Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics.

BACKGROUND: Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS: Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS: Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS: The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.

[Self-immolation as an effort of self-rescue during a psychotic episode]. / Selbstverbrennung als Versuch der Selbstrettung im Rahmen einer psychotischen Episode.

Self-immolation as reported in the literature usually happens in the context of suicide acts or political martyrdom. We report a case in which a patient during a first psychotic episode attempted to immolate herself: she covered her legs with pieces of clothing and set them a fire. Severe burning made amputation of both her legs necessary, one above, one below the knee. The patient had not acted in this way in order to die, but to save herself from the impending end of the world. She was convinced the earth was going to explode, and she would only be able to flee to Venus by self-immolation. She acted under the influence of imperative acoustic hallucinations encouraging her and pressing her to proceed. Antipsychotic treatment with clozapine resulted in complete remission of all psychotic symptoms. Other than during psychosis the patient didn't believe in life on other planets, had no fantasies about the end of the earth, no contact with sects and no religious or cultural motives for self-immolation.

[A patient who for one year shared his apartment with his dead lady-friend's corpse]. / Ein Patient, der ein Jahr lang mit dem Leichnam seiner Partnerin in einer Wohnung lebte.

A 58-year old unemployed painter had for one year shared his apartment with his lady-friend's corpse and not talked to anyone about her death. When admitted to our hospital, loss of drive, initiative, interest, psychomotor activity and emotional response as well as poverty of speech were the main clinical features. Not having been able to care for his own vital needs such as food, shelter and protection against cold temperature, he was neglected and suffered from frost-bites. We diagnosed a schizophrenia simplex and initiated neuroleptic treatment using olanzapine. During the course of treatment there was some improvement regarding affect and psychomotor activity, his loss of drive and initiative and indifference regarding his own situation in life did hardly improve.