Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial.

BACKGROUND: Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion. METHODS: This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model. RESULTS: 97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017). CONCLUSIONS: Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.

[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.

Sexual minorities between equality and exclusion.

The situation of people with different sexual orientations and gender identities varies worldwide depending on the legal and social situation despite a formal depathologization in the medical classification systems DSM 1973 and ICD 1991. The spectrum ranges from equality to discrimination and exclusion to social ostracism, sometimes combined with legal persecution, in some countries even with the threat of a death penalty. On the basis of a historical overview of the medical-social discourse, it will be shown which scientific and societal advances make depathologization possible, although even in today's times a consistent and sustainable effect of this depathologization appears to be increasingly difficult in some countries, and in some cases even a societal re-pathologization is taking place. Aspects of persistent medical and societal stigma on the health of LGBT (lesbian, gay, bisexual, transgender) people are highlighted. Scientific models that empirically explain the increased risk of mental illness among LGBT people as a result of various forms of stigma and guidelines for psychotherapeutic treatment are presented. In an outlook, the continuing precarious situation of sexual minorities worldwide is pointed out and the importance of medical, social and political destig matization as a prerequisite for the mental health of LGBT people is emphasized. Non-discriminatory legislation is an important element in addition to medical statements and medical guidelines for treatment.

[Sexual minorities between equality and exclusion].

The situation of people with different sexual orientations and gender identities varies worldwide depending on the legal and social situation despite a formal depathologization in the medical classification systems DSM 1973 and ICD 1991. The spectrum ranges from equality to discrimination and exclusion to social ostracism, sometimes combined with legal persecution, in some countries even with the threat of a death penalty. On the basis of a historical overview of the medical-social discourse, it will be shown which scientific and societal advances make depathologization possible, although even in today's times a consistent and sustainable effect of this depathologization appears to be increasingly difficult in some countries, and in some cases even a societal re-pathologization is taking place. Aspects of persistent medical and societal stigma on the health of LGBT (lesbian, gay, bisexual, transgender) people are highlighted. Scientific models that empirically explain the increased risk of mental illness among LGBT people as a result of various forms of stigma and guidelines for psychotherapeutic treatment are presented. In an outlook, the continuing precarious situation of sexual minorities worldwide is pointed out and the importance of medical, social and political destig matization as a prerequisite for the mental health of LGBT people is emphasized. Non-discriminatory legislation is an important element in addition to medical statements and medical guidelines for treatment.

Effect of standardized post-coercion review session on symptoms of PTSD: results from a randomized controlled trial.

OBJECTIVE: Post-coercion review is increasingly regarded as a mean to reduce the negative consequences of coercive interventions, including the development of posttraumatic symptoms. However, the efficacy of this intervention in preventing posttraumatic symptoms or PTSD has not been sufficiently studied. The objective of this study is to examine the influence of a single, standardized post-coercion review session on the development or exacerbation of PTSD symptoms in patients with psychotic disorders. METHODS: In a multi-center, two-armed, randomized controlled trial, patients who experienced coercive interventions during current hospitalization were either randomized to standard treatment or an intervention group receiving a guideline-based, standardized reflecting review session. Factorial MANCOVA and subsequent ANCOVAs investigated the effects of the post-coercion reflecting review session on post-traumatic symptoms as measured by the subscales of the Impact of Events Scale-Revised (IES-R). Similarly, the effect of the intervention on the intensity of the peritraumatic reactions measured by the Peritraumatic Distress Inventory (PDI) was analyzed by conducting a factorial ANCOVA. RESULTS: N = 82 patients were included in an intention-to-treat analysis. MANCOVA and post hoc ANCOVAs revealed a significant main effect of the intervention for the IES-R subscales intrusion and hyperarousal, when controlling for levels of peritraumatic distress, whereby intervention group participants presented lower respective mean scores. There was no significant difference regarding the intensity of the peritraumatic reaction. CONCLUSION: Standardized post-coercion review contributes to a reduction of the burden of PTSD symptoms in patients with psychotic disorders experiencing coercive interventions in acute settings and shall be recommended as a measure of trauma-informed care. The trial was registered at ClinicalTrials.gov (ID NCT03512925) on 01/30/2018 (retrospectively registered).

Ethical Aspects of Mental Health Care for Lesbian, Gay, Bi-, Pan-, Asexual, and Transgender People: A Case-based Approach.

