Patient-reported experience measures (PREMs) in outpatient psychiatry - is there an association to perceived discrimination and devaluation?

Patient-Reported Experience Measures (PREMs) are gaining significance in the field of psychiatry, with patient satisfaction being a key measure. However, it is unclear if patient satisfaction in psychiatry is influenced by variables outside the treatment setting. This brief report thus examines the possible impact of perceived discrimination and devaluation (PDD) on patient satisfaction in the psychiatric outpatient setting. Data from 1,126 individuals who were undergoing or had recently completed treatment at 15 outpatient centers of the Psychiatric University Clinic in Basel, Switzerland, was analyzed. Patient satisfaction was assessed using the Münsterlingen Patient Satisfaction Questionnaire (MüPF), and perceived stigma was measured with the Perceived Discrimination Devaluation Scale. The results revealed a positive small effect size relationship between MüPF and PDD, suggesting that patients who perceived less stigma report higher treatment satisfaction. This relationship may affect most ratings, with the total MüPF score remaining relatively robust against this potential influence. Linear regression analysis indicated that a one-unit increase in PDD score could lead to a maximum change of 1.8 points on the 7-point Likert scale for the MüPF item correlating highest with PDD and 0.4 points on the total MüPF score. These findings highlight the importance of considering perceived stigma when evaluating patient satisfaction with psychiatric outpatient treatment. Future research should investigate associations between stigma, patient satisfaction, treatment outcome, as well as other external factors that may influence patient satisfaction in psychiatric settings.

Treatment-seeking threshold and accessibility of psychiatric outpatient services in Switzerland: the relationship with stigma and self-esteem.

Perceived stigmatization and low self-esteem are linked to poorer mental health outcomes, but their impact on treatment-seeking thresholds and the importance of outpatient service location remain unclear. The study included 525 outpatients of the University Psychiatric Clinic (UPK) Basel, Switzerland, of whom 346 were treated at inner city services and 179 at services located on the main site of the UPK at the outer city limits. Perceived discrimination and devaluation (PDD), self-esteem (SE), treatment-seeking threshold (TST), and accessibility were measured via a self-reported questionnaire. The PDD consisted of 12 items evaluating beliefs about the level of stigma towards individuals with mental illness in the general population on a 5-point Likert scale. SE, TST and accessibility were assessed through single-item 7-point Likert scales. PDD and SE were positively correlated (p < 0.001), suggesting that lower perceived stigma was linked to higher self-esteem, and were not associated with TST. The relationship between PDD and SE remained consistent after controlling for age, gender, and nationality. Age was negatively correlated with TST (p = 0.022), while gender did not significantly influence any of the variables. There was little variation regarding PDD, with emergencies at the site of the psychiatric clinic and substance use disorder (SUD) patients reporting higher levels of stigmatization. Emergency patients and those with SUD and personality disorder reported the lowest SE ratings. TST showed a broad range and was highest for emergency services and transcultural psychiatry patients. Differences in accessibility were mainly linked to the location, with outpatient service users in the inner city reporting better accessibility (p < 0.001) and higher SE (p = 0.009). In comparison to patients using services with planned contacts only, patients in emergency settings differed by higher TST (p = 0.018) and better ratings of accessibility (p = 0.004). In conclusion, there was a relevant amount of stigmatization, impaired self-esteem, and, for some outpatient services, high thresholds to seek treatment. Future research should explore other factors influencing TST. The findings highlight the need to address stigmatization and accessibility when planning mental health services.

Comparing the latent state-trait structure of the PANSS in cariprazine-medicated and placebo-controlled patients with acute schizophrenia.

After over a hundred years of research, the question whether the symptoms of schizophrenia are rather trait-like (being a relatively stable quality of individuals) or state-like (being substance to change) is still unanswered. To assess the trait and the state component in patients with acute schizophrenia, one group receiving antipsychotic treatment, the other not. Data from four phase II/III, 6-week, randomized, double-blind, placebo-controlled trials of similar design that included patients with acute exacerbation of schizophrenia were pooled. In every trial, one treatment group received a third-generation antipsychotic, cariprazine, and the other group placebo. To assess symptoms of schizophrenia, the Positive and Negative Symptom Scale (PANSS) was applied. Further analyses were conducted using the five subscales as proposed by Wallwork and colleagues. A latent state-trait (LST) model was developed to estimate the trait and state components of the total variance of the observed scores. All symptom dimensions behaved more in a trait-like manner. The proportions of all sources of variability changed over the course of the observational period, with a bent around weeks 3 and 4. Visually inspected, no major differences were found between the two treatment groups regarding the LST structure of symptom dimensions. This high proportion of inter-individual stability may represent an inherent part of symptomatology that behaves independently from treatment status.

