Legislation and policy for involuntary mental healthcare across countries in the FOSTREN network: rationale, development of mapping survey and protocol.

BACKGROUND: Several countries are currently revising or have already revised their mental health laws to align with the global movement to reduce the use of coercive care. No government has yet fully implemented the recommendation of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) to eliminate the use of coercion in mental healthcare. Consequently, the international field of mental health law and policy is in a degree of flux. AIMS: To describe the rationale, development and protocol for a project that will map and examine how mental health laws, policies and service capacity across European countries relate to the use of coercive measures, including involuntary admissions and treatment, restraints and seclusion. This will help to better understand the current situation and explore future directions of policies regarding coercive care. METHOD: The project is being carried out under the purview of the European Cooperation in Science and Technology (COST) action network, entitled FOSTREN (Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services). A multidisciplinary group of experts developed a comprehensive survey assessing mental health laws, policies and service frameworks, based on World Health Organization and UNCRPD recommendations. The survey was piloted in three countries, revised and disseminated to 30 FOSTREN country representatives. The survey will provide data for three strands of work on legislation, policies and service-level context. A comprehensive evaluation will be conducted, drawing on findings from all work packages. CONCLUSIONS: The project could inform the development of strategies, interventions and legislation to address gaps and promote compliance with international standards.

Coercion in psychiatry: psychometric validation of the Portuguese Staff Attitudes to Coercion Scale (SACS).

BACKGROUND: There is a growing recognition that staff attitudes toward coercion in mental health care may influence its application. This study presents the psychometric properties of the Portuguese version of the Staff Attitudes towards Coercion Scale (SACS) and describes mental health professionals' attitudes towards coercion in Portugal. METHODS: Mental health professionals working in five Portuguese mental health services in urban and rural regions of Portugal were invited to complete a questionnaire comprising the SACS and a socio-demographic form. Psychometric analyses including construct validity and internal consistency were carried out using R software. RESULTS: A total of 91 out of 119 questionnaires completed were valid for analysis. Fifty-seven (62.64%) respondents were female, with an age range of 24 to 69 years (M = 39.33; SD = 11.09). More than half of them were nurses (52.75%, n = 48), and a third were psychiatrists (36.26%, n = 33). A three-factor structure was confirmed and showed the best fit compared to previously proposed models with a cumulative explained variance of 59%. The Portuguese SACS exhibited adequate internal consistency for both the full-scale and subscales. The highest mean score was in the pragmatic attitude domain (20.60; SD = 3.37). A negative correlation was observed between the critical attitude domain and both age and years of experience (p < 0.05). CONCLUSION: A three-factor structure was confirmed and showed the best fit compared to previously proposed models. The Portuguese SACS showed excellent psychometric properties and is acceptable for assessing staff attitudes towards coercion.

Coercion in Psychiatry: Exploring the Subjective Experience of Coercion Among Patients in Five Portuguese Psychiatric Departments.

The subjective experience of coercion may have a more significant impact on clinical outcomes than formal coercive measures. This study aimed to investigate the subjective experience of coercion among patients on admission in Portuguese psychiatric departments by assessing their perceived coercion, procedural justice, and negative pressures during admission. The study also investigated whether this subjective experience of coercion changed with time during admission, and the predictors of this change. Validated instruments, including the McArthur Admission Experience Survey (AES) and the Client Assessment of Treatment Scale, were used to collect information from 208 adults admitted to five public psychiatric inpatient departments in rural and urban regions of Portugal. About a third (32.24%, n = 49) of the sample had a legal involuntary admission status, while more than a third of them perceived their admission to be involuntary (40.13%, n = 61). The subjective experience of coercion was significantly higher among people who perceived their admission to be involuntary compared to people who perceived their admission to be voluntary (Median = 10, IQR = 5.5 vs. Median = 3, IQR = 6; p < 0.001). Satisfaction with their care was significantly inversely correlated with the subjective experience of coercion (p < 0.01). The changes in the subjective experience of coercion at the second assessment were predicted by the perceived admission status rather than the legal admission status, and the initial procedural justice (p < 0.05). The study findings highlight the importance of improving procedural justice in psychiatric admissions, regardless of the legal status of admission.