The lives of lesbian, gay, bi-, pan-, asexual, and transgender (LGBTA+/LGBT) people are not considered to be standard in society, unlike those of heterosexual cisgender people. This can lead to prejudices against LGBT people and may negatively influence their access to high-quality health care. Medical and mental health care have been characterized by attitudes (psycho-)pathologizing LGBT lives and therefore supported the stigmatization of LGBT people in the service of heteronormativity. Mental health professionals (MHPs) largely have transferred principles guiding counseling and psychotherapy with heterosexual (straight) cisgender persons to treatment of LGBT individuals without considering the specific features of LGBT lives. This is true even if the treatment is not exclusively LGBT-related, but can address LGBT-unrelated issues. To counteract this, the present paper aims to provide an insight into ethically sound mental health care for LGBT people. By applying the principles of biomedical ethics, we have analyzed how LGBT individuals can be discriminated against in mental health care and what MHPs may need to offer LGBT-sensitive high-quality mental health care. We argue that MHPs need LGBT-related expertise as well as LGBT-related sensitivity. MHPs should acquire specialist knowledge for the diverse lives and the challenges of LGBT people. We encourage MHPs to develop an understanding of how their own implicit attitudes towards LGBT people can affect treatment. However, the demand for special training should not be mistaken as a demand for a specific type of mental health care. The principles of general psychotherapy are equally the basis of psychotherapy with LGBT people.

[Therapeutic attitudes and structures in (open) acute psychiatry: the Wedding model]. / Therapeutische Haltung und Strukturen in der (offenen) Akutpsychiatrie: das Weddinger Modell.

The Wedding model is a recovery-orientated treatment model that was implemented in 2010 as part of a complex change project in the Department of Psychiatry of the Charité at the St. Hedwig Hospital (PUK-SHK). According to this model, all ward structures were changed in order to promote transparency, participation, trialogue and multiprofessional work. A strong focus was also laid on therapeutic attitudes and the opening of acute psychiatric wards. The relevance of the Wedding model as a possible tool to implement a recovery-orientated, person-centered approach of care and its possible role in the reduction of coercion are the subject of this article.

[Effects and side effects of the disease concept "Homosexuality"]. / Wirkungen und Nebenwirkungen des Krankheitskonzepts "Homosexualität".

The diagnosis of homosexuality was removed from the DSM in 1973 and from the ICD in 1991. Despite this formal depathologization, negative effects of the concept of "homosexuality" as a disease, which stems from the 19th century, are still evident to this day and will be highlighted in this article. Furthermore, we also demonstrate the related interactions between social and medical processes. First, we give a global overview of the legal and social situation of sexual minorities, ranging from gender equality to marginalization and persecution. This is followed by a historical outline of the medical-social discourses in order to understand the connection between social stigmatization and pathologizing theories on homosexuality. Thereby, it can be demonstrated how scientific and social progress made the depathologization of homosexuality necessary, but also how difficult a consistent and sustainable effect of this depathologization appears to be. Additionally, we focus on the effects of persistent medical and social stigma on the health of LGB (lesbian, gay, bisexual) people. For this purpose, scientific models will be utilised in order to explain the increased risk of mental illness in LGB people arising as a direct result of various forms of stigmatization. In an outlook, we point out the ongoing precarious situation of sexual minorities in many parts of the world and emphasize the importance of destigmatizing polices and guidelines as carried out by the World Medical Association in 2013.

[Contributions to reduce coercion in psychiatric care]. / Beiträge zur Vermeidung von Zwang in der Akutpsychiatrie.

Reduction in coercion in psychiatric treatment requires successful interaction between changes in structural preconditions and therapeutic processes, as well as in individual therapeutic skills and attitudes. The article gives an overview of current approaches and possibilities to minimize the use of coercive interventions and to create non-violent and participative therapeutic settings. These opportunities are discussed against the background of structural and staff resources, social and legal aspects, as well as subjective experience of patients and their right to protection and treatment in phases when freedom of will and self- determination are compromised.

A need for orientation: The WMA statement on natural variations of human sexuality.

