Implementation of guidelines on prevention of coercion and violence (PreVCo) in psychiatry: a multicentre randomised controlled trial.

Background: Interventions to prevent the use of coercion in psychiatric hospitals have been summarized in the 2018 German Association for Psychiatry, Psychotherapy, and Psychosomatic's comprehensive guidelines. Twelve recommendations for implementation of these guideline on psychiatric wards have been deducted and their feasibility has been tested in a pilot study, using external implementation consultants as facilitators. The objective of the PreVCo study was to test their effect in a randomised clinical trial. Methods: Fifty-four psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to either an intervention or to a waiting list condition. The intervention consisted of the implementation of three out of 12 suggested recommendations as selected by the ward teams, supported by external study workers. As the primary outcome measure, the number of coercive measures used per bed and month in the final 3 months of the intervention period was determined. Secondary outcomes were the cumulative duration of coercive measures used per bed and months and assaults per bed and month. Achieved guideline adherence was measured by a fidelity scale developed for this purpose during a pilot study for the PreVCo Rating Tool. After a 3-month baseline collection period under routine conditions, randomisation was done after matching wards pairwise according to frequency of coercive measures used and scores on the PreVCo Rating Tool at baseline. The duration of the intervention period was 12 months; control wards received only an initial workshop presentation of the study and completed their PreVCo ratings. We used the Wilcoxon signed rank test and the paired t-test and conducted sensitivity analyses for different periods of observation. Findings: Neither the number of coercive measures used per month and bed nor their cumulative duration nor the number of assaults per bed and months differed significantly between the 27 intervention wards and the 27 control wards in the final 3 months of the intervention period. The median number of coercive measures used decreased by 45% (median 0.96 (IQR 1.34)-0.53 (IQR 0.59) from baseline until the end of the intervention period on the intervention wards and by 28% (median 0.98 (IQR 1.71)-0.71 (IQR 1.08) on waiting list wards. The PreVCo Rating Tool showed a significant improvement in intervention wards compared to control wards, indicating a successful implementation. Interpretation: The study demonstrated that guideline adherence could be significantly improved by the intervention. However, there was no evidence for an effect on the frequency or duration of coercive measures used. Spill-over effects and the impact of the COVID-19 pandemic on in-patient care might have limited the effect of the intervention. Further research from robust randomised controlled trials are necessary to identify effective interventions to reduce the use of coercion in psychiatric hospitals. Funding: The study was funded by the German Innovationsfonds beim Gemeinsamen Bundesausschuss (project no. 01VSF19037). The funder had no role in study design or data collection.

One-year follow-up of functional impairment in inpatients with mood and anxiety disorders - Potentials of the Mini-ICF-APP.

BACKGROUND: The aim of the study was to investigate functional impairment and its relationship to illness severity in a sample of patients with a diagnosis of mood or anxiety disorder during inpatient treatment and 1 year after discharge. METHODS: Two hundred thirty-nine inpatients with primary diagnoses of mood or anxiety disorders were assessed at baseline and at follow-up by a range of validated instruments. Mini-ICF-APP was used for the assessment of functional impairment, BDI-II for the assessment of clinical symptoms and remission. Sample characteristics and measures of impairment at baseline and at follow-up were analysed descriptively. Symptomatically remitted and non-remitted patients were compared with regard to capacity limitations. RESULTS: Initially, the sample showed considerable impairment in many capacities, particularly endurance, spontaneous activities, structuring of tasks, competency and flexibility. After 1 year, all capacities significantly improved. The level of impairment was correlated with employment status and severity of clinical symptoms. About 50% of the patients remitted in clinical symptomatology. Retrospectively, the remitted and the unremitted did not differ in functional impairment at baseline but there were considerable differences at follow-up. CONCLUSIONS: Mini-ICF-APP is a useful instrument to monitor functional status and change in psychiatric samples, complementing the usual focus on symptom reduction.

