A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry.

BACKGROUND: The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far. METHODS: Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate. RESULTS: After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended. CONCLUSIONS: Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.

Characteristics of Suicides and Toxicology in a Cohort of Individuals With Opioid Use Disorder.

Suicide in patients with opioid use disorder (OUD) is a complex issue. In addition to accidental intoxications, a higher prevalence of fatal suicides in patients with OUD can be found compared to the general population. In this study, suicides with a diagnosis of OUD documented in the project "Suicides, A National Survey" were extracted from our data bank. Individuals with a diagnosis of OUD in their medical history were compared to other suicides. The analyses included clinical and demographic factors as well as an investigation of suicide methods and toxicology of psychotropic drugs. For the statistical analyses, we applied chi-square tests and calculated odds ratios. Out of 6,495 suicide cases in Switzerland between 2000 and 2010, 215 individuals with a medical history of OUD could be identified. Persons in OUD cases were significantly younger than in other suicide cases (p < .001) and had more frequently a positive history for suicide attempts (p = .02). In addition, persons in OUD cases were more often female (p = .076). Intentional self-poisoning with medication was applied more often in individuals with OUD compared to other suicide methods (p < .001). When self-poisoning with drugs was compared to violent suicide methods, a combination of benzodiazepines with antidepressants was predominantly found. Our study yielded significant characteristics and risk factors for suicides in individuals with OUD. The predominant method of suicide in individuals with OUD was intended self-poisoning by medication. This knowledge is of clinical importance for the monitoring of at-risk individuals with OUD as well as for suicide prevention in this patient group.

Assisted Suicide in Switzerland: An Analysis of Death Records From Swiss Institutes of Forensic Medicine.

BACKGROUND: The aim of this research project, part of a program initiated by the Swiss Federal Council, was to trace the development of organized assisted suicide in Switzerland, starting from the very first case in 1985. METHODS: Retrospective data on 3666 death records from Swiss institutes of foren- sic medicine for the years 1985 to 2014 were systematically compiled, read into a database, and for the most part quantitatively evaluated. RESULTS: Alongside a marked increase in the overall number of assisted suicides since the turn of the century, the number of people traveling to Switzerland from other countries-predominantly Germany-for this purpose has risen steadily. The proportion of women was 60%, and the age at death ranged from 18 to 105 years (median 73). The largest diagnostic category was malignancy overall, neurological disease for those from other countries. The next largest category was age-related functional limitation, e.g., sensory impairment (loss of sight and hearing), the conse- quences of which were stated in writing as the reason for the wish to die. Following the Swiss Federal Court's promulgation of binding requirements in 2006, the docu- mentation contained in the death records for the subsequent period up to 2014 is much more detailed, but still not uniform or even necessarily complete. CONCLUSION: The number of candidates for organized assisted suicide increased steadily during the study period, but no standard procedures were followed. The question therefore arises of whether further regulation or the introduction of a cen- tral registration office to maximize standardization and promote transparency would lead to improved quality assurance.

Suicide by hanging: Results from a national survey in Switzerland and its implications for suicide prevention.

BACKGROUND: Hanging is a frequent suicide method, but developing measures to prevent suicide by this method is particularly challenging. The aim of this study is to gain new knowledge that would enable the design of effective of measures that would help prevent suicide by hanging. METHODS: A total of 6,497 suicides registered across the eight Swiss Forensic Institutes (IRM) were analysed. Of these, 1,282 (19.7%) persons hung themselves. T-test and chi-square tests. and chi-square tests were used to analyse …(or determine, or investigate) …group differences regarding sociodemographic variables and triggers. FINDINGS: Men and women who hung themselves showed no significant differences in sociodemographic variables. However, women were significantly more likely to have a psychiatric illness history, whereas men were more likely to have somatic diagnoses. In controlled environments, people used shelves, plumbing and windows more often than beams, pipes, bars and hooks to hang themselves. Compared with other suicide methods, hanging was more likely to have been triggered by partner and financial problems. CONCLUSIONS: Suicide by hanging can be best prevented in institutions (e.g. psychiatric hospitals, somatic hospitals, prisons). These institutions should be structurally evaluated and modified with a primary focus on sanitary areas, windows and shelves. Otherwise, it is important to use general suicide prevention measures, such as awareness raising and staff training in medical settings, low-threshold treatment options and regular suicide risk assessment for people at risk.

Attitudinal variance among patients, next of kin and health care professionals towards the use of containment measures in three psychiatric hospitals in Switzerland.