An alarming stigmatization and discrimination of homosexual people persists despite the formal depathologization of homosexuality, which occurred through the removal of the diagnosis from the DSM- (1973) and classification from the ICD (1991). The adoption of an expedited Statement on sexual orientation by the majority at the 64th General Assembly of the WMA is therefore an important and overdue measure. The Statement clearly asserts, among other things, that homosexuality is not an illness and therefore requires no cure. It also suggests that direct and indirect discrimination and stigmatization of people due their sexual orientation often leads to psychological and physical illnesses. Furthermore, delegates of the WMA condemned so-called reparative or conversion "therapies", which strive to induce heterosexual or asexual behavior. These are not only ineffective and unethical, but are strongly associated with serious negative impacts on health. Such a statement from the World Medical Association (WMA) is of particular importance as ambivalence and uncertainty in regards to homosexuality exists even within the medical and therapeutic professions. The latent or manifest attribution of homosexuality as an illness or developmental disorder is still widespread. One possible explanation for this may be the disruption of an open and sustainable discourse on causes, effects and definitions of sexual orientation following the "official depathologization". Especially those working in the medical and therapeutic contexts should be aware of their special responsibility not to pathologize homosexuality.

Coercive measures in psychiatry - When do they occur and who is at risk?

Coercive measures (CM) in psychiatry adversely affect patients and efforts to minimize CM are steadily increasing. One area that has not been a strong focus of preventative efforts to date is the time of use of CM during hospitalization although previous research indicates that the admission situation and early hospitalization are times of increased risk for CM. This study therefore aims to contribute to the body of research in this field by analyzing in detail the times of use of CM and identifying patient characteristics serving as predictors for CM during early hospitalization. Using a large sample (N = 1556) of all cases admitted in 2019 via the emergency room at the Charité Department of Psychiatry at St. Hedwig Hospital in Berlin, this study supports previous research showing that the risk of CM is highest within the first 24 h h of hospitalization. Of 261 cases who experienced CM, 71.6% (n = 187) experienced a CM within the first 24 h of hospitalization and 54.4% (n = 142) of cases only experienced CM within the first 24 h of hospitalization and did not receive any CM after. Furthermore, this study identified significant predictors for the early use of CM during hospitalization including acute intoxication (p < .01), aggression (p < .01), male gender (p < .001) and limited communication ability (p < .001). The results highlight the importance of directing preventative efforts to minimize the use of CM not only to psychiatric units but also to mental health crisis response and to develop interventions specifically tailored to this time and patient groups at highest risk.

Implementation of guidelines on prevention of coercion and violence: baseline data of the randomized controlled PreVCo study.

Introduction: The PreVCo study examines whether a structured, operationalized implementation of guidelines to prevent coercion actually leads to fewer coercive measures on psychiatric wards. It is known from the literature that rates of coercive measures differ greatly between hospitals within a country. Studies on that topic also showed large Hawthorne effects. Therefore, it is important to collect valid baseline data for the comparison of similar wards and controlling for observer effects. Methods: Fifty five psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to an intervention or a waiting list condition in matched pairs. As part of the randomized controlled trial, they completed a baseline survey. We collected data on admissions, occupied beds, involuntarily admitted cases, main diagnoses, the number and duration of coercive measures, assaults and staffing levels. We applied the PreVCo Rating Tool for each ward. The PreVCo Rating Tool is a fidelity rating, measuring the degree of implementation of 12 guideline-linked recommendations on Likert scales with a range of 0-135 points covering the main elements of the guidelines. Aggregated data on the ward level is provided, with no patient data provided. We performed a Wilcoxon signed-rank-test to compare intervention group and waiting list control group at baseline and to assess the success of randomization. Results: The participating wards had an average of 19.9% involuntarily admitted cases and a median 19 coercive measures per month (1 coercive measure per occupied bed, 0.5 per admission). The intervention group and waiting list group were not significantly different in these measurements. There were 6.0 assaults per month on average (0.3 assaults per occupied bed and 0.1 per admission). The PreVCo Rating Tool for guideline fidelity varied between 28 and 106 points. The percentage of involuntarily admitted cases showed a correlation with coercive measures per month and bed (Spearman's Rho = 0.56, p < 0.01). Discussion: Our findings that coercion varies widely within a country and mainly is associated with involuntarily admitted and aggressive patients are in line with the international literature. We believe that we included a sample that covers the scope of mental health care practice in Germany well.Clinical trial registration: www.isrctn.com, identifier ISRCTN71467851.

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.

Patient communication ability as predictor of involuntary admission and coercive measures in psychiatric inpatient treatment.