[DGPPN pilot study on the implementation of the S3 guideline "Prevention of coercion: prevention and therapy of aggressive behavior in adults"]. / DGPPN-Pilotstudie zur Implementierung der S3-Leitlinie "Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen".

OBJECTIVE: To investigate whether implementation recommendations derived from the German guidelines "Prevention of coercion" can be implemented on acute psychiatric wards by means of implementation consultants into ward work and if this contributes to an increased level of adherence to guideline intervention recommendations approved by the DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde)? MATERIAL AND METHODS: Two medical or nursing experts advised ward teams on the implementation of three individually selected recommendations from the guidelines in a structured consulting process over 6 months. The degree of implementation of the recommendations was assessed before and after the intervention by the ward teams together with the implementation consultants using a tool developed for this purpose (PreVCo rating tool). RESULTS: A total of five wards responsible for compulsorily admitted patients took part in the pilot study; three of them completed the intervention. On all three wards, implementation of the guideline recommendations improved for both selected and unselected recommendations. The strategy of using implementation consultants as well as the application of the PreVCo rating tool were well accepted and considered feasible by both the treatment teams and the implementation consultants. CONCLUSION: This pilot study showed that an implementation of recommendations on psychiatric wards derived from the German guidelines "Prevention of coercion" supported by implementation consultants is feasible, well acceptable among treatment teams and can lead to positive changes. The sample of five wards with diverse patient profiles was convincing. The efficacy in terms of reduction of coercive measures is currently being investigated in a randomized controlled trial on 55 psychiatric wards in different parts of Germany, with an intervention based on this pilot study.

Psychometric evaluation of the German version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC).

BACKGROUND: Healthcare professionals can be a source of stigma and discrimination for people with mental illness, and anti-stigma programs are needed for this target group. However, there is no validated German language scale to assess attitudes of healthcare professionals towards people with mental illness. This study had the aim to validate the German language version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC), a self-report measure of stigmatizing attitudes. METHODS: Staff (n = 392) on general psychiatric inpatient wards (excluding child, forensic and geriatric psychiatry) at five psychiatric hospitals in Switzerland (n = 3) and Germany (n = 2) participated in the study. The internal consistency of the OMS-HC was examined as well as its factor structure using exploratory and confirmatory factor analyses. To assess the scale's concurrent validity, we used the Social Distance Scale. RESULTS: Internal consistency for the OMS-HC total score was good (α = 0.74), acceptable for the subscales Attitudes (α = 0.62) and Social Distance (α = 0.69), and poor for the Disclosure subscale (α = 0.55). The original three-factor structure fit our data well. The OMS-HC total score and the Social Distance subscale score were significantly correlated with the Social Distance Scale, supporting concurrent validity. CONCLUSION: The German version of the OMS-HC demonstrated satisfactory psychometric properties and can be recommended for future research and intervention evaluation.

[Aftercare of Psychiatric and Psychosomatic Inpatients with ICD-10 Disorders F3 and F4 (PfAD Study)]. / Poststationäre Weiterbehandlung von Patienten mit ICD-Diagnosen F3 und F4 in Psychiatrie und Psychosomatik (PfAD-Studie).

OBJECTIVE: We investigated treatment pathways after discharge from in-patient treatment and their predictors. METHODS: Within a prospective naturalistic study, 320 adult inpatients treated in four settings were examined at admission, discharge, and two follow-up time points. In addition to sociodemographic and clinical data, standardized instruments have been employed to collect data on pathways within the mental care system a half year before and one year after index treatment, respectively. Descriptive analyses and logistic regression models were applied. RESULTS: Inpatient admissions in the first half of the follow-up year were common in psychiatric inpatients as planned aftercare. The majority of participants received outpatient aftercare. Main predictors of both inpatient readmission and outpatient psychotherapy after discharge were the setting of the index-treatment (psychiatry versus psychosomatics) as well as previous and planned forms of care. CONCLUSION: Though according to plan, the pathways of aftercare in psychiatry and psychosomatics are predominantly disconnected and show little overlap.

