[Psychiatry without coercion-Exclude the coercion or the patients?] / Psychiatrie ohne Zwang ­ den Zwang ausschließen oder Patient:innen?

BACKGROUND: With reference to the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD), a fundamental change in psychiatric care in Germany was proposed in 2019 by Zinkler and von Peter, supported by a legal perspective from Kammeier, which has since led to controversial debates. Essentially, the aim is not only to reduce coercion in psychiatry to a minimum, but also to fundamentally exclude it in a psychiatry that only provides care. The function as an agent of social control is to be returned from psychiatry to state institutions. Psychiatric hospitals will only admit patients with their consent; patients who refuse therapy will not be admitted regardless of their capacity for self-determination and will remain untreated or, if they have committed a criminal offence or threaten to commit a criminal offence, they will be taken into custody or imprisoned in accordance with the legal regulations applicable to all people. There they will receive psychiatric care if they so wish. AIM OF THE PAPER: The paper outlines the background of this concept, including international sources, traces the discussion in German specialist literature and takes a critical look at it. RESULTS: The criticism is primarily directed against the fact that responsibility for a relevant proportion of psychiatric patients would be handed over to the police and judiciary and that, as a result, two realities of care would be established that would considerably differ in terms of quality. CONCLUSION: Arguments are put forward in favor of retaining the function of social control and considerations are suggested as to how caring coercion can be largely minimized.

The Basaglia Law. Returning dignity to psychiatric patients: the historical, political and social factors that led to the closure of psychiatric hospitals in Italy in 1978.

Law no. 180 of 1978, which led to the closure of psychiatric hospitals in Italy, has often been erroneously associated with one man, Franco Basaglia, but the reality is much more complex. Not only were countless people involved in the movement that led to the approval of this law, but we should also take into account the historical, social, and political factors that came into play. The 1970s in Italy were a time of change and political ferment which made this psychiatric revolution possible there and nowhere else in the world.

The Law and Practice of Off-Label Prescribing and Physician Promotion.

Prescription of medications for off-label indications is an increasingly common practice; recent events highlight such prescribing as one of the cornerstones of evolving clinical treatment. Clinicians are afforded substantial deference in prescribing practices and other treatments falling within the realm of the actual practice of medicine, including prescribing for off-label indications. Yet clinicians are not necessarily free to promote a medication for the same off-label indication they may have just prescribed for a patient. While trends in jurisprudence appear to be favoring clinicians' freedom to promote prescription medication for any use, in a majority of jurisdictions, the U.S. government can still bring considerable weight to bear on clinicians promoting off-label uses of prescription medications. We review the relevant laws and regulations pertaining to off-label prescription and promotion, as well as the possible legal consequences. The regulations pertaining to physician and pharmaceutical manufacturers regarding off-label drug use are complex. Suggestions are provided to help physicians better navigate the medical-legal landscape when prescribing or promoting medications for off-label use. Physician mindfulness to pertinent legal precedents will allow them to prescribe and promote medications with a higher level of critical reasoning to optimize care and reduce risk.

[Professional liability in psychiatry: evolution and critical issues]. / La responsabilità professionale in psichiatria: evoluzione e criticità.

The aim of the article is to present the evolution of professional liability in psychiatry from law 36 of 1904 to today. Through an examination of the doctrinal positions and of the jurisprudential expression it was possible to highlight three distinct phases in which professional responsibility has declined over the years. A custodial phase, in which the spirit that animated the law of psychiatric assistance was inspired by principles of social defense and the responsibility of the psychiatrist was recognized mainly in the lack of custody of the psychiatric patient. A phase of indulgence, in which, like other disciplines, the psychiatrist was recognized with "reduced impunity" due to an alleged "special difficulty" in exercising the medical profession. A phase of empowerment, in which the doctor in general, and the psychiatrist in particular, was confronted with empowering positions that led to convictions. An examination of the application of the guarantee position to psychiatry allows us to highlight current difficulties, sometimes a legacy of the past.

A Human Rights-Based Approach to Psychiatry: Is It Possible?

While it is becoming more common to hear calls for a human rights-based approach (HRBA) to health, documented efforts to apply the approach in practice remain scant. This paper presents a review of a pilot study applying an HRBA to psychiatric care in Gothenburg, Sweden. Based on the reflections of some involved in the pilot, and on the evaluation carried out, it presents the context, process, effects, and lessons learned. In the paper, we structure our experiences of an HRBA around the United Nations' guiding principles of dignity and empowerment, equality and non-discrimination, participation and inclusion, accountability, and transparency. We discuss challenges encountered during the project, such as realizing meaningful participation and challenging the hierarchies of different professions within care. We also discuss successes, such as contributing to an overall strategic goal to eliminate all coercive measures in psychiatric care. We then offer our reflections, as the core team involved in the pilot, on how to make an HRBA sustainable in a large organization and provide practical recommendations based on our experiences.

Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons.

BACKGROUND: Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research. METHODS: Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis. RESULTS: We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians. CONCLUSIONS: The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Emergency mental health legislation in response to the Covid-19 (Coronavirus) pandemic in Ireland: Urgency, necessity and proportionality.

Many countries have enacted, or are in the process of enacting, emergency mental health legislation in response to the global pandemic of Covid-19 (coronavirus). In Ireland, the Emergency Measures in the Public Interest (Covid-19) Act, 2020 amends the Mental Health Act 2001 to permit the Mental Health Commission to request an independent psychiatric report about an involuntary patient from any consultant psychiatrist who is not treating the patient (and not just those on its designated panel). This independent examination may occur 'in person', 'by other appropriate means', or even, 'due to the exigencies of the public health emergency', not occur at all, once this is explained in the resultant report. The 2020 Act acknowledges that 'the exigencies of the public health emergency' might hamper the independent psychiatrist's work and requires a written report from the patient's treating psychiatrist 'no earlier than the day before' the tribunal, in lieu of the psychiatrist physically attending a tribunal hearing, although, if possible, they will attend (i.e. phone in to) a tribunal held by conference call. The 2020 Act permits the Mental Health Commission to, if necessary, appoint tribunals 'consisting of one member who shall be a practising barrister or solicitor'. Such a tribunal shall, if possible, consult with a consultant psychiatrist if the reports from the independent psychiatrist and treating psychiatrist conflict or if it is otherwise 'necessary in the interest of the patient'. A tribunal can extend an involuntary order by a second period of 14 days 'of its own motion if the tribunal, having due regard to the interest of the patient, is satisfied that it is necessary'. Tribunals for current involuntary patients will be prioritised over retrospective tribunals for discharged patients; a tribunal can direct a witness to provide 'a written statement' rather than attending; and the patient can make written representation to the tribunal instead of physically attending a tribunal hearing, although they may attend (i.e. phone in to) a tribunal held by conference call. Psycho-surgery for involuntary patients is banned. While it is clear that revisions are urgent and necessary in light of Covid-19, the proportionality of these changes will depend on how, and the extent to which, they are used in practice. With good communication, efficient team-working and close adherence to professional codes of practice and ethics, it is hoped that these amendments will result in a review system that is as reasonable, robust and reassuring as the current, highly unusual circumstances permit.

[Psychiatry and bioethics: a critical relationship, an incentive to reflect]. / Psichiatria e bioetica: un rapporto critico, uno stimolo alla riflessione.

In the western world, especially in Italy, also legal attention to bioethical aspects is increasingly taking on importance in the debate at the medical, political and public level. In this debate, Psychiatry, as a scientific discipline closely integrated with the human and cultural, is underrepresented, little questioned on the many psychopathologal issues closely related to ethical aspects on complex themes. Against this background, Rivista di psichiatria, always keen to these topics, is designed to be a very special space for discussion with all the experts involved in mental health.

Italian Law no. 219/2017: consequences on the informed consent of the psychiatric patient and on the therapeutic privilege.

1Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome.

Restraints and seclusion in psychiatry: striking a balance between protection and coercion. Critical overview of international regulations and rulings.

Restraint and seclusion (R&S) measures in psychiatric settings are applied worldwide, despite poor scientific evidence to back up their effectiveness. The medical, ethical and medico-legal implications of coercive interventions are broad-ranging and multifaceted. The review aims to shed a light on the most relevant and meaningful standards that have been laid out by international treaties, supranational institutions (United Nations, Council of Europe, World Health Organization), scientific institutions (American Medical Association, Australian Department of Health), legislative bodies and courts of law. Several court cases are herein expounded upon, with a close focus on meaningful analysis, decisions and conclusions that have laid the groundwork for a different, more restrictive and more clearly defined approach towards R&S imposed upon psychiatric patients. It is reasonable to assume that changing norms, civil rights enforcement, court rulings and new therapeutic options have influenced the use of R&S to such an extent that such measures are among the most strictly regulated in psychiatric practice; health care providers should abide by a strict set of cautionary rules when making the decision to resort to R&S, which must never be put in place as a substitute for patient-centered therapeutic planning. Case law shows that R&S should only be weighed in terms of their effectiveness towards therapeutic goals. Being able to prove that R&S was employed as part of a therapeutic path rather than used to maintain order or to exact punishment may go a long way towards shielding operators against negligence lawsuits and litigation.