Responding to the needs of survivors of intimate partner violence in Lithuania: perceptions of mental health and social care professionals.

Around eight-out-of-ten survivors of domestic violence in Lithuania are women, and of those, eight-out-of-ten suffer violence specifically from their intimate partners (IPV). Women who experience IPV are at higher risk of having mental health conditions. This study aims to explore the perspectives of mental health and social care professionals regarding the provision of mental health support to IPV survivors in Lithuania. Four focus groups were conducted among 29 service providers from across the country. Audio-recordings were transcribed verbatim and analyzed thematically using MAXQDA software. The five main themes derived from the analysis reveal: 1) low levels of IPV awareness among IPV survivors who seek support with their mental health; 2) a lack of specialized training among professionals as a barrier to effective support; 3) a low prioritization on the national level; 4) little inter-sectoral collaboration which undermines the complexity of needed responses; 5) broader systemic problems. The provision of mental health support to IPV survivors lacks the recognition that IPV is gender-based violence and a major public (mental) health problem. The complexity of needed services is absent. Further research needs to explore the utilization of mental health services by IPV survivors and their perceptions concerning it.

Internet Gaming Disorder and the Incidence of Suicide-Related Ideation and Behaviors in College Students.

OBJECTIVES: The longitudinal associations between DSM-5 Internet Gaming Disorder (IGD) and suicide-related ideation and behaviors have not been explored. In this study, we therefore seek to examine the association between baseline IGD and incident suicide ideation, plans, and attempts. METHODS: This is a prospective cohort study of 2586 Mexican college students followed up from September 2018 to June 2022. We estimated hazards ratios modeling incidence of suicide ideation, plans, and attempts by fitting proportional hazards Cox models with person-time scaled in years. RESULTS: Among 2140 students without suicide ideation at baseline, there were 467 incident cases in 3987.6 person-years; ideation incidence rates were 179 cases per 1000 person-years among students with IGD and 114 cases per 1000 person-years among those without IGD. Incidence rates for suicide plans were 67 and 39 per 1000 among IGD and non-IGD students, and 15 and 10 per 1000, respectively for attempts. After controlling for age, sex, and mood, anxiety, and substance use disorders, IGD was associated with an 83% increased risk of suicide ideation. Although incidence rate estimates for plans and attempts were higher among students with IGD, results were not statistically significant. CONCLUSIONS: This study helps to raise awareness of the increased risk of at least suicidal ideation in people experiencing IGD. Clinicians treating patients with IGD may encounter complaints of suicide ideation over time, and even reports of suicidal behavior that should not be disregarded. Identifying these patients and treating/referring them for underlying suicidality should form part of IGD treatment.

Genome-wide association analyses identify 95 risk loci and provide insights into the neurobiology of post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 new). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (for example, GRIA1, GRM8 and CACNA1E), developmental, axon guidance and transcription factors (for example, FOXP2, EFNA5 and DCC), synaptic structure and function genes (for example, PCLO, NCAM1 and PDE4B) and endocrine or immune regulators (for example, ESR1, TRAF3 and TANK). Additional top genes influence stress, immune, fear and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Mental health conditions and utilisation of mental health services by survivors of physical intimate partner violence in Portugal: Results from the WHO world mental health survey.

The aim of this article is to study mental health conditions among survivors of severe physical intimate partner violence (IPV) and their utilisation of mental health services. This study is an integrated part of the World Mental Health Survey Initiative-Portugal, for which data was collected from a nationally representative adult sample using well-validated scales. Logistic regression models were used in the analysis. The most common statistically significant mental health conditions among IPV survivors were suicide ideation, PTSD, major depressive episode, and generalised anxiety disorder. More than one in three survivors developed PTSD. Suicide ideation was likely to occur after first experiencing IPV. Almost a half of survivors received specialised mental health treatment; in most cases, delivered by a psychiatrist. Over 60 % addressed their mental health issues consulting general physicians or other healthcare professionals. Those who experienced family violence in childhood had greater odds of also experiencing IPV; survivors of IPV with this experience were more likely to receive mental health treatment. The need to promote greater awareness and competencies of not only mental health professionals but also of general physicians and other healthcare professionals to provide support more effectively to survivors of any type of IPV deserves to be emphasised.