[Clinical courses of depressive and anxiety disorders over 1 year : Direct comparison of four treatment settings in psychiatry and psychosomatic medicine-results of the PfAD study]. / Erkrankungsverläufe depressiver und Angststörungen über ein Jahr : Direkter Vergleich von vier Behandlungssettings in Psychiatrie und Psychosomatik ­ Ergebnisse der PfAD-Studie.

BACKGROUND: Inpatient care for patients with depressive and anxiety disorders (ICD-10 F3/F4 diagnoses) is provided in Germany in different settings of psychiatry and psychosomatic medicine. OBJECTIVE: Apart from the question of the effectiveness of treatment, it is of interest whether the course of the disease differs between four different settings up to a period of 1 year after discharge. MATERIAL AND METHODS: A total of 320 patients with main clinical diagnoses from the ICD-10 F3/F4 spectrum were recruited and interviewed consecutively in four treatment settings (psychiatric depression unit, psychiatric crisis intervention unit, psychiatric day hospital, psychosomatic acute hospital). The interviews were conducted after admission, before discharge and 6 and 12 months after discharge. RESULTS: Overall, treatment in all four settings was shown to be highly effective. The slight increase in symptoms in the postinpatient phase described in the literature was observed across all settings. In terms of treatment intensity, those treated in the crisis intervention unit received the most services after index treatment; however, this group was also the one with the most pronounced symptom burden at admission. Patients treated in the psychosomatic department had the lowest symptom burden at admission and overall received the least inpatient services over the observation period; however, outpatient follow-up treatment was apparently used most by those patients. CONCLUSION: The treatments proved to be effective in the long-term in both psychiatric and psychosomatic units. The different settings seem to be successful in adapting the treatments to the respective patient groups.

Refusing Medication Therapy in Involuntary Inpatient Treatment-A Multiperspective Qualitative Study.

Objective: Between June 2012 and February 2013, two decisions by the German Federal Constitutional Court restricted the so-far common practice to use involuntary medication in inpatients who were involuntarily hospitalized. Up to then, involuntary medication was justified by a judge's decision on involuntary hospitalization. It could be applied according to clinical judgment even against the declared will of a patient. Since then, all domestic laws related to involuntary treatment had to be revised. For several months, involuntary medication was allowed only in an emergency. We were interested in the impact of the changed legal framework on the experiences of inpatients, their relatives, and clinical professionals during that time. Methods: Thirty-two interviews were analyzed qualitatively using a grounded theory methodology framework. Results: As a consequence of the restrictions to involuntary medication, special efforts by nursing and medical staff were required concerning de-escalation, ward management, and the promotion of treatment commitment in inpatients who refused medication. Family caregivers were also under strong pressure. They wanted to help and to protect their relatives, but some also welcomed the use of coercion if the patient refused treatment. Most of the interviewed patients had not even noticed that their rights to refuse medication had been strengthened. They complained primarily about the involuntary hospital stay and the associated limitations of their everyday lives. While patients and family members evaluated the refusal of medication from a biographical perspective, the mental health care professionals' focus was on the patients' symptoms, and they understood the situation from a professional perspective. It was obvious that, in any of the four perspectives, the problem of feeling restricted was crucial and that all groups strived to gain back their scope of action. Conclusion: The temporary ban on involuntary medication questioned the hitherto common routines in inpatient treatment, in particular when patients refused to take medication. Each of the different groups did not feel good about the situation, for different reasons, however. As a consequence, it might be indispensable to increase awareness of the different perspectives and to focus the efforts on the establishment of nonviolent treatment structures and practices.

Knowledge on types of treatment pressure. A cross-sectional study among mental health professionals.

