Electroconvulsive Therapy in Forensic Psychiatry: A Systematic Review.

ABSTRACT: Patients with schizophrenia are the largest population in forensic hospitals, and treatment-resistant psychosis is associated with length of stay. For patients with severe and treatment-resistant psychotic disorders, electroconvulsive therapy (ECT) is a potentially effective treatment. Data regarding the use of ECT in forensic psychiatry are scarce. This systematic review aims to provide an overview of the use of ECT in forensic psychiatry. Three databases (PubMed, Web of Science, and PsycINFO) were searched for publications since 1980. Peer-reviewed articles describing patients who underwent ECT treatment in the context of forensic psychiatry were included when a treatment outcome was reported. We identified 5 case reports and 1 case series comprising 13 patients treated with ECT in forensic settings. The quality of evidence was poor accompanied by a considerable risk of bias. Patients were diagnosed with schizophrenia spectrum disorders (n = 10) or depression with psychotic features (n = 3). Eleven patients (84.6%) were described as responders in terms of symptom improvement associated with a reduction of aggressive behavior and improved functioning. At least 3 patients were able to return to community settings. Despite the very limited evidence base, our review suggests that patients in forensic hospitals may benefit from ECT, but more systematic and higher-quality evidence is urgently needed. In addition to prospective, controlled observational studies, a qualitative view focusing on patients' perspectives in this specific setting is of particular importance.

Strategies to promote treatment compliance: a grounded theory study with relatives of people with a serious mental health condition.

BACKGROUND: Treatment pressures encompass communicative strategies that influence mental healthcare service users' decision-making to increase their compliance with recommended treatment. Persuasion, interpersonal leverage, inducements, and threats have been described as examples of treatment pressures. Research indicates that treatment pressures are exerted not only by mental healthcare professionals but also by relatives. While relatives play a crucial role in their family member's pathway to care, research on the use of treatment pressures by relatives is still scarce. Likewise, little is known about other strategies relatives may use to promote the treatment compliance of their family member with a serious mental health condition. In particular, no study to date has investigated this from the perspective of relatives of people with a serious mental health condition. AIM: The aim of this study was to answer the following research questions: Which types of treatment pressures do relatives use? Which other strategies do relatives use to promote the treatment compliance of their family member with a serious mental health condition? How do treatment pressures relate to these other strategies? METHODS: Eleven semi-structured interviews were conducted with relatives of people with a serious mental health condition in Germany. Participants were approached via relatives' self-help groups and flyers in a local psychiatric hospital. Inclusion criteria were having a family member with a psychiatric diagnosis and the family member having experienced formal coercion. The data were analyzed using grounded theory methodology. RESULTS: Relatives use a variety of strategies to promote the treatment compliance of their family member with a serious mental health condition. These strategies can be categorized into three general approaches: influencing the decision-making of the family member; not leaving the family member with a choice; and changing the social or legal context of the decision-making process. Our results show that the strategies that relatives use to promote their family member's treatment compliance go beyond the treatment pressures thus far described in the literature. CONCLUSION: This qualitative study supports and conceptually expands prior findings that treatment pressures are not only frequently used within mental healthcare services but also by relatives in the home setting. Mental healthcare professionals should acknowledge the difficulties faced and efforts undertaken by relatives in seeking treatment for their family member. At the same time, they should recognize that a service user's consent to treatment may be affected and limited by strategies to promote treatment compliance employed by relatives.

Intersectional Discrimination in Mental Health Care: A Systematic Review With Qualitative Evidence Synthesis.

OBJECTIVE: Discriminatory practices in mental health care undermine the right to health of marginalized service users. Intersectional approaches enable consideration of multiple forms of discrimination that occur simultaneously and remain invisible in single-axis analyses. The authors reviewed intersectionality-informed qualitative literature on discriminatory practices in mental health care to better understand the experiences of marginalized service users and their evaluation and navigation of mental health care. METHODS: The authors searched EBSCO, PubMed, MEDLINE, and JSTOR for studies published January 1, 1989-December 14, 2022. Qualitative and mixed-methods studies were eligible if they used an intersectional approach to examine discrimination (experiences, mechanisms, and coping strategies) in mental health care settings from the perspective of service users and providers. A qualitative evidence synthesis with thematic analysis was performed. RESULTS: Fifteen studies were included in the qualitative evidence synthesis. These studies represented the experiences of 383 service users and 114 providers. Most studies considered the intersections of mental illness with race, sexual and gender diversity, or both and were performed in the United States or Canada. Four themes were identified: the relevance of social identity in mental health care settings, knowledge-related concerns in mental health care, microaggressions in clinical practice, and service users' responses to discriminatory practices. CONCLUSIONS: Discriminatory practices in mental health care lead to specific barriers to care for multiply marginalized service users. Universities and hospitals may improve care by building competencies in recognizing and preventing discrimination through institutionalized training.

[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.

Intersectionality as a tool for clinical ethics consultation in mental healthcare.

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-inferiority trial in Norway.

