, in practice, the process of decision-making differs from the procedure prescribed in the MHCA 2002. To further explore how decision-making for involuntary admission occurs in practice, we interviewed 20 mental healthcare practitioners, all with extensive experience of making involuntary admission decisions, working in district, regional, and tertiary hospitals across five provinces. We also interviewed four mental health advocates to explore patient-centered insights. Our analysis suggests that the final decision to involuntarily admit individuals for a 72-h assessment period under the MHCA 2002 was preceded by a series of 'micro-decisions' made by a range of stakeholders: 1) the family's or police's decision to bring the individual into hospital, 2) a triage nurse's decision to prioritise the individual along a mental healthcare pathway in the emergency centre, and 3) a medical officer's decision to sedate the individual. Practitioners reported that the outcomes of each of these 'micro-decisions' informed aspects of their final decision to admit an individual involuntarily. Our analysis therefore suggests that the final decision to admit involuntarily cannot be understood in isolation because practitioners draw on a range of additional information, gleaned from these prior 'micro-decisions', to inform the final decision to admit.

Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events.

BACKGROUND: A small but significant group of patients with anorexia nervosa (AN) undergo multiple involuntary treatment (IT) events. To enhance our understanding of IT and potentially inform treatment, we explored experiences and perspectives on IT of these patients. METHODS: We designed a qualitative semi-structured interview study and used reflexive thematic analysis. Participants were at least 18 years of age, had multiple past IT events (≥ 5) related to AN over a period of at least one month of which the last IT event happened within the preceding five years. Participants had no current IT, intellectual disability, acute psychosis, or severe developmental disorder. We adopted an inductive approach and constructed meaning-based themes. RESULTS: We interviewed seven participants. The data portrayed a process of living and leaving a life of coercion with a timeline covering three broad themes: living with internal coercion, coercive treatment, and leaving coercion; and five subthemes: helping an internal battle, augmenting suffering, feeling trapped, a lasting imprint, and changing perspectives. We highlighted that patients with AN and multiple IT events usually experienced internal coercion from the AN prior to external coercion from the health care system. IT evoked significant negative affect when experienced, and often left an adverse imprint. Moreover, IT could help an internal battle against AN and perspectives on IT could change over time. CONCLUSIONS: Our study suggests that feeling internally coerced by AN itself sets the stage for IT. Clinicians should be conscious of the potential iatrogenic effects of IT, and reserve IT for potentially life-threatening situations.

Some patients with anorexia nervosa refuse treatment and receive multiple involuntary treatment events. To learn more about involuntary treatment and potentially inform treatment, we explored experiences and perspectives of patients with multiple involuntary treatment events. We conducted interviews with seven participants and used a qualitative approach, namely reflexive thematic analysis, to construct themes. The data portrayed a process of living and leaving a life of coercion. We highlighted that patients with anorexia nervosa and multiple involuntary treatment events experience a life of coercion­both internally from the illness itself and from involuntary treatment experiences. Involuntary treatment can help an internal battle against anorexia nervosa and perspectives of patients about involuntary treatment can change over time. Nevertheless, involuntary treatment can have a negative impact on patients, such as feelings of being hunted or assaulted. Wider awareness of potential negative effects of involuntary treatment is needed. Clinicians should be conscious of these potential negative effects and reserve IT for potentially life-threatening situations.

The association between Compulsory Community Treatment Order status and mortality in New Zealand.

BACKGROUND: Compulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical. AIMS: To report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis. METHOD: Data for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis. RESULTS: A total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14-1.45; P < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23-2.42; P < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07-1.40; P < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81-2.12; P = 0.22). CONCLUSIONS: Increased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.

Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions.