Treatment pressure restricts patients' voluntary and autonomous decisions. Yet interventions involving treatment pressure are widely used in mental health and psychosocial services. This cross-sectional study explored whether mental health professionals' knowledge on five types of treatment pressure (no coercion, persuasion or conviction, leverage, threat, and formal coercion) was associated with sociodemographic, professional and contextual factors. A more positive attitude towards interventions involving treatment pressure was associated with underrating the level of those interventions compared with a predefined default value. The treatment setting and professional group played a minor role in 'leverage' and 'formal coercion' types of treatment pressure, respectively.

Antipsychotic treatment of psychotic disorders in forensic psychiatry: Patients' perception of coercion and its predictors.

BACKGROUND: Despite the major encroachment of coercive measures on the fundamental rights of affected forensic psychiatric patients, there is relatively few research done in this field. Considering the relevance of this subject for psychiatric care and the recent changes of the legal basis of coercive treatment in Germany, more studies are needed. The present study examines forensic psychiatric inpatients' perception of coercion regarding the prescribed antipsychotic medication and factors associated with the perception of coercion. MATERIAL AND METHODS: Patients with schizophrenia, schizotypal and delusional disorders in two forensic psychiatric institutions in Southern Germany were interviewed about their experience of coercion related to antipsychotic medication. Due to a lack of appropriate psychometric scales, the perception of coercion regarding antipsychotic medication was assessed using an adapted version of the MacArthur Admission Experience Survey (aAES). The influence of sociodemographic and illness-related factors, of the attitude towards medication, insight into illness and symptom severity on the extent to which patients felt coerced to take the prescribed medication was analyzed. Two Visual Analog Scales, the Drug Attitude Inventory DAI-10, the Positive and Negative Syndrome Scale PANSS, the Fragebogen zur Krankheitseinsicht (Questionnaire about insight into illness) FKE-10 and the Coercion Experience Scale CES were used as psychometric scales. RESULTS: 50% of all patients eligible for the study gave their written consent. 70% of all participants had experienced coercive measures between admission and time of data assessment. The DAI-10 and the aAES correlated moderately, a high level of insight into illness being correlated to less perceived coercion. The FKE-10 and the aAES correlated moderately as well, a high level of insight into illness being correlated to less perceived coercion. The severity of symptoms (PANSS score) and the level of perceived coercion (aAES score) correlated weakly, participants with more severe symptoms perceived more coercion than those with less marked symptoms. A linear regression model showed that to what extent patients felt coerced to take the prescribed antipsychotic medication was mainly influenced by their attitude towards medication and the degree of insight into illness, to a lesser extent by symptom severity (R2 = 0.565, p < 0.001). Sociodemographic factors were not related to the extent to which patients felt coerced to take the antipsychotic medication. CONCLUSIONS: Predictors of the experience of coercion related to the prescribed antipsychotic medication of forensic psychiatric inpatients with schizophrenia and related disorders are not so much sociodemographic or illness-related factors as education or past medical history, but rather potentially influenceable variables such as insight into illness or attitude towards medication.

Informal coercion as a neglected form of communication in psychiatric settings in Germany and Switzerland.

AIMS: Informal coercion is a frequently used form of communication among mental health professionals to influence treatment outcomes. This study investigates the recognition, attitude, and application of different forms of informal coercion by mental health professionals. METHODS: Mental health professionals of five psychiatric institutions in Germany and Switzerland (n = 424) took part in an online survey assessing the recognition of, attitudes towards, and application of different forms of informal coercion. RESULTS: Mental health professionals did not recognize the extent of informal coercion adequately; especially stronger forms were underestimated. Recognition and application of informal coercion was predicted by attitudes towards coercion. Furthermore, there were differences between profession of participants regarding the recognition and application of informal coercion. CONCLUSIONS: It is important to realize that the extent of applied informal coercion in therapeutic communication is often not recognized by practitioners, although it might interfere with a sound therapeutic relationship.

