Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa.

INTRODUCTION: Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN. METHODS: 23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up. RESULTS: At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05). DISCUSSION: Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.

Debate: Involuntary treatment and detention are a necessary part of mental health care for children and young people - a perspective from an Independent Advocate in England, United Kingdom.

This is a perspective from an Independent Advocate in England, United Kingdom on the importance of equality in the involuntary treatment of children and young people (CYP). The article highlights the need for safeguards when CYP require detention as part of their mental health care. The paper raises concern that CYP and their families who are less empowered to advocate for optimal care plans may be at risk of less satisfactory outcomes from mental health detention. It notes that CYP in the care system may be particularly vulnerable to such outcomes due to their lower levels empowerment. To mitigate this risk, services need to be proactive in reducing inequity arising from differential levels of empowerment among service users. This could be achieved by adopting strong participation and coproduction activities and ensuring access to Advocacy services for all CYP.

Debate: The experience of involuntary psychiatric hospitalisation for children and young people.

Involuntary treatment has been reported to be traumatic, stigmatising and frightening, as well as sometimes lifesaving. However, there has been little research into the experiences of people who have been hospitalised involuntarily prior to the age of 18. A greater understanding of this may help us to make changes which could improve the experience of involuntary psychiatric treatment for children and young people. Lizzie Mitchell is an expert by experience who was admitted to a psychiatric hospital in England under the Mental Health Act (MHA) when she was 16 years old. Here, in discussion with Susan Walker, a child and adolescent psychiatrist, Lizzie reflects on her own experiences alongside wider reflections around the involuntary hospitalisation of young people, including the potential short and long-term impact on mental health, education, friendships, family and identity.

Debate: Involuntary treatment and detention are a necessary part of mental health care - a perspective from low and middle-income countries.

Mental health care is underpinned by human rights. However, certain mental health presentations can be associated with increased risk to self or others. Thus, appropriate and effective care plan to mitigate the risk may include a temporary restriction of the person's human rights. Legal frameworks are required to ensure appropriate safeguards for the affected person, and clarity about boundaries of necessity and proportionality for clinicians. The restriction needs to be proportionate, for the shortest possible period, done in a humane manner, and in a safe environment. Effective early mental interventions can reduce need for human right restrictions by preventing acute escalations in risk-related behaviours. While these principles apply across all regions, we discuss the particular circumstances in low and middle-income countries.

Debate: Involuntary treatment and detention are a necessary part of mental health care for children and young people.

People of all ages are subject to involuntary psychiatric detention and treatment worldwide but there is current discussion about whether this complies with modern human rights law. The use of involuntary psychiatric hospitalisation among children and young people has largely eschewed research and policy interest to date. In this debate section, we hear from people with experience of child mental health services in the UK, USA and low- and middle-income countries about their views on the use of involuntary treatment in young people.

Debate: Involuntary treatment - not whether, but when and what else is needed.

Involuntary treatment is a complex dialectic balancing self-autonomy and the individual's right to consent to treatment with society's duty to protect those suffering from severe mental illness who are at risk of causing harm to themselves or others. When necessary, involuntary treatment should provide evidence-based and medically justified care, with sufficient oversight and due process to protect the rights of patients. Clinically, the issue is not whether involuntary treatment should ever be used, but rather what other services are needed to enhance the quality of care within comprehensive community systems of care, thus limiting or preventing the need for involuntary interventions while also improving the outcomes of individuals affected by severe mental illness.

Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors.

BACKGROUND: A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN. METHODS: In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics. RESULTS: IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these. CONCLUSIONS: High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018.

INTRODUCTION: Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018. METHOD: We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender. RESULTS: Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%). CONCLUSION: Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

Systematic review of involuntary hospitalisation and long-term compliance.