Just Not Enough: Utilization of Outpatient Psychotherapy Provided by Clinical Psychologists for Patients With Psychosis and Bipolar Disorder in Switzerland.

Treatment guidelines state that evidence-based psychotherapy is effective for people with psychosis and bipolar disorder and should be offered during every phase of the treatment process. However, research has indicated a lack of outpatient psychotherapeutic services for this patient group, for example, in the United States or Germany. We extend this finding by presenting survey data from Switzerland. We surveyed 112 inpatients with a diagnosis of a schizophrenia spectrum disorder or bipolar disorder and assessed outpatient treatment over the 5 years prior to their index hospitalization by using retrospective self-reports. The survey focused on psychotherapy provided by clinical psychologists. Results indicate that only 23.2% of participants retrospectively reported having utilized any outpatient psychotherapy within the reporting period and only 8% of participants reported having received a number of outpatient sessions that reaches recommended levels of psychotherapy. Exploratory analyses did not detect a significant association between self-reported utilization of outpatient psychotherapy sessions and most demographic, psychiatric, and psychological attributes, but patients with a bipolar disorder diagnosis (vs schizophrenia spectrum diagnosis) reported having utilized outpatient treatment more often. These findings are preliminary. When replicated they highlight the need for increased access to outpatient psychotherapy and better alignment between guideline recommendations and outpatient supply.

Implementation of a Budo group therapy for psychiatric in- and outpatients: a feasibility study.

Introduction: Physical exercise has been shown to have numerous health benefits on co-morbid somatic conditions in psychiatry and can also enhance mental health. Thus, it is not difficult to recommend physical training programs as part of an integrated and holistic treatment approach for mental health disorders. However, getting patients to participate and keeping them engaged is a major challenge. Programs based on martial arts training could be interventions improving physical and mental health with higher attachment rates. The structured discipline, holistic approach integrating physical and mental elements, and empowering activities, may explain higher participant attachment rates. Methods: Thus, the main objective of this feasibility study is to describe a newly established group therapy program incorporating interventions from martial arts training with its physical and philosophical parts including mindfulness and breath work. Results: During the 14-month study period from April 2021 to May 2022, a Budo group therapy was used by 215 individual persons with a total of 725 group therapy participations. Retention in the program was good across all settings and very good for persons who participated as outpatients. The mean age of the participants was 33.5 years with a range from 14 to 69 years of age, and about 41% of the participants were female. The therapy program was able to address patients over the whole spectrum of psychiatric diagnoses. Satisfaction and motivation were uniformly self-reported as very good. Patients self-reported improved mental and physical health after participating in a Budo session compared to pre-session. Discussion: Budo group therapy thus can be seen as a feasible, well-accepted and promising new transdiagnostic treatment approach, combining physical activation with resilience enhancement. With minimal contraindications, a broad spectrum of individuals seeking mental health support can engage in this group therapy.

The association between the admission to wards with open- vs. closed-door policy and the use of coercive measures.

Introduction: Psychiatric treatment on a ward with open-door policy is associated with reduced numbers of coercive measures. The effect of the door policy of previous stays, however, has not been investigated. Methods: The data set consisted of 22,172 stays by adult inpatients in a psychiatric university hospital between 2010 and 2019. Pairs of consecutive stays were built. The outcome variable was the occurrence of coercive measures during the second stay. Results: Compared to treatments on wards with a closed-door policy at both stays, treatments on wards with an open-door policy at the second stay had smaller odds for coercive measures (OR ranging between 0.09 and 0.33, p < 0.01). In addition, coercive measures were more frequent in treatment histories where patients previously treated on a closed ward were admitted to a ward with an open-door policy and subsequently transferred to a ward with a closed-door policy at the second stay (OR=2.97, p = 0.046). Discussion: Treatment under open-door policy is associated with fewer coercive measures, even in patients with previous experience of closed-door settings. The group of patients who were admitted to a ward with an open-door, then transmitted to a ward with a closed-door policy seem to be prone to experience coercive measures. Clinical strategies to keep these patients in treatment in an open-door setting could further reduce coercive measures.

Therapeutic leave and direct inpatient healthcare costs in inpatients with mental illness.