Pregabalin Use Among Users of Illicit Drugs: A Cross-Sectional Survey in Southern Germany.

BACKGROUND: The antiepileptic drug pregabalin is one of the best-selling pharmaceutical products worldwide. There are increasing concerns about its potential for misuse and dependence especially among patients with former or current substance use disorders (SUDs). OBJECTIVE: Our objective was to clarify the extent and pattern of pregabalin use as well as motives and predictors in this population. METHODS: We conducted a cross-sectional study with patients on a detoxification ward for illicit drugs at the Center for Psychiatry, Südwürttemberg, Ravensburg in southern Germany from August 2012 until July 2013. We used an extensive questionnaire, part of the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) Axis I Disorders (SCID-I) and urine samples. RESULTS: Of the 253 participating patients, 56% had used pregabalin at least once. Of these, 92% had acquired it at least in part from illegal sources. The main motives for the use of pregabalin were the attenuation of opioid withdrawal symptoms, the augmentation of other psychotropic substances, and the psychotropic effects of pregabalin itself. Predictors for pregabalin use were opioid and sedative use as well as younger age. The criteria of dependency according to DSM-IV was met by 11% of pregabalin users and 13% of urine samples were positive for pregabalin. CONCLUSIONS: Use of pregabalin is common among users of illicit drugs in large parts of southern Germany, with motives for use, acquisition, and mode of use suggesting misuse. The mode of use, especially intake of high doses and concomitant use of other drugs, poses a serious risk to this population, including the development of dependency.

Dissociation in patients with borderline personality disorder in acute inpatient care - A latent profile analysis.

PURPOSE: Dissociation is a common symptom in Borderline Personality disorder (BPD) and its consideration is important for the therapeutic outcome. The aim of this cross-sectional study was to scrutinize the co-occurrence of BPD symptoms and dissociative experiences. In particular, we were interested in the occurrence of specific symptom clusters characterizing qualitatively different patient groups in a clinical sample of BPD patients. BASIC PROCEDURES: We analyzed the data of 103 patients in a specialized acute inpatient care crisis intervention unit. Measures were the Borderline Symptom List (BSL-95), a German adaption of the Dissociative Experience Scale (FDS), and the Symptom Checklist SCL-90-R. We applied a Latent Profile Analysis (LPA) using the subscales of BSL-95 and FDS to investigate the existence of distinct latent classes of symptom profiles. Afterwards, we related the obtained profiles to other clinical and demographic characteristics. MAIN FINDINGS: Dissociative experiences of moderate to severe intensity were common among patients with BPD. LPA revealed that a model of three classes fitted the data best: one class was characterized by co-occurrence of severe borderline symptoms and frequent dissociative experiences, one class showed low symptom burden in both measures, and one class showed considerable borderline symptoms but only moderate dissociative experiences. The classes were closely related to the severity of other self-rated psychological problems and showed significantly different occurrences of stress-related comorbid disorders. PRINCIPAL CONCLUSIONS: The results underline that dissociation is an important factor in many (but not all) BPD patients. This should be addressed by increased attention to dissociative symptoms in the diagnostic process and the adjustment of treatment plans.

Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample.

BACKGROUND: The BSI-18 contains the three six-item scales somatization, depression, and anxiety as well as the Global Severity Index (GSI), including all 18 items. The BSI-18 is the latest and shortest of the multidimensional versions of the Symptom-Checklist 90-R, but its psychometric properties have not been sufficiently clarified yet. METHODS: Based on a representative sample of N = 2516 participants (aged 14-94 years), detailed psychometric analyses were carried out. RESULTS: The internal consistency was good: Somatization α = .82, Depression α = .87, Anxiety α = .84 and GSI α = .93. Confirmatory factor analysis supported the three scales as second-order and GSI as first-order factors. The model fit based on RMSEA is good but that model fit based on CFI and TLI are too low. CONCLUSIONS: Therefore, it is a very short, reliable instrument for the assessment of psychological distress. The BSI-18 can be used to reliably assess psychological distress in the general population. However, further studies need to evaluate the usefulness of standardization in clinical samples.