Prevalence and acceptability of psychological and/or economic intimate partner violence, and utilization of mental health services by its survivors in Lithuania.

BACKGROUND: Lithuania has one of the highest averages in the European Union when it comes to psychological and/or economic intimate partner violence (PE-IPV). IPV survivors are several times more likely to have mental health conditions than those without IPV experiences. The aim of this article is to study the prevalence, characteristics and attitudes of PE-IPV survivors in Lithuania, and the predictors of them accessing mental health services. METHODS: A cross-sectional study based on a national survey representative of the adult population. The survey was implemented by a third-party independent market research company employing an online survey panel. Logistic regression models were used in the analysis. RESULTS: Almost 50% of women in Lithuania experience PE-IPV. Females are significantly more likely to experience it than males. The vast majority of women find PE-IPV unacceptable; however, only one-third of survivors seek any type of help. Only one-tenth approach mental health services, with divorcees being at higher odds of doing so. CONCLUSIONS: Further research is needed to explore predictors and contextual factors of why IPV survivors seek mental healthcare, or not. Policy implications include the need to eliminate IPV and mental health stigma; develop accessible mental health services and effective treatment approaches.

Revisiting the psychometric properties of the McArthur admission experience survey: Validating the Portuguese version using a bifactor approach.

Cultural factors play a significant role in shaping the perception of coercion during psychiatric admissions. The present study aimed to assess the psychometric properties of the Portuguese Admission Experience Survey(P-AES). The study employed a cross-sectional approach in five psychiatric departments in three regions of Portugal. A total of 208 patients participated in the survey. Reliability was assessed through internal consistency and test-retest procedures. Internal validity was analyzed using a two-parameter logistic item response model, exploring three models, including a bifactor model. Convergent validity was determined by correlating AES scores with the Coercion Ladder (CL), Client Assessment of Satisfaction (CAT), and Global Assessment of Functioning (GAF) scale. Discriminatory power was assessed by comparing scores between patients with voluntary and involuntary admission status. The P-AES demonstrated satisfactory internal consistency and test-retest reliability. The bifactor model exhibited superior fit compared to the one-factor and three-factor models. Correlations between P-AES and CL, as well as CAT scores, indicated good convergent validity. Additionally, P-AES scores were notably higher in patients with compulsory psychiatric hospital admission compared to those admitted voluntarily, confirming its discriminatory power. The bifactor model suggests that all three domains of the AES should be used to measure the subjective experience of coercion.

Use of coercion in mental healthcare services in Nigeria: Service providers' perspective.

BACKGROUND: There is increasing advocacy to reduce coercive practices in mental healthcare. Little research has been done on the topic in developing countries. AIMS: To explore what mental health professionals in Nigeria think about coercion, why it is used, and what contextual factors influence its use in mental healthcare services. METHODS: Semi-structured interviews were carried out with 16 doctors and 14 nurses from two psychiatric hospitals in two regions of Nigeria. The audio-recorded interviews were analyzed thematically with the aid of MAXQDA software. RESULTS: Three broad categories relating to the perception of, reasons for, and barriers/facilitators to the use of coercion were derived. Coercion was viewed as being for the best interests of patients, a means to an end, and effective for achieving desired outcomes. Safety was both a reason to use a coercive measure and a deterrent to using specific coercive measures thought to be unsafe. The socio-cultural context, obsolete mental health legislation, staff shortages, and attitudes were factors influencing the use of coercion in mental healthcare. CONCLUSION: Coercion was perceived to be ultimately beneficial in mental health practice. There is need for a new mental health legislation and more resources for mental health care in Nigeria to address the problem of coercion.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World.

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

Discovery of 95 PTSD loci provides insight into genetic architecture and neurobiology of trauma and stress-related disorders.

Posttraumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 novel). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (e.g., GRIA1, GRM8, CACNA1E ), developmental, axon guidance, and transcription factors (e.g., FOXP2, EFNA5, DCC ), synaptic structure and function genes (e.g., PCLO, NCAM1, PDE4B ), and endocrine or immune regulators (e.g., ESR1, TRAF3, TANK ). Additional top genes influence stress, immune, fear, and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Contextual factors influencing the use of coercive measures in Portuguese mental health care.

The use of coercive measures in mental health care is an important indicator of the quality of care being provided, and non-patient-related factors are increasingly recognized to contribute to their use. The study aimed to explore the perspectives of mental health care professionals who have first-hand experience with the use of coercion on the contextual factors that influence the use of coercion in the Portuguese mental health care. Five focus group discussions were conducted among 23 doctors and 17 nurses from five psychiatric departments in urban and rural regions of Portugal. Discussions were audio recorded, transcribed, and analyzed with the aid of MAXQDA. Four broad themes related to insufficient resources, staff-related factors, inefficient services, and socio-legal factors were derived. Participants highlighted how inadequate structures, staff shortages, staff attitudes, a lack of training, restrictive ward rules, an inefficient organization of services, the mental health legislation, and public attitudes contributed to the use of coercive measures. The COVID-19 pandemic complicated existing shortfalls in the system and increased the use of coercive measures. The study confirms that the use of coercive measures in mental health care is influenced by factors that are independent of patient characteristics. Addressing existing systemic problems is crucial for the successful implementation of interventions to reduce coercion in mental health care.

Beyond Patient Characteristics: A Narrative Review of Contextual Factors Influencing Involuntary Admissions in Mental Health Care.

Variations in the rates of involuntary admission (IA) reflect the influence of unexplained contextual variables that are typically too heterogeneous to be included in systematic reviews. This paper attempts to gather and analyze factors unrelated to the patients that have been linked to IA. The articles included in this review were selected by iteratively searching four electronic databases (PubMed, PsychINFO, EMBASE, and Web of Science). A total of 54 studies from 19 different countries and regions, including 14 European countries, the United States, Canada, China, Vietnam, and Taiwan, were selected. The factors were categorized as service-related factors, impactful events, seasonal and temporal factors, mental health legislation, staff factors, and public attitudes. The factors rarely act in isolation but rather interact and reinforce each other, causing a greater influence on IA. This paper explains how these factors present opportunities for robust and sustainable interventions to reduce IAs. The paper also identifies future directions for research, such as examining the effects of economic recessions. Enhancing global reporting standards is essential to validate future research and support further in-depth studies. The complexity of the factors influencing IA and the implicit role of society suggest that resolving it will require social change.

Findings From the World Mental Health Surveys of Civil Violence Exposure and Its Association With Subsequent Onset and Persistence of Mental Disorders.