Background: Multiple studies have examined the effects of compulsory community treatment (CCT), amongst them there were three randomized controlled trials (RCT). Overall, they do not find that CCT affects clinical outcomes or reduces the number or duration of hospital admissions more than voluntary care does. Despite these negative findings, in many countries CCT is still used. One of the reasons may be that stakeholders favor a mental health system including CCT. Aim: This integrative review investigated the opinions of stakeholders (patients, significant others, mental health workers, and policy makers) about the use of CCT. Methods: We performed an integrative review; to include all qualitative and quantitative manuscripts on the views of patients, significant others, clinicians and policy makers regarding the use of CCT, we searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane CENTRAL Register of Controlled Trials (via Wiley), and Google Scholar. Results: We found 142 studies investigating the opinion of stakeholders (patients, significant others, and mental health workers) of which 55 were included. Of these 55 studies, 29 included opinions of patients, 14 included significant others, and 31 included mental health care workers. We found no studies that included policy makers. The majority in two of the three stakeholder groups (relatives and mental health workers) seemed to support a system that used CCT. Patients were more hesitant, but they generally preferred CCT over admission. All stakeholder groups expressed ambivalence. Their opinions did not differ clearly between those who did and did not have experience with CCT. Advantages mentioned most regarded accessibility of care and a way to remain in contact with patients, especially during times of crisis or deterioration. The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Other disadvantages mentioned were that CCT was stigmatizing and that it focused too much on medication. Conclusion: Stakeholders had mixed opinions regarding CCT. While a majority seemed to support the use of CCT, they also had concerns, especially regarding the restrictions CCT imposed on patients' freedom and autonomy, stigmatization, and the focus on medication.

Mental health legislation in Luxembourg, a small country in Western Europe.

The article provides a brief overview of the legislation governing involuntary admissions to psychiatric hospitals in Luxembourg. The legislation was completely overhauled in 2009 and several human rights principles are enshrined into it. Emphasis is placed on voluntary, community-based treatment, and where compulsory treatment is required, it uses the least restrictive treatment option. Mentally ill offenders are dealt with through separate specialist legislation. Young people under the age of 18 are often detained using family law.

Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand.

BACKGROUND: Compulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use. AIMS: To examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis. METHOD: New Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status. RESULTS: In total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups. CONCLUSIONS: CTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.

Open Doors by Fair Means: a quasi-experimental controlled study on the effects of an open-door policy on acute psychiatric wards.

BACKGROUND: Psychiatric wards treating involuntarily admitted patients are traditionally locked to prevent absconding. However, on the basis of observational evidence, the necessity for locked units in psychiatric hospitals has increasingly been questioned. Updated Mental Health Laws in several Federal States of Germany legitimate involuntary commitment without generally locked doors. METHODS: We examined the effects of an open-door policy in a quasi-experimental, prospective design. For the first time, at each of two locations, two identical wards serving as control and intervention could be compared. After a baseline period of three months, one ward at each location started the 12 month intervention period with the implementation of an open-door policy, while the respective control ward, as before, used open doors only facultatively. Primary outcomes were average opening times of the four wards between 8 a.m. and 8 p.m., and the number of involuntary treatment days with the doors open. Secondary outcomes were adverse events including aggressive incidents, absconding, suicide attempts and coercive measures. RESULTS: Overall, door-opening times increased significantly at both sites´ intervention wards. The number of adverse events did not increase during intervention period. Frequencies of coercive measures decreased in Friedrichshafen and remained unchanged in Tuebingen. In case of the intervention ward in Friedrichshafen, doors were open in up to 91% of all involuntary treatment days, whereas in the control ward, this was only the case in 67% of all involuntary treatment days (p < .001). In case of the intervention ward in Tuebingen, 45% of involuntary treatment days had open doors, compared to 30% in the control ward (p < .001). CONCLUSIONS: It is possible to manage psychiatric wards with open doors without taking inappropriate risks. The extent to which open-door policies are achievable is be dependent on staffing and patient characteristics. Further research is necessary to explore the role of staff attitudes. TRIAL REGISTRATION: Our trial "Open Doors by Fair Means" is retrospectively registered with DRKS ( DRKS00015154 ) on Sept. 10th 2018 and displayed on the public web site. It is searchable via its meta-registry ( http://apps.who.int/trialsearch/ ).

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa.

PURPOSE: We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment. METHODS: This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)). RESULTS: Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment. CONCLUSIONS: Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment. LEVEL OF EVIDENCE: Level III, cohort study.