[Implementation and Stakeholders' Experiences with Home Treatment in Germany's Integrative and Flexible Psychiatric Care Models - A Mixed-Methods Study]. / Implementierungsstand und Erfahrungen der Stakeholder mit der Zuhause-Behandlung in psychiatrischen Modellvorhaben (nach §64b SGB V) ­ Eine Mixed-Methods Untersuchung.

OBJECTIVE: This paper seeks to illustrate current implementation of and the stakeholders' experiences with Home Treatment (=HT) according to §64b of the German Social Code Book V (=SGB V). METHODS: 381 Patients from 8 hospitals were questioned about their experiences and evaluation of HT using a standardized questionnaire (SEPICC-Scale). Further interviews and focus groups with 37 participants (including users, carers and employees) were thematically analysed. In addition, structural and performance data were collected from participating hospitals and HT teams. RESULTS: HT according to §64b SGB V is implemented quite heterogeneously, especially between rural and urban catchment areas. It provides a long-term, cross-sectoral care, which seems to strengthen the integration of patients' everyday life, treatment flexibility and continuity of care. After having experienced HT once, it is generally rated better. CONCLUSION: An important strength of HT (§64b SGB V) is its adaption to the users' needs and to regional distinctions. Implications for the implementation of outreach services on a larger scale in Germany can be drawn.

Psychotherapy in Psychiatry: Fighting Alternative Facts.

In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non-evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

Coercive care and human rights; a complex juxtaposition - part 2.

OBJECTIVE: To examine capacity assessment, coercive care and principles by which a seemingly reasonable request for the discontinuation of treatment may be considered. CONCLUSIONS: A clinical and socio-legal case may be made for 'coercive care'.

Humane treatment versus means of control: coercive measures in Norwegian high-security psychiatry, 1895-1978.

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway - Kriminalasylet (Criminal Asylum) and Reitgjerdet - during the period 1895-1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

Coercion in psychiatry: is it right to involuntarily treat inpatients with capacity?

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent-all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily.

Involuntary admission of psychiatric patients: Referring physicians' perceptions of competence.

BACKGROUND: Involuntary admissions can be detrimental for patients. Due to legal, ethical and clinical considerations, they are also challenging for referring physicians. Nevertheless, not much is known about the subjective perceptions of those who have to decide whether to conduct an involuntary admission or not. AIMS: This study aimed at answering the question whether psychiatrists' perceptions of confidence during psychiatric emergency situations and consecutive involuntary admissions differ from those of physicians without a psychiatric training. METHOD: We assessed the professional background and subjective perceptions during psychiatric emergency situations in physicians who executed involuntary admissions to the University Hospital of Psychiatry Zurich. We used one-way analysis of variance (ANOVA) with Bonferroni-adjusted post hoc tests and chi-square tests to compare the responses of 43 psychiatrists with those of 64 other physicians. RESULTS: Psychiatrists felt less time constraints compared with non-psychiatric residents. The latter also had more doubts on the necessity of the involuntary admission issued. Psychiatrists considered themselves significantly more experienced in handling psychiatric emergency situations and in handling the criteria for involuntary admissions than other physicians. Psychiatrists and other physicians did not differ in their satisfaction concerning course and results of psychiatric emergency situations which was overall high. About half of all participants felt pressure from third parties. CONCLUSION: Psychiatric emergency situations are challenging situations not only for patients but also for the involved physicians. Physicians with a specialized training might be more confident in the handling of psychiatric emergency situations and exertion of involuntary admissions. Non-psychiatric physicians might benefit from specialized training programs.

The Mental Healthcare Act 2017 of India: A challenge and an opportunity.

The Mental Healthcare Act 2017 replaced the Mental Health Act 1987, subsequent to India's ratification of the United Nations Convention on the Rights of Persons with Disabilities in 2007. The Mental Healthcare Act (MHCA) 2017 upholds patient autonomy, dignity, rights and choices during mental healthcare and thus marks a bold step in India's mental health legislation. This new Law marks a major shift in the way mental healthcare is delivered, as it aims to protect and promote the rights of people during the delivery of mental healthcare. Within this Act, a capacitous individual cannot be coerced into receiving treatment for mental illness and inpatient admissions can be 'independent' or 'supported'. 'Supported admission' replaces involuntary admission from the previous legislation. State mental health authorities and mental health review boards will play a major role in the implementation of the new Act. The Mental Healthcare Act 2017 is aimed at bringing about radical transformation to mental healthcare in India.