Coercive measures (CM) and involuntary admission to psychiatric treatment can have detrimental consequences for patients. Past research shows that certain clinical, treatment and admission-related characteristics put patients at a higher risk of experiencing CM and involuntary admission. Although of high societal importance, the association between patients' communication ability and CM and involuntary admission has not been subject of past research. To explicitly examine this association the authors conducted a retrospective study using data from patients admitted to psychiatric inpatient treatment via the emergency room at Charité St. Hedwig Hospital, Berlin in 2019. As independent variable, communication ability at admission was recorded (perfect; limited due to language or other reasons; impossible due to language or other reasons) along with possibly confounding variables including demographic, clinical and admission-related details. As dependent variables, involuntary admission and CM were recorded. Multivariate logistic regression analyses were conducted examining the association between communication ability and involuntary admission and CM. In a sample of N = 1556, controlling for potential confounders, limited (OR = 3.08; p = .004) or no communication ability (OR = 4.02; p = .003) due to language barrier or limited (OR = 3.10; p < .001) or no communication ability (OR = 13.71; p < .001) due to other factors were significant predictors for involuntary admission. Limited communication ability due to language barrier (OR = 4.53; p < .001) and limited (OR = 1.58; p = .034) and no communication ability (OR = 3.55; p < .001) due to other factors were significant predictors for CM. These findings show that patients impaired in their communication ability are at higher risk of involuntary admission and CM and highlight the urgency of implementing appropriate interventions facilitating communication during admission and treatment.

Effects of Recovery-Orientation on the Use of Forced Medication and Maximum Daily Drug Dose: The "Weddinger Modell".

Objective: The aim of the present study was to analyze the effects of the implementation of the Recovery-orientated psychiatric care concept "Weddinger Modell" on the incidence of forced medication, the total number of forced medication incidents per affected case, the maximum dose of a singular forced medication and the maximum voluntary daily drug dose of different psychotropic drugs administered during an inpatient stay. Methods: This retrospective case-control study included 234 patients. A pre/post-comparison of patients on two acute psychiatric wards before (control group, n = 112) and after (intervention group, n = 122) the implementation of the Weddinger Modell in 2010 was performed. Patient data was selected at two reporting periods before and at two reporting periods after 2010. Results: No significant differences were found in the incidence of forced medication and the total number of forced medications. A significant reduction of the maximum forced medication dose of haloperidol in the intervention group was seen. Furthermore, the analysis of the intervention group showed a significant reduction of the maximum voluntary daily drug doses of clozapine, haloperidol and risperidone. Discussion: The results indicate that the implementation of the Weddinger Modell had no effect on the incidence of forced medication, but it can help to improve the approach to psychotropic drugs. Despite the reduction of mechanical coercive measures by the model, as shown in a previous study, there is no increase in forced medications or administered drug doses. Focus on Recovery helps in reducing coercion in acute psychiatric care.

The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry.

Many determinants leading to the use of different coercive measures in psychiatry have been widely studied and it seems that staff attitudes play a crucial role when it comes to the decision-making process about using coercion. However, research results about staff attitudes and their role in the use of coercive measures are inconsistent. This might be due to a focus on self-report studies asking for explicit answers, which involves the risk of bias. This study aimed to expand research on this topic by examining the impact of explicit and implicit staff attitudes on the use of coercive measures in clinical practice. In addition, the influence of gender, profession (nurses, psychiatrists), and years of professional experience as well as their influence on staff attitudes were examined. An adaption of the implicit association measure, the Go/No-Go Association Task (GNAT), with the target category coercion and distracter stimuli describing work load, as well as the explicit questionnaire Staff Attitudes to Coercion Scale (SACS) was completed by staff (N = 149) on 13 acute psychiatric units in 6 hospitals. Data on coercive measures as well as the total number of treated cases for each unit was collected. Results showed that there was no association between staff's implicit and explicit attitudes toward coercion, and neither measure was correlated with the local frequency of coercive measures. ANOVAs showed a significant difference of the GNAT result for the factor gender (F = 9.32, p = 0.003), demonstrating a higher tendency to justify coercion among female staff members (M = -0.23, SD = ±0.35) compared to their male colleagues (M = -0.41, SD = ±0.31). For the SACS, a significant difference was found for the factor profession (F = 7.58, p = 0.007), with nurses (M = 2.79, SD = ±1.40) showing a more positive attitude to the use of coercion than psychiatrists (M = 2.15, SD = ±1.11). No significant associations were found regarding the extent of professional experience. Results indicate a complex interaction between implicit and explicit decision-making processes dependent on specific contexts. We propose future research to include primers for more context-related outcomes. Furthermore, differences in gender suggest a need to direct attention toward occupational safety and possible feelings of anxiety in the workplace, especially for female staff members.