BACKGROUND: In psychiatric treatment containment measures are used to de-escalate high-risk situations. These measures can be characterized by their immanent amount of coercion. Previous research could show that the attitudes towards different containment measures vary throughout countries. The aim of this study was to compare the attitudes towards containment measures between three study sites in Switzerland which differ in their clinic traditions and policies and their actual usage of these measures. METHODS: We used the Attitude to Containment Measures Questionnaire (ACMQ) in three psychiatric hospitals in Switzerland (Zurich, Muensingen and Monthey) in patients, their next of kin (NOK) and health care professionals (HCP). Furthermore, we assessed the cultural specifics and rates of coercive measures for these three hospitals. RESULTS: We found substantial differences in the usage of and the attitudes towards some containment measures between the three study sites. The study site accounted for a variance of nearly zero in as needed medication to 15% in seclusion. The differences between study sites were bigger in the HCPs' attitudes (up to 50% of the variance), compared to NOK and patients. In the latter the study site accounted for up to 6% of the variance. The usage/personal experience of containment measures in general was associated with higher agreement. CONCLUSIONS: Although being situated in the same country, there are substantial differences in the rates of containment measures between the three study sites. We showed that the HCP's attitudes are more associated with the clinic traditions and policies compared to patients' and their NOKs' attitudes. One can conclude that patients' preferences depend less on clinic traditions and policies. Therefore, it is important to adapt treatment to the individual patients' attitudes. TRIAL REGISTRATION: The study was reviewed and approved by the Cantonal Ethics Commission of Zurich, Switzerland (Ref.-No. EK: 2016-01526, decision on 28.09.2016) and the Cantonal Ethics Commission of Bern, Switzerland (Ref.-Nr. KEK-BE: 2015-00074). This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The permission for conduction of the study was granted by the medical directors at the three study sites. The authors informed the respondents (patients, NOK, HCP) of their rights in the study in an oral presentation and/or a cover letter. They assured the participants of the confidentiality and anonymity of the data, and the voluntariness of participation. Patients were given an information sheet with the possibility to consent in the conduction of the study. Return of the completed questionnaires from HCP and NOK was constituted as confirmation of their consent. No identifying factors were collected to ensure privacy. This article does not contain any studies with animals performed by any of the authors.

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin.

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.

Suicide by firearm in Switzerland: who uses the army weapon? Results from the national survey between 2000 and 2010.

AIMS: In comparison with other central European countries, Switzerland has a high prevalence of gun ownership and a high rate of suicide by shooting. After the Army XXI reform in 2003, which reduced personnel from about 400,000 to approximately 200,000, a decline in suicides by firearms and a decline in the total number of suicides was observed in national data spanning the period from 2000 to 2010. It is, however, unclear whether this decline can be linked to the reduced availability of military guns. This study explored whether the decline in suicide by firearms is related to the decline of suicides by army weapons. METHODS: In 83.1% (n = 1112) of the 1338 suicides by firearm between 2000 and 2010 in Switzerland, the firearm could be categorised as an army weapon or a non-army weapon. The army weapon was used in 39.1% of these suicides. In comparison with other firearms, those who used army weapons tended to be younger and more likely to have a university degree. A prior suicide attempt was found less often in cases using a military weapon than other firearms. After the Army XXI reform, there was a significant drop in suicides by males aged 18 to 43 years using an army weapon, but no change in male suicide rates in the same age group who used a non-army weapon. The drop was statistically linked to a reduction of suicide by the army gun. RESULTS: The army weapon was used in 39.1% of suicides by firearm between 2000 and 2010 in Switzerland. In comparison with other methods, those who used army weapons tended to be younger and more likely to have a university degree. A prior suicide attempt was found less often in cases using a military weapon than other methods. After the Army XXI reform, there was a significant drop in suicides by males aged 18 to 43 years using an army weapon, but no change in males' suicide rates in the same age group who used a non-army weapon. The drop was statistically linked to a reduction of suicide by the army gun. CONCLUSIONS: Males who use army weapons differ from those who use other types of weapons. The significant drop in suicides was found in males aged 18 to 43 but there was no change in males of the same age group who used a non-army weapon. These results support the hypotheses that the observed drop in suicides is linked to the Army XXI reform and that restriction of access to guns is essential for reducing suicides by firearm.

Hepatitis C virus genetic diversity by geographic region within genotype 1-6 subtypes among patients treated with glecaprevir and pibrentasvir.

Hepatitis C virus (HCV) is genetically diverse and includes 7 genotypes and 67 confirmed subtypes, and the global distribution of each HCV genotype (GT) varies by geographic region. In this report, we utilized a large dataset of NS3/4A and NS5A sequences isolated from 2348 HCV GT1-6-infected patients treated with the regimen containing glecaprevir/pibrentasvir (GLE/PIB) to assess genetic diversity within HCV subtypes by geographic region using phylogenetic analyses, and evaluated the prevalence of baseline amino acid polymorphisms in NS3 and NS5A by region/country and phylogenetic cluster. Among 2348 NS3/4A and NS5A sequences, phylogenetic analysis identified 6 genotypes and 44 subtypes, including 3 GT1, 8 GT2, 3 GT3, 13 GT4, 1 GT5, and 16 GT6 subtypes. Phylogenetic analysis of HCV subtype 1a confirmed the presence of two clades, which differed by geographic region distribution and NS3 Q80K prevalence. We detected phylogenetic clustering by country in HCV subtypes 1a, 1b, 2a, 2b, and 5a, suggesting that genetically distinct virus lineages are circulating in different countries. In addition, two clades were detected in HCV GT4a and GT6e, and NS5A amino acid polymorphisms were differentially distributed between the 2 clades in each subtype. The prevalence of NS3 and NS5A baseline polymorphisms varied substantially by genotype and subtype; therefore, we also determined the activity of GLE or PIB against replicons containing NS3/4A or NS5A from HCV GT1-6 clinical samples representing 6 genotypes and 21 subtypes overall. GLE and PIB retained activity against the majority of HCV replicons containing NS3/4A or NS5A from HCV GT1-6 clinical samples, with a median EC50 of 0.29 nM for GLE and 1.1 pM for PIB in a transient replicon assay. The data presented in this report expands the available data on HCV epidemiology, subtype diversity by geographic region, and NS3 and NS5A baseline polymorphism prevalence.