AIMS: Balancing the economic costs related to mental illness is a pressing matter globally. Scarce monetary and staff resources impose an ongoing challenge. Therapeutic leaves (TL) are an established clinical tool in psychiatry possibly improving therapy outcome and potentially lowering direct mental healthcare costs in the long term. We thus examined the association between TL and direct inpatient healthcare costs. METHODS: We analyzed the association between the number of TL and direct inpatient healthcare costs in a sample of 3151 inpatients, using a tweedie multiple regression model, including eleven confounders. Using multiple linear (bootstrap) and logistic regression models we assessed the robustness of our results. RESULTS: The tweedie model showed that the number of TL was associated with lower costs following the initial inpatient stay (B = -.141, CI 95% = [-0.225, -.057], p < 0.001). Results of the multiple linear and the logistic regression models matched those of the tweedie model. CONCLUSION: Our findings suggest a link between TL and direct inpatient healthcare costs. TL might lower direct inpatient healthcare costs. In the future RCTs might examine whether an increased utilization of TL leads to a reduction of outpatient treatment costs and evaluate the association of TL with outpatient treatment costs and indirect costs. The systematic use of TL during inpatient treatment could reduce healthcare costs following the initial inpatient stay which is highly relevant due to global rise of mental illness and the associated financial pressure on healthcare systems.

General and Case-Specific Approval of Coercion in Psychiatry in the Public Opinion.

BACKGROUND: Psychiatric patients are subjected to considerable stigmatization, in particular, because they are considered aggressive, uncontrollable, and dangerous. This stigmatization might influence the approval of coercive measures in psychiatry by the public and healthcare professionals and might have an influence on the clinical practice of coercive measures. We examined whether the general approval of coercive measures for psychiatric patients with dangerous behaviors differs from case-specific approval. METHOD: We conducted a representative survey of the general population (n = 2207) in the canton of Basel-Stadt, Switzerland. In total, 1107 participants assessed a case vignette depicting a fictitious character with a mental illness and indicated whether they would accept coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for the person in the vignette. It was explicitly stated that within the last month, the fictitious character displayed no dangerous behavior (Vignette ND) or dangerous behavior (Vignette D). Another 1100 participants were asked whether they would approve coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for psychiatric patients with dangerous behavior in general (General D), i.e., without having received or referring to a specific case vignette. FINDINGS: The logistic regression model containing all variables explained 45% of the variance in approval of any type of coercive measures. Assessment of case vignettes without dangerous behavior (Vignette ND) was associated with significantly reduced approval of coercive measures compared to assessment of a case vignette with dangerousness (Vignette D), while approval for coercive measures in a person with mental health disorder with dangerous behavior in general (General D) was significantly higher than for the case vignette with dangerousness. CONCLUSIONS: The general approval of coercive measures for people with mental disorders seems to differ depending on if the respondents are asked to give a general assessment or to examine a specific and detailed clinical case vignette, indicating an increased role of stigmatization when asking about generalized assessments. This may contribute to diverging findings on the acceptance of coercive measures in the literature and should be considered when designing future studies.

Compulsory psychiatric admissions in the canton of Basel-Stadt between September 2013 and April 2022: Analysis of the cantonal database of the Health Department of Basel-Stadt.

BACKGROUND: According to federal and cantonal law, persons with an acute mental illness can be admitted to a psychiatric hospital or another suitable institution against their will, when other therapeutic options are not available or have been exhausted. In the canton of Basel-Stadt, this is the responsibility of public health officers employed by the division of Social Medicine of the cantonal Health Department. AIMS: This study aims to elucidate which factors influence the decision-making of public health officers regarding compulsory admissions over the period from September 2013 to April 2022 in the canton of Basel-Stadt. METHOD: Leveraging comprehensive clinical data from the health department of the canton Basel-Stadt (N = 5,'550), we estimated a mixed effects logistic regression model to identify factors contributing to the decision of public-health officers to compulsorily admit patients, while controlling for potential clustering effects among public health officers. RESULTS: The risk for compulsory admissions was most strongly predicted by the presence of potential self-harm. In comparison, while being a strong predictor, potential harm to others played a considerably lesser role. Furthermore, psychiatric syndrome, previous compulsory admissions, and the specific context of evaluation were significant predictors. Finally, we found no meaningful personal bias among public health officers. CONCLUSION: The results suggest that public health officers' decision-making regarding compulsory admissions focuses on preventing self-harm and, to a lesser degree, harm to others. This indicates that such measures are only used as a measure of last resort, which is in line with current evidence regarding the detrimental effects of compulsory measures on treatment outcomes in psychiatry. Our findings suggest that all relevant stakeholders, including the police, share this perspective. Decision-making regarding compulsory admissions was mostly free of personal biases, suggesting adherence to shared professional standards by public health officers.

Meaning Analysis and Alienation: A Method of Immanent Critique in Acute Psychiatry.