INTRODUCTION: Involuntary hospitalisation denies autonomy and freedom of decision-making and is frequent in psychiatric clinical practice. However, there is still a lack of knowledge of long-term compliance after Involuntary commitment. METHODS: We conducted a systematic review of published studies reporting people compliance after involuntary hospitalisation and people compliance after voluntary admission. Two investigators independently searched PubMed, PsycINFO, EMBASE and CINAHL up to December 17th, 2021 to identify eligible studies. The study is registered with PROSPERO number CRD42022299437. RESULTS: Ten independent studies analysing the main indicators of compliance, engagement with services and medication adherence, were included. Three studies show that compliance is worse in people that have been involuntary hospitalised and in the others no association is found. Just two of the ten studies show an association with improved compliance. Outcomes are assessed from the first follow-up appointment after discharge up to 96 months. CONCLUSIONS: Although evidences carried out so far are weak, the data do not show a trend of improvements and do not seem to exclude the possibility of worse compliance after compulsory hospitalisation. More appropriate methodologies and reliable assessment are needed in future research to provide scientific evidence on involuntary admission health effects.

Exploring correlates of involuntary treatment in substance use disorders: a global systematic review and meta-analysis.

Given the legislative heterogeneity about involuntary treatment and psychoactive substance users, we opted to perform a systematic review and meta-analysis of the correlates of involuntary substance use disorders (SUD) treatment across different countries. We conducted research on the Pubmed database, searching for involuntary SUD treatment data worldwide. The systematic review analysed a total of 36 articles and included a sample of 47,739 patients. Our review highlights the elevated risk of involuntary treatment among male, unmarried individuals with alcohol and/or opioid use disorders. Targeted preventive and therapeutic interventions should focus on addressing the underlying factors contributing to involuntary treatment, such as psychosis, aggressiveness, suicidal ideation, legal problems, and severe social exposure. By targeting these factors and providing comprehensive care, we can strive to improve outcomes and reduce the burden of substance use disorders in this vulnerable population. It is essential to critically examine and understand the factors contributing to the selection of patients for compulsory treatment. By doing so, we can identify potential gaps or inconsistencies in the current processes and work towards ensuring that decisions regarding compulsory treatment are based on sound clinical and ethical principles.

Professional caregivers' perceived barriers hindering the prevention and reduction of involuntary treatment among older persons receiving long-term care: A mixed methods study.

AIMS: To gain insights into the barriers towards the prevention and/or reduction of involuntary treatment in long-term geriatric care. DESIGN: Mixed methods. BACKGROUND: Measures to which a person resists and/or does not provide consent for are defined as involuntary treatment. The use of involuntary treatment violates the autonomy of (older) persons and causes more harm than benefit. Moreover, it contradicts the values of person-centred care. Nevertheless, its use among people living with dementia (PLWD) is still common practice. METHODS: We conducted a cross-sectional, mixed methods study, including an online survey for professional caregivers and a semistructured focus group interview with professional caregivers. RESULTS: A total of 218 participants completed the questionnaire. The percentage of participants who perceived barriers in one of the 22 survey items ranged from 15% to 42%. Lack of time, the experienced need to use involuntary treatment, uncertainty about responsibilities of stakeholders and a lack of knowledge on methods to prevent and/or reduce the use of involuntary treatment were most seen as barriers. Nursing staff perceived a lack of time hindering them in the prevention or reduction of involuntary treatment more often than other professional caregivers. Working in home care and having no former experience with involuntary treatment usage increased perceived barriers. Participants of the focus group interview confirmed these findings and added that professional caregivers in general lack awareness on the concept of involuntary treatment. CONCLUSIONS: One out of four professional caregivers experiences barriers hindering prevention and/or reduction of involuntary treatment. More research is needed to gain a better understanding of how professional caregivers can be supported to remove barriers and, consequently, prevent and/or reduce the use of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE: Professional caregivers experience many barriers towards the prevention and reduction of involuntary treatment. Future initiatives should aim to remove the perceived barriers.

Clinical determinants of involuntary psychiatric hospitalization: A clinical profile approach.