Importance: Understanding the association of civil violence with mental disorders is important for developing effective postconflict recovery policies. Objective: To estimate the association between exposure to civil violence and the subsequent onset and persistence of common mental disorders (in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) in representative surveys of civilians from countries that have experienced civil violence since World War II. Design, Setting, and Participants: This study used data from cross-sectional World Health Organization World Mental Health (WMH) surveys administered to households between February 5, 2001, and January 5, 2022, in 7 countries that experienced periods of civil violence after World War II (Argentina, Colombia, Lebanon, Nigeria, Northern Ireland, Peru, and South Africa). Data from respondents in other WMH surveys who immigrated from countries with civil violence in Africa and Latin America were also included. Representative samples comprised adults (aged ≥18 years) from eligible countries. Data analysis was performed from February 10 to 13, 2023. Exposures: Exposure was defined as a self-report of having been a civilian in a war zone or region of terror. Related stressors (being displaced, witnessing atrocities, or being a combatant) were also assessed. Exposures occurred a median of 21 (IQR, 12-30) years before the interview. Main Outcomes and Measures: The main outcome was the retrospectively reported lifetime prevalence and 12-month persistence (estimated by calculating 12-month prevalence among lifetime cases) of DSM-IV anxiety, mood, and externalizing (alcohol use, illicit drug use, or intermittent explosive) disorders. Results: This study included 18 212 respondents from 7 countries. Of these individuals, 2096 reported that they were exposed to civil violence (56.5% were men; median age, 40 [IQR, 30-52] years) and 16 116 were not exposed (45.2% were men; median age, 35 [IQR, 26-48] years). Respondents who reported being exposed to civil violence had a significantly elevated onset risk of anxiety (risk ratio [RR], 1.8 [95% CI, 1.5-2.1]), mood (RR, 1.5 [95% CI, 1.3-1.7]), and externalizing (RR, 1.6 [95% CI, 1.3-1.9]) disorders. Combatants additionally had a significantly elevated onset risk of anxiety disorders (RR, 2.0 [95% CI, 1.3-3.1]) and refugees had an increased onset risk of mood (RR, 1.5 [95% CI, 1.1-2.0]) and externalizing (RR, 1.6 [95% CI, 1.0-2.4]) disorders. Elevated disorder onset risks persisted for more than 2 decades if conflicts persisted but not after either termination of hostilities or emigration. Persistence (ie, 12-month prevalence among respondents with lifetime prevalence of the disorder), in comparison, was generally not associated with exposure. Conclusions: In this survey study of exposure to civil violence, exposure was associated with an elevated risk of mental disorders among civilians for many years after initial exposure. These findings suggest that policy makers should recognize these associations when projecting future mental disorder treatment needs in countries experiencing civil violence and among affected migrants.

Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

A qualitative integrative analysis of service users' and service providers' perspectives on ways to reduce coercion in mental health care.

PURPOSE: The movement to develop and implement non-coercive alternatives in the provision of mental health care is gaining momentum globally. To strengthen the basis of potential interventions that will be contextually relevant, and to complement the body of literature which is largely from high-income settings, the current study sought to explore the suggestions of service users and providers in Nigeria on how to reduce the use of coercive measures in mental health settings. METHODS: Semi-structured interviews with 30 mental health professionals and four focus group discussions among 30 service users from two psychiatric hospitals in Nigeria were conducted. The data were analyzed thematically with the aid of MAXQDA. RESULTS: The suggestions proposed by service users and mental health professionals were within the broad themes of communication, policies and legislation, and increased resources. Service users felt that improved communication, home consultations, non-legal advocates and clear rules and legislation would reduce the use of coercion, while service providers suggested increased public mental health literacy, better interpersonal relationships with patients, increased resources for mental health care, more research on the topic and regulation of coercive measures. CONCLUSION: Many of the suggestions from this study reinforce strategies already in place to decrease coercion in other settings. However, additional recommendations that are relevant to the study setting, such as enhancing public mental health literacy, mental health legislation reform and increasing access to mental health services, deserve further consideration.

Development and evaluation of a risk algorithm predicting alcohol dependence after early onset of regular alcohol use.

AIMS: Likelihood of alcohol dependence (AD) is increased among people who transition to greater levels of alcohol involvement at a younger age. Indicated interventions delivered early may be effective in reducing risk, but could be costly. One way to increase cost-effectiveness would be to develop a prediction model that targeted interventions to the subset of youth with early alcohol use who are at highest risk of subsequent AD. DESIGN: A prediction model was developed for DSM-IV AD onset by age 25 years using an ensemble machine-learning algorithm known as 'Super Learner'. Shapley additive explanations (SHAP) assessed variable importance. SETTING AND PARTICIPANTS: Respondents reporting early onset of regular alcohol use (i.e. by 17 years of age) who were aged 25 years or older at interview from 14 representative community surveys conducted in 13 countries as part of WHO's World Mental Health Surveys. MEASUREMENTS: The primary outcome to be predicted was onset of life-time DSM-IV AD by age 25 as measured using the Composite International Diagnostic Interview, a fully structured diagnostic interview. FINDINGS: AD prevalence by age 25 was 5.1% among the 10 687 individuals who reported drinking alcohol regularly by age 17. The prediction model achieved an external area under the curve [0.78; 95% confidence interval (CI) = 0.74-0.81] higher than any individual candidate risk model (0.73-0.77) and an area under the precision-recall curve of 0.22. Overall calibration was good [integrated calibration index (ICI) = 1.05%]; however, miscalibration was observed at the extreme ends of the distribution of predicted probabilities. Interventions provided to the 20% of people with highest risk would identify 49% of AD cases and require treating four people without AD to reach one with AD. Important predictors of increased risk included younger onset of alcohol use, males, higher cohort alcohol use and more mental disorders. CONCLUSIONS: A risk algorithm can be created using data collected at the onset of regular alcohol use to target youth at highest risk of alcohol dependence by early adulthood. Important considerations remain for advancing the development and practical implementation of such models.