In acute psychiatry, where people with severe mental disorders are frequently treated, there can be contradictions between concepts of illness among, e.g., patients and healthcare professionals, and also between medical and legal aspects. These contradictions do not manifest themselves openly but are immanent in the social practices of the treatment teams as contradictions between the social level and the individual level. They can lead to alienation, which may be reflected in poorer quality of treatment, such as the more frequent use of coercive measures or poorer adherence to therapy in patients. In the normal daily routine of a clinic, these contradictions are mostly hidden by hierarchical structures or by unbalanced concepts of psychiatric illness, or external critique is used to try to solve these contradictions. However, another way of dealing with these contradictions could be to analyze the potential and causes for alienation through systematic analysis and transformation of the whole system of a psychiatric ward to reduce the level of contradiction within it. The aim of this work is to use the concept of meaning elaborated by Luhmann to identify and recognize alienation potentials as concretely as possible and thus make them accessible to immanent critique. Meaning in Luhmann's use of the term serves to reduce complexity in a social context and always opens up consequential possibilities for action. Consequential limited possibilities at the level of action in a rigid social system (which psychiatric wards can be) can-at an individual level-lead to people subordinating themselves to the rigid system to an excessive degree and thus alienating themselves from the system. Thus, a rigid system with a narrowing of consequential possibilities excludes meaningful consequential possibilities. This leads to alienating contradictions and to possibilities of world appropriation being missed. The aim of the current analysis is not to make a general critique of psychiatry but to improve the theoretical basis to better understand the problem of alienation in acute psychiatry as a symptom of system-immanent contradictions and thus open up the possibility of transforming systems, e.g., psychiatric acute care units, by means of immanent critique.

Physician assisted-dying in mentally and somatically ill individuals in Switzerland: Protocol for survey-based study.

Background: Article 115 of the Swiss Penal Code (StGB) permits physician-assisted dying (PAD), provided it is not performed for "selfish reasons," and thus, occupies a special role in international comparison. However, the Swiss federal law does not regulate who exactly is entitled to access PAD, and there is no universal agreement in the concerned professional societies. Additional uncertainty arises when assessing the wish for PAD of a mentally ill person compared to a somatically ill person. Objectives: This study aims to contribute to the discussion of PAD among the mentally ill and to provide insight into the current situation in Switzerland. Methods: This is a monocentric prospective observational survey-based study. We will conduct an exploratory online/telephone survey about PAD in somatic vs. mental illness in Switzerland. The survey sample will comprise 10,000 Swiss residents of the general population from all three language regions (German, Italian, and French) as well as 10,000 medical professionals working in the seven states ("cantons") of Basel-Stadt, Basel-Landschaft, Aargau, Lucerne, Graubünden, Ticino, and Vaud. Opinions on PAD in mentally and somatically ill patients will be assessed using 48 different case vignettes. Each participant will be randomly assigned a somatic terminal, a somatic non-terminal, and a mental non-terminal case vignette. Furthermore, the attitude toward the ethical guidelines of the Swiss Medical Association of 2004, 2018, and 2022, as well as the stigmatization of mentally ill people will be assessed. Discussion: Physician-assisted dying in mentally ill persons is a highly relevant yet controversial topic. On the one hand, mentally ill persons must not be discriminated against in their desire for PAD compared to somatically ill persons while at the same time, their vulnerability must be considered. On the other hand, treating physicians must be protected in their ethical integrity and need security when judging PAD requests. Despite its relevance, data on PAD in the mentally ill is sparse. To regulate PAD for the mentally ill, it is therefore important for Switzerland-but also internationally-to gain more insight into the ongoing debate. Clinical trial registration: ClinicalTrials.gov, identifier: NCT05492461.

Personality, self-esteem, familiarity, and mental health stigmatization: a cross-sectional vignette-based study.