[Effects of the Psychiatric Care Concept "Weddinger Modell" on Mechanical Coercive Measures]. / Auswirkungen der Etablierung des psychiatrischen Behandlungskonzepts "Weddinger Modell" auf mechanische Zwangsmaßnahmen.

The aim of the present study was to analyze the effects of the implementation of the Recovery-orientated psychiatric care concept "Weddinger Modell" on mechanical coercive measures. A retrospective case-control study design was implemented, investigating 375 patients treated in in-patient care on three acute psychiatric wards who were selected at four different reporting dates. The study compared two groups of patients, one treated according to the Weddinger Modell (intervention group; n = 122) and the other one conventionally (control group; n = 235). The results show a significant reduction of the maximum frequency of restraint events as well as the duration of seclusion incidents in the group of patients treated according to the Weddinger Modell. In conclusion, the results indicate that the implementation of the Weddinger Modell and similar treatment concepts in inpatient psychiatric setting can help reduce coercion.

Correlates of seclusion and restraint of patients admitted to psychiatric inpatient treatment via a German emergency room.

Coercive measures in psychiatry are associated with negative consequences for both patients and staff. When it comes to preventing coercive measures, innovative models of care like the Weddinger Modell focusing on recovery, participation and supported decision-making have proven successful. However, observations from clinical practice show that emergency admissions to psychiatric facilities pose a great challenge in this regard and that most coercive measures take place during or shortly after emergency admission. This study retrospectively examined all cases (N = 1477) admitted to inpatient treatment at the Department of Psychiatry of the Charité at St. Hedwig Hospital in Berlin via the emergency room in 2018 aiming to identify patient characteristics that serve as predictors for coercive measures. Physical aggression, involuntary admission, police referral and younger age were found to be significant predictors (p < .001). Of 218 cases who experienced coercive measures, 81.2% (n = 177) were subjected to seclusion or restraint within the first 24 h of their hospital stay and 56.9% (n = 124) of cases only experienced coercive measures within these first 24 h and were not subjected to any coercive measures after. These results show that certain patient characteristics put individuals at higher risk of being secluded or restrained and that the risk of experiencing coercive measures is highest at the time during and shortly after emergency admission. To prevent coercive measures, it is crucial to target more resources and put in place measures specifically tailored to these emergency situations and the most vulnerable patient groups.

Implementation of Guidelines on Prevention of Coercion and Violence (PreVCo) in Psychiatry: Study Protocol of a Randomized Controlled Trial (RCT).

BACKGROUND: Coercive measures are among the most controversial interventions in psychiatry. There is a large discrepancy between the sheer number of high-quality guidelines and the small number of scientifically accompanied initiatives to promote and evaluate their implementation into clinical routine. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry. METHODS: The study presented examines whether coercive measures on psychiatric wards can be reduced by means of an operationalized implementation of the guidelines "Prevention of coercion: prevention and therapy of aggressive behavior in adults". Out of a set of 12 interventions offered, wards are free to choose three interventions they want to implement. The primary outcome is the number of coercive measures per bed and month/year. Secondary outcomes are cumulative duration of coercive measures per bed and month/year. The most important control variable is the number of aggressive incidents. We plan to recruit 52 wards in Germany. Wards treating both voluntary and compulsorily admitted patients will be included. A 1:1 stratified randomized controlled trial will be conducted stratified by the amount of coercive measures and implemented aspects of the guidelines. In addition to the control group analysis, a waiting list design allows a pre-post analysis for all participating wards of the waiting list group. A parallel qualitative study will examine factors related to successful implementation and to successful reduction of coercion as well as relevant barriers. DISCUSSION: We are planning a nationwide study on the implementation of evidence- and consensus-based guidelines in psychiatric hospitals. This study intends to promote the transfer of expert knowledge as well as results from clinical trials into clinical routine with the potential to change supply structures in mental health sector. CLINICAL TRIAL REGISTRATION: www.isrctn.com, identifier ISRCTN71467851.