[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.

[Incidence of coercive measures as an indicator of quality in psychiatric hospitals. Problems of data recording and processing, preliminary results of a benchmarking study]. / Die Inzidenz von Zwangsmassnahmen als Qualitätsindikator in psychiatrischen Kliniken. Probleme der Datenerfassung und -verarbeitung und erste Ergebnisse.

OBJECTIVE: The clinical practice concerning the use of coercive measures in psychiatry should be compared. METHOD: A common documentation of physical restraint, seclusion, and medication by coercion was introduced among 10 hospitals. RESULTS: 8.4 % of cases treated within the first 6 months of 2004 were exposed to coercive measures with the highest percentage among patients with psychoorganic disorders (32.1 %). The incidence of coercive measures varied highly between different diagnostic groups and hospitals. DISCUSSION: The processing of the large multi-site data sets yields considerable technical problems. Data interpretation should consider confounding factors such as case mix and hospital structure characteristics.

Diagnosis-related frequency of compulsory measures in 10 German psychiatric hospitals and correlates with hospital characteristics.

OBJECTIVE: To investigate the incidence of coercive measures in standard psychiatric care in different psychiatric hospitals. METHODS: We developed a common documentation of mechanical restraint, seclusion, and medication by coercion, and introduced it in 10 participating hospitals. We developed software able to process the data and to calculate four key indicators for routine clinical use. RESULTS: 9.5% of 36,690 cases treated in 2004 were exposed to coercive measures with the highest percentage among patients with organic psychiatric disorders (ICD-10 F0) (28.0%). Coercive measures were applied a mean 5.4 times per case and lasted a mean 9.7 h each. The incidence and duration of coercive measures varied highly between different diagnostic groups and different hospitals. Use of detailed guidelines for seclusion and restraint was associated with a lower incidence of coercive measures. DISCUSSION: Data interpretation should consider numerous confounding factors such as case mix and hospital characteristics. Suggestions on how to cope with ethical and technical problems in the processing of large multi-site data sets in routine clinical use are made.

[Poverty and deficits in basis social supplies among inpatient psychiatric patients]. / Armut und soziale Unterversorgung bei stationär behandelten psychisch Kranken.

OBJECTIVE: People with psychiatric diseases are often afflicted by processes of social disintegration and social problems are of great importance for the treatment of the mentally ill. METHODS: Two departments of psychiatry and psychotherapy with obligatory service for their area - one in an inner city area of a large town with disadvantageous social structure, one in a small town with more favourable economic data - collected data during a two-months-period in 1998 according to the social situation of their patients. RESULTS: 38,0 % resp. 31,9 % of the patients were living under conditions of poverty; 12,2 % resp. 11,5 % had acute housing problems, only 17,3 % resp. 31,7 % had some kind of payed occupation. Poverty was defined either as being dependent on public assistance or having an income below 50 % of the average. Patients with schizophrenic psychosis and patients with substance abuse related disorders formed in both departments the main groups and were at the same time those with the lowest income. Patients with substance abuse, mainly alcoholics, were more afflicted by social disintegration in the inner city area than in the small town sample. Concerning schizophrenic disorders, regional differences were not as prominent. CONCLUSIONS: The high risk of poverty among the mentally ill has to be taken in account in the development of community services, hospital staff and social legislation.