Experiences and perceptions of coercive practices in mental health care among service users in Nigeria: a qualitative study.

BACKGROUND: People with mental health problems are more vulnerable to a broad range of coercive practices and human rights abuses. There is a global campaign to eliminate, or at the very least decrease, the use of coercion in mental health care. The use of coercion in psychiatric hospitals in developing countries is poorly documented. The primary aim of this study was to explore service users' perceptions and experiences of coercion in psychiatric hospitals in Nigeria. METHODS: Four focus group discussions were carried out among 30 service users on admission in two major psychiatric hospitals in Nigeria. The audio recordings were transcribed verbatim and then analyzed thematically with the aid of MAXQDA software. RESULTS: The Focus group participants included 19 males and 11 females with a mean age of 34.67 ± 9.54. Schizophrenia was the most common diagnosis (40%, n = 12) and had a secondary school education (60%, n = 18). The focus group participants perceived coercion to be a necessary evil in severe cases but anti-therapeutic to their own recovery, an extension of stigma and a vicious cycle of abuse. The experience of involuntary admission revolved mainly around deception, maltreatment, and disdain. Participants in both study sites narrated experiences of being flogged for refusing medication. Mechanical restraint with chains was a common experience for reasons including refusing medications, to prevent absconding and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful. CONCLUSION: The experiences of coercion by participants in this study confirm that human rights violations occur in large psychiatric hospitals and underscore the need for mental health services reform. The use of coercion in this context reflects agelong underinvestment in the mental health care system in the country and obsolete mental health legislation that does not protect the rights of people with mental health problems. The study findings highlight an urgent need to address issues of human rights violations in psychiatric hospitals in the country.

Rare copy number variation in posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is a heritable (h2 = 24-71%) psychiatric illness. Copy number variation (CNV) is a form of rare genetic variation that has been implicated in the etiology of psychiatric disorders, but no large-scale investigation of CNV in PTSD has been performed. We present an association study of CNV burden and PTSD symptoms in a sample of 114,383 participants (13,036 cases and 101,347 controls) of European ancestry. CNVs were called using two calling algorithms and intersected to a consensus set. Quality control was performed to remove strong outlier samples. CNVs were examined for association with PTSD within each cohort using linear or logistic regression analysis adjusted for population structure and CNV quality metrics, then inverse variance weighted meta-analyzed across cohorts. We examined the genome-wide total span of CNVs, enrichment of CNVs within specified gene-sets, and CNVs overlapping individual genes and implicated neurodevelopmental regions. The total distance covered by deletions crossing over known neurodevelopmental CNV regions was significant (beta = 0.029, SE = 0.005, P = 6.3 × 10-8). The genome-wide neurodevelopmental CNV burden identified explains 0.034% of the variation in PTSD symptoms. The 15q11.2 BP1-BP2 microdeletion region was significantly associated with PTSD (beta = 0.0206, SE = 0.0056, P = 0.0002). No individual significant genes interrupted by CNV were identified. 22 gene pathways related to the function of the nervous system and brain were significant in pathway analysis (FDR q < 0.05), but these associations were not significant once NDD regions were removed. A larger sample size, better detection methods, and annotated resources of CNV are needed to explore this relationship further.