OBJECTIVES: The study examines the clinical determinants of involuntary psychiatric hospitalization. Specifically, it investigates whether distinct clinical profiles of hospitalized patients can be discerned, what other characteristics they are linked with, and which profiles predict involuntary admission. METHODS: In this cross-sectional multicentre population study, data were collected for 1067 consecutive admissions in all public psychiatric clinics of Thessaloniki, Greece, during 12 months. Through Latent Class Analysis distinct patient clinical profiles were established based on Health of the Nation Outcome Scales ratings. The profiles were then correlated with sociodemographic, other clinical, and treatment-related factors as covariates and admission status as a distal outcome. RESULTS: Three profiles emerged. The "Disorganized Psychotic Symptoms" profile, combining positive psychotic symptomatology and disorganization, included mainly men, with previous involuntary hospitalizations and poor contact with mental health services and adherence to medication, indicating a deteriorating condition and chronic course. Τhe "Active Psychotic Symptoms" profile included younger persons with positive psychotic symptomatology in the context of normal functioning. The "Depressive Symptoms" profile, characterized by depressed mood coupled with nonaccidental self-injury, included mainly older women in regular contact with mental health professionals and treatment. The first two profiles were associated with involuntary admission and the third with voluntary admission. CONCLUSIONS: Identifying patient profiles allows the examination of the combined effect of clinical, sociodemographic, and treatment-related characteristics as risk factors for involuntary hospitalization, moving beyond the variable-centered approach mainly adopted to date. The identification of two profiles associated with involuntary admission necessitates the development of interventions tailored to chronic patients and younger persons suffering from psychosis respectively.

Caregivers' perceptions of compulsory treatment of physical illness in involuntarily psychiatric hospitalization.

BACKGROUND: Physical morbidity is rife among patients with serious mental illness. When they are involuntarily hospitalized and even treated, they may still refuse treatment for physical illness leading clinicians to wonder about the ethics of coercing such treatments. RESEARCH AIM: This survey study explored psychiatric caregivers' perceptions on whether compulsory treatment of physical illness is legal and whether it is justifiable in patients with serious mental illness and under what circumstances. RESEARCH DESIGN: A questionnaire that included two case vignettes of an involuntarily hospitalized psychiatric patient with diabetes refusing treatment with insulin for various reasons. The cases differed in terms of diabetes severity. Participants answered questions regarding the appropriateness of involuntary treatment. PARTICIPANTS AND RESEARCH CONTEXT: Psychiatric medical doctors and nurses working in a mental health center. (N = 89, 50 female, ages 26-66). ETHICAL CONSIDERATIONS: The study was approved by the Medical Centre Institutional Review Board (IRB) and the University Ethics Committee. The respondents' anonymity was kept. Participation was voluntary and consent was obtained. RESULTS: The severity of the patient's medical condition and their reason for refusing treatment were associated with participants' willingness to give insulin despite patient objection [(F(1, 87) = 49.41, p < .01; (F(1, 87) = 33.44, p < .01), respectively]. Participants were more inclined to support compulsory treatment if the patient's refusal was "illness-oriented" (i.e. directly related to psychiatric illness). Participants presented diverse views regarding the perceived legality of compulsory treatment of physical illness in such situations (illegal 63.09%; legal 23.8%; 13% unsure). The majority (53.5%-55.3%) of those who thought it was illegal supported compulsory treatment in high-severity, illness-oriented refusal situations. CONCLUSIONS: The severity of the medical condition and the reason for treatment refusal influence psychiatric caregivers' willingness to provide compulsory treatment for physical illness in involuntary hospitalized psychiatric patients. Beyond the legal framework, ethical guidelines for these situations are warranted, while decisions should be made on a case-by-case basis.

Variation in the use of compulsory community treatment orders between district health boards in New Zealand.

OBJECTIVE: To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability. METHODS: The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions. RESULTS: The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Maori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe. CONCLUSIONS: CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

Coercion and Compulsory Treatment in Anorexia Nervosa: a Systematic Review on Legal and Ethical Issues.