The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis.

Clinicians and patients differ concerning the goals of treatment. Eighty individuals with schizophrenia were assessed online about which symptoms they consider the most important for treatment, as well as their experience with different interventions. Treatment of affective and neuropsychological problems was judged as more important than treatment of positive symptoms (p < 0.005). While most individuals had experience with Occupational and Sports Therapy, only a minority had received Cognitive-Behavioral Therapy, Family Therapy, and Psychoeducation with family members before. Patients appraised Talk, Psychoanalytic, and Art Therapy as well as Metacognitive Training as the most helpful treatments. Clinicians should carefully take into consideration patients' preferences, as neglect of consumers' views may compromise outcome and adherence to treatment.

Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review.

BACKGROUND: The United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) aims at stimulating profound changes and social development in many areas of the society. We wanted to examine the impact of the convention on mental health care research up to now by a systematic review. METHODS: We searched relevant electronic databases for empirical studies from the area of mental health which focused directly on the content of the UN-CRPD. RESULTS: One thousand six hundred ten articles were screened, 36 of which fulfilled the inclusion criteria and came from 22 different countries. 25 studies (69 %) are related to persons with intellectual disabilities, only 11 to other mental disorders. Study designs were quantitative and qualitative as well. Issues were realisation of the UN-CRPD, implementation and financing, development of instruments, and attitudes towards the UN-CRPD. CONCLUSIONS: In contrast to possible wide-reaching consequences for the organisation of mental health care, theoretical debates prevail as of yet and empirical research is still scarce. Research on the UN-CRPD is more advanced for intellectual disabilities and provides good suggestions for relevant research aspects in major mental disorders.

Control beliefs, therapeutic relationship, and adherence in schizophrenia outpatients: a cross-sectional study.

OBJECTIVES: To examine the interactions among the different dimensions of the health locus of control (HLC), the patient-doctor relationship and medication adherence in patients with schizophrenia. METHODS: In a cross-sectional design, 69 chronically ill schizophrenia outpatients were assessed by established self-rating scales. The statistical analyses were based on multiple regression models. RESULTS: Patients' ratings of the therapeutic relationship and the powerful others dimension of the HLC were significantly correlated with medication adherence. The effect of the powerful others HLC on adherence was mediated by therapeutic relationship. CONCLUSIONS: A trustful working alliance between therapists and patients is supportive for medication adherence in patients with schizophrenia.

Rehospitalization risk of former voluntary and involuntary patients with schizophrenia.

BACKGROUND: The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. METHODS: In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %) involuntarily. Follow-up assessments were conducted half-yearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a random-effect logit model and a random-effect tobit model. RESULTS: After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. CONCLUSIONS: Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients.

Identification of psychopathological course trajectories in schizophrenia.

Course trajectory analyses have been performed primarily for treatment response in acute episodes of schizophrenic disorders. As yet, corresponding data for the long-term course are lacking. Within a multicenter prospective observational study, 268 patients with schizophrenia were assessed at discharge from hospital and followed up after 6, 12, 18, and 24 months. A latent class growth analysis was performed on the scores from the Positive and Negative Syndrome Scale (PANSS). A two-class conditional latent class model showed the best data fit (Entropy: 0.924). The model divided the sample into a group with amelioration in all PANSS subscales (60%) and a group with stable positive/negative and deteriorating general psychopathology symptoms (40%). Global functioning (GAF score), gender, age, living situation and involuntary admission predicted course trajectory class membership. The model was predictive of significant differences between the two groups in health care service costs and quality of life. The results underline the heterogeneous course of the illness, which ranged from amelioration to deterioration over a 2-year period. Statistical models such as trajectory analysis could help to identify more homogenous subtypes in schizophrenia.