BACKGROUND: Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures. METHODS: We conducted a pragmatic, randomised controlled, non-inferiority trial comparing two open-door policy wards and three treatment-as-usual acute psychiatric wards at Lovisenberg Diaconal Hospital in Oslo, Norway. An exemption from the consent requirements enabled inclusion and random allocation of all patients admitted to these wards using an open list (2:3 ratio) administrated by a team of ward nurses. The primary outcome was the proportion of patient stays with one or more coercive measures, including involuntary medication, isolation or seclusion, and physical and mechanical restraints. The non-inferiority margin was set to 15%. Primary and safety analyses were assessed using the intention-to-treat population. The trial is registered with ISRCTN registry and is complete, ISRCTN16876467. FINDINGS: Between Feb 10, 2021, and Feb 1, 2022, we randomly assigned 556 patients to either open-door policy wards (n=245; mean age 41·6 [SD 14·5] years; 119 [49%] male; 126 [51%] female; and 180 [73%] admitted to the ward involuntarily) or treatment-as-usual wards (n=311; mean age 41·6 [4·3] years; 172 [55%] male and 138 [45%] female; 233 [75%] admitted involuntarily). Data on race and ethnicity were not collected. The open-door policy was non-inferior to treatment-as-usual on all outcomes: the proportion of patient stays with exposure to coercion was 65 (26·5%) in open-door policy wards and 104 (33·4%) in treatment-as-usual wards (risk difference 6·9%; 95% CI -0·7 to 14·5), with a similar trend for specific measures of coercion. Reported incidents of violence against staff were 0·15 per patient stay in open-door policy wards and 0·18 in treatment-as-usual wards. There were no suicides during the randomised controlled trial period. INTERPRETATION: The open-door policy could be safely implemented without increased use of coercive measures. Our findings underscore the need for more reliable and relevant randomised trials to investigate how a complex intervention, such as open-door policy, can be efficiently implemented across health-care systems and contexts. FUNDING: South-Eastern Norway Regional Health Authority and The Research Council of Norway.

Self-binding directives in psychiatric practice: a systematic review of reasons.

Self-binding directives (SBDs) are an ethically controversial type of advance decision making involving advance requests for involuntary treatment. This study systematically reviewed the academic literature on psychiatric SBDs to elucidate reasons for and against their use in psychiatric practice. Full-text articles were thematically analysed within the international, interdisciplinary authorship team to produce a hierarchy of reasons. We found 50 eligible articles. Reasons for SBD use were promoting service user autonomy, promoting wellbeing and reducing harm, improving relationships, justifying coercion, stakeholder support, and reducing coercion. Reasons against SBD use were diminishing service user autonomy, unmanageable implementation problems, difficulties with assessing mental capacity, challenging personal identity, legislative issues, and causing harm. A secondary finding was a clarified concept of capacity-sensitive SBDs. Future pilot implementation projects that operationalise the clarified definition of capacity-sensitive SBDs with safeguards around informed consent, capacity assessment, support for drafting, and independent review are required.

Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives.

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as "procedural ethics" and the identification and handling of ethical issues by researchers during the research process as "ethics in practice." While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

When Treatment Pressures Become Coercive: A Context-Sensitive Model of Informal Coercion in Mental Healthcare.

Treatment pressures are communicative strategies that mental health professionals use to influence the decision-making of mental health service users and improve their adherence to recommended treatment. Szmukler and Appelbaum describe a spectrum of treatment pressures, which encompasses persuasion, interpersonal leverage, offers and threats, arguing that only a particular type of threat amounts to informal coercion. We contend that this account of informal coercion is insufficiently sensitive to context and fails to recognize the fundamental power imbalance in mental healthcare. Based on a set of counterexamples, we argue that what makes a proposal coercive is not whether service users will actually be made worse off if they reject the proposal, but rather whether they have the justified belief that this is the case. Whether this belief is justified depends on the presence of certain contextual factors, such as strong dependency on professionals and the salient possibility of formal coercion.

Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries.

BACKGROUND: Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs. AIMS: This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom. METHOD: Comparisons between the empirical findings were drawn using a structured expert consensus process. RESULTS: Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns. CONCLUSIONS: Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

Situational vulnerability within mental healthcare - a qualitative analysis of ethical challenges during the COVID-19 pandemic.

BACKGROUND: Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability. METHODS: We present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability. RESULTS: Difficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics. CONCLUSIONS: Applying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability.

The Content of Psychiatric Advance Directives: A Systematic Review.