BACKGROUND: The aim of this systematic review is to critically summarize current literature concerning ethical and legal issues related compulsory treatment (CT) in patients with anorexia nervosa (AN). SUBJECTS AND METHODS: Relevant articles were identified following the PRISMA guidelines after performing title/abstract screening and full text screening. We built the search string using the following terms: "coercion", "compulsory/involuntary treatment", "eating disorders", "anorexia nervosa", "mental capacity", "ethical/legal issues". Research was conducted on original articles published from any time until June 2023. RESULTS: Out of 302 articles retrieved, seven were included for the analysis, including five studies on mental health practitioners, and two on hospital records. The results show that mental health practitioners a) favor the use of CT, but the support is weaker in AN vs other psychiatric conditions (i.e., schizophrenia or depression); b) support of mental capacity is controversial and some variability was found between different categories of psychiatrists; in particular, both ED-treating and CT experienced mental health practitioners support higher use of CT and lack of capacity of AN patients vs. general psychiatrists; c) use of CT is more supported in the early vs. chronic AN, when chances of success are lower. The analysis of hospital records identified 1) comorbidities, previous admissions and current health risk as CT predictors in 96 Australian patients; 2) family conflicts association with longer hospitalizations in 70 UK patients. CONCLUSION: CT is usually intended for patients with AN at the onset of disease, mainly to prevent risk of death and self-injury. However, there is some variability in the attitude to perform CT among psychiatrists working in different setting, also related to the concept of mental capacity. There are also cross-national variabilities regarding CT. We can conclude that forcing patients to treatment is a conceivable option, but the balance between protection respect for patient's autonomy should be evaluated on individual bases.

Duration of Involuntary Treatment in a Psychiatric Inpatient Unit: the experience of Umbria, Central Italy.

OBJECTIVES: The present retrospective study was aimed at analyzing the socio-demographic and clinical correlates of the duration of involuntary treatment (IT) in a Psychiatric Inpatient Unit in central Italy. SUBJECTS AND METHODS: We reviewed clinical charts of subjects admitted following IT, extracting sociodemographic and clinical information. We used the duration of the IT as a "proxy" for the early cessation of the conditions that determined the need for involuntary commitment. Hospitalizations were thus labeled as "short-IT" and "ultra-short-IT" depending on their duration (< 7 days or < 3 days). Bivariate analyses (p<0.05). were performed to compare "short-ITs" with hospitalizations that were longer that 7 days. The same procedure was repeated for comparing "ultra-short-ITs" with hospitalizations lasting >3 days. RESULTS: In the present sample (362 subjects, 459 hospitalizations), 112 (24.4%) hospitalizations belonged to the "short-IT" and 56 (12.2%) to the "ultra-short-IT" subgroups. Both subgroups were characterized by a lower prevalence of single marital status and by a higher prevalence of admissions due to psychomotor agitation. The diagnoses of schizophrenia spectrum and mood disorders were less frequent in the two subgroups, with lower antipsychotic prescription rates, while higher prevalence of substance-related and impulse control disorders were detected. Both hospitalization types were more frequently followed by a "revolving door". As for "short-IT", subjects were referred to the ward by community mental health services in fewer cases. CONCLUSIONS: The early cessation of IT is more frequent in case of subjects who do not suffer from a serious psychiatric disorder and are referred to the inpatient ward due behavioral disturbances. The engagement with community mental health services should be improved in order to propose possible alternative solutions to IT and avoid revolving doors.

Psychiatric patients' attitudes towards being hospitalized: a national multicentre study in Norway.