OBJECTIVE: Psychiatric advance directives (PADs) enable users of mental health services to express their treatment preferences for future mental health crises. PAD completion rates remain low despite high rates of interest among service users and empirically confirmed benefits of their use. A systematic review of service users' preferences regarding the content of PADs could be a valuable resource for clinicians and policy makers and might help reduce barriers to PAD implementation. METHODS: A systematic review concordant with PRISMA guidelines was conducted. CINAHL, Cochrane, EMBASE, PsycINFO, MEDLINE, PubMed, SCOPUS, and Web of Science databases were searched up to July 2, 2021. Included articles contained original empirical data on service users' preferences regarding the content of PADs or a document analysis of existing PADs. Studies were analyzed thematically, and a narrative synthesis was conducted. The Mixed Methods Appraisal Tool was used to assess the methodological quality and risk of bias of the included studies. RESULTS: The search yielded 4,047 articles, 42 of which were eligible for inclusion. Six themes emerged (most of which included subthemes): signs of crisis, general treatment approach, preferences regarding the treatment setting, treatment preferences, coercion, and social instructions. CONCLUSIONS: The concern that PADs may be unclear or incompatible with practice standards was not confirmed. Service users generally included clear, comprehensible, and clinically relevant information in their PADs, often providing underlying reasons for their preferences. These reasons were related to previous adverse effects of medication and personal experiences with hospital admissions.

Mental Health Service Users' Perspectives on Psychiatric Advance Directives: A Systematic Review.

OBJECTIVE: Psychiatric advance directives (PADs) are documents that allow users of mental health services to express their preferences for treatment in future mental health crises. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and implementation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making. METHODS: A systematic review concordant with PRISMA guidelines was conducted. Relevant electronic databases were searched up to July 2, 2021. Articles containing original empirical data on service users' perspectives on PADs were included. Data were analyzed thematically, tabulated, and narratively synthesized. RESULTS: Fifty-three articles were identified and included. The following categories were identified: general preferences regarding factors such as legal force and revocability; benefits of PADs at the personal, treatment-related, and social levels; challenges and barriers concerning PAD creation and application; and possible and experienced facilitators of PAD creation. CONCLUSIONS: Users of mental health services are highly interested in PADs and regard them as tools to improve their involvement in care. They generally prefer legally binding PADs that can be revoked only when users are competent to consent. Barriers reported by service users were mainly related to the creation and application of PADs, and support in PAD creation was the most important facilitator identified. The involvement of mental health professionals in creating PADs appears essential to realize the benefits of PADs and to reduce barriers to their use.

Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany.

Purpose: Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law. Methods: Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis. Results: Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice. Conclusions: The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.

[Shared Decision-Making for Patients with Mental Disorders or Cognitive Impairments]. / Shared Decision-Making bei Patient_innen mit psychischen Störungen oder kognitiven Beeinträchtigungen.

Shared Decision-Making for Patients with Mental Disorders or Cognitive Impairments Abstract. Shared Decision-Making (SDM) describes a model of collaborative decision-making that combines the expert knowledge of health professionals and the experiential knowledge of patients. This allows patients to play a more active role in the decision-making process. SDM is also becoming increasingly important in the treatment of persons with mental disorders or cognitive impairments. However, implementation of SDM for this group of patients may face specific challenges, for example, if their decision-making capacity is impaired or if coercion has to be used to prevent acute danger to themselves or others. On the other hand, SDM offers important opportunities in this area. For example, mental health professionals are often more dependent on the patients' experiential knowledge in clinical decision-making than in somatic care. Furthermore, empowerment and a good therapeutic relationship are central aspects in the treatment of people with mental disorders or cognitive impairments, which can be strengthened by SDM. Against the background of these specific challenges, an overview of opportunities for and experiences with SDM in the care of people with mental disorders or cognitive impairments is given. In addition, different approaches for promoting the implementation of SDM for this patient group will be identified.

Effectiveness of electroconvulsive therapy in patients lacking decision making capacity: A systematic review and meta-analysis.

BACKGROUND: Electroconvulsive therapy (ECT) is provided for patients with severe and often life-threatening illness, who lack decision making capacity to consent to treatment (DMC-T) in clinical settings. OBJECTIVE: The aim of this study is to summarize previous studies investigating clinical outcomes of ECT in patients lacking DMC-T. METHODS: A systematic review and meta-analysis of studies reporting clinical outcomes of ECT in patients lacking DMC-T with any psychiatric diagnoses was conducted. The primary outcome was clinical improvement. Secondary outcomes were cognitive outcomes and six month readmission rate. Hedges' g and odds ratios were calculated using a random-effects model. The protocol was registered in Open Science Framework (https://osf.io/rxjkm). RESULTS: Of 3552 identified articles, 41 studies (n = 1299) were included. Approximately 80% of patients lacking DMC-T responded to ECT, and part of the patients regained capacity to consent and consented to further treatment with ECT. A total of seven studies (n = 1081) were included for meta-analysis. Patients without DMC-T showed superior clinical improvement and less cognitive side effects compared with those with DMC-T, whereas the groups did not show any difference in readmission rate. Several clinical characteristics at baseline and ECT techniques were significantly different between the groups. CONCLUSION: ECT is equally, if not superiorly, effective in patients lacking DMC-T compared to patients with DMC-T. ECT can potentially enhance patients' autonomy, without increasing the risk of cognitive side effects. These results support the clinical and ethical legitimacy of ECT provision for patients with the most severe illness who lack DMC-T at start of treatment.