BACKGROUND: The aim of the study was to explore patients' attitudes towards voluntary and involuntary hospitalization in Norway, and predictors for involuntary patients who wanted admission. METHODS: A multi-centre study of consecutively admitted patients to emergency psychiatric wards over a 3 months period in 2005-06. Data included demographics, admission status (voluntary / involuntary), symptom levels, and whether the patients expressed a wish to be admitted regardless of judicial status. To analyse predictors of wanting admission (binary variable), a generalized linear mixed modelling was conducted, using random intercepts for the site, and fixed effects for all variables, with logit link-function. RESULTS: The sample comprised of 3.051 patients of witch 1.232 (40.4%) were being involuntary hospitalised. As expected 96.5% of the voluntary admitted patients wanted admission, while as many as 29.7% of the involuntary patients stated that they wanted the same. The involuntary patients wanting admission were less likely to be transported by police, had less aggression, hallucinations and delusions, more depressed mood, less use of drugs, less suicidality before admission, better social functioning and were less often referred by general practitioners compared with involuntary patients who did not want admission. In a multivariate analysis, predictors for involuntary hospitalization and wanting admission were, not being transported by police, less aggression and less use of drugs. CONCLUSIONS: Almost a third of the involuntary admitted patients stated that they actually wanted to be hospitalized. It thus seems to be important to thoroughly address patients' preferences, both before and after admission, regarding whether they wish to be hospitalized or not.

Compulsory treatment of physical illness under MHA 1983.

Taken together, Sections 145 and 63 of the Mental Health Act 1983 (MHA) provide for treatment without consent of physical illness ancillary to the mental disorder with which a patient presents. On a daily basis, clinicians make both the decision that the Act's authority can be applied to their patient's case, and that it should be applied. But in the unusual circumstances where there is uncertainty as to the applicability of the MHA to the ancillary treatment of physical illness, the assistance of a court may be sought. In so doing, the law (and thence the courts) may justify compulsion but never prescribes it; the clinician is presented with authority that he or she could use but is left to decide whether it should be employed. This paper explores how the clinical question is set before the court, and whether the distinction between symptom, manifestation and consequence is sufficiently understood. This has important consequences in the context of self-neglect and its close cousin self-harm: the question whether the relevant ailment was attributable to or exacerbated by neglect or self- inflicted harm will determine whether compulsion under the MHA is applicable; and furthermore, whether or not compulsion is clinically acceptable.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry.

BACKGROUND: Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. MAIN BODY: The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002-2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. CONCLUSION: Ross Upshur's principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

A Quasi-experimental study on prevention and reduction of involuntary treatment at home (PRITAH) in people with dementia.

AIM AND OBJECTIVES: To examine the implementation (reach, dose, fidelity, adaptations, satisfaction), mechanisms of impact (attitude, subjective norm, perceived behavioural control and intention) and context of the PRITAH intervention. BACKGROUND: Involuntary treatment, defined as care provided against one's will, is highly prevalent in home care. The PRITAH intervention comprises policy, workshops, coaching and alternative measures for professional caregivers to prevent and reduce involuntary treatment in home care. DESIGN: Quasi-experimental study. METHODS: Eight home care teams from two care organisations participated in this study. Guided by the Theory of Planned Behavior, the mechanisms of impact were evaluated with questionnaires. Implementation and context were assessed using attendance lists, evaluation questionnaires, focus groups and logbooks. The study adhered to the TREND checklist. RESULTS: 124 of 133 eligible professional caregivers participated (93%). All four components were delivered with minor deviations from protocol. Participants' subjective norms and perceived behavioural control changed over time in favour of the intervention group. No effects were seen for attitude and intention. Barriers included an unclear policy and lack of communication between stakeholders. The multidisciplinary approach and possibility to discuss involuntary treatment with the specialised nurse were described as facilitators. CONCLUSIONS: Prevention and reduction of involuntary treatment at home is feasible in home care practice and contributes to changing professional caregivers' subjective norms and perceived behavioural control, prerequisites for behavioural change in order to prevent and reduce involuntary treatment. A follow-up study on the effectiveness of PRITAH on actual use, prevention and reduction of involuntary treatment in home care is needed. Future studies should emphasise the role of family caregivers and GPs and actively involve them in the prevention and reduction of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE: Involuntary treatment is commonly used in dementia home care and professional and family caregivers need to be supported in prevention and reduction of involuntary treatment in people with dementia.