There has been little research exploring the relationship between personality traits, self-esteem, and stigmatizing attitudes toward those with mental disorders. Furthermore, the mechanisms through which the beholder's personality influence mental illness stigma have not been tested. The aim of this study is to examine the relationship between Big Five personality traits, self-esteem, familiarity, being a healthcare professional, and stigmatization. Moreover, this study aims to explore the mediating effect of perceived dangerousness on the relationship between personality traits and desire for social distance. We conducted a vignette-based representative population survey (N = 2207) in the canton of Basel-Stadt, Switzerland. Multiple regression analyses were employed to examine the associations between personality traits, self-esteem, familiarity, and being a healthcare professional with the desire for social distance and perceived dangerousness. The mediation analyses were performed using the PROCESS macro by Hayes. Analyses showed associations between personality traits and stigmatization towards mental illness. Those who scored higher on openness to experience (ß = - 0.13, p < 0.001), (ß = - 0.14, p < 0.001), and those who scored higher on agreeableness (ß = - 0.15, p < 0.001), (ß = - 0.12, p < 0.001) showed a lower desire for social distance and lower perceived dangerousness, respectively. Neuroticism (ß = - 0.06, p = 0.012) was inversely associated with perceived dangerousness. Additionally, high self-esteem was associated with increased stigmatization. Personal contact or familiarity with people having mental disorders was associated with decreased stigmatization. Contrarily, healthcare professionals showed higher perceived dangerousness (ß = 0.04, p = 0.040). Finally, perceived dangerousness partially mediated the association between openness to experience (indirect effect = -  .57, 95% CI [- .71, - 0.43]) as well as agreeableness (indirect effect = - 0.57, 95% CI [- 0.74, - 0.39]) and desire for social distance. Although the explained variance in all analyses is < 10%, the current findings highlight the role of personality traits and self-esteem in areas of stigma. Therefore, future stigma research and anti-stigma campaigns should take individual differences into consideration. Moreover, the current study suggests that perceived dangerousness mediates the relationship between personality traits and desire for social distance. Further studies are needed to explore the underlying mechanisms of such relationship. Finally, our results once more underline the necessity of increasing familiarity with mentally ill people and of improving the attitude of healthcare professionals towards persons with mental disorders.

The relationship between psychological characteristics of patients and their utilization of psychiatric inpatient treatment: A cross-sectional study, using machine learning.

High utilizers (HU) are patients with an above-average use of psychiatric inpatient treatment. A precise characterization of this patient group is important when tailoring specific treatment approaches for them. While the current literature reports evidence of sociodemographic, and socio-clinical characteristics of HU, knowledge regarding their psychological characteristics is sparse. This study aimed to investigate the association between patients' psychological characteristics and their utilization of psychiatric inpatient treatment. Patients from the University Psychiatric Clinics (UPK) Basel diagnosed with schizophrenia spectrum or bipolar affective disorders participated in a survey at the end of their inpatient treatment stay. The survey included assessments of psychological characteristics such as quality of life, self-esteem, self-stigma, subjective experience and meaning of psychoses, insight into the disease, and patients' utilization of psychiatric inpatient treatment in the last 30 months. The outcome variables were two indicators of utilization of psychiatric inpatient treatment, viz. "utilization pattern" (defined as HU vs. Non-HU [NHU]) and "length of stay" (number of inpatient treatment days in the last 30 months). Statistical analyses included multiple regression models, the least absolute shrinkage and selection operator (lasso) method, and the random forest model. We included 112 inpatients, of which 50 were classified as HU and 62 as NHU. The low performance of all statistical models used after cross-validation suggests that none of the estimated psychological variables showed predictive accuracy and hence clinical relevance regarding these two outcomes. Results indicate no link between psychological characteristics and inpatient treatment utilization in patients diagnosed with schizophrenia spectrum or bipolar affective disorders. Thus, in this study, the examined psychological variables do not seem to play an important role in patients' use of psychiatric inpatient treatment; this highlights the need for additional research to further examine underlying mechanisms of high utilization of psychiatric inpatient treatment.

Corrigendum: Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization.

[This corrects the article DOI: 10.3389/fpsyt.2021.819573.].

Implementing Home Office Work at a Large Psychiatric University Hospital in Switzerland During the COVID-19 Pandemic: Field Report.

BACKGROUND: During the COVID-19 pandemic in 2020, psychiatric hospitals all over the world had to adapt their services to the prevailing governmental regulations. As a consequence, home office use and telepsychiatry boomed. OBJECTIVE: The purpose of this study was to evaluate the potential of home office use, its adoption, and the association of home office use with employees' mental health in a large psychiatric university hospital in Switzerland. METHODS: We obtained and analyzed home office implementation and use data from the psychiatric university hospital's information technology services. We also conducted a cross-sectional web-based survey to assess the employees' attitudes toward the clinic's crisis management during the COVID-19 pandemic in early 2020. Part of this web-based survey consisted of questions about home office use between March and June 2020, attitudes toward home office implementation, and mental health. Three mental health measures assessed depressive symptoms (Patient Health Questionnaire [PHQ]-2), anxiety (General Anxiety Disorder [GAD]-2), and stress factors (stress module of the PHQ-D); a cut-off score ≥3 was used for the PHQ-2 and GAD-2. RESULTS: Of the 200 participating employees, 69 reported that they had worked from home at least partially (34.5%). Home office use differed significantly across professional groups (χ162=72.72, P≤.001, n=200). Employees experienced neither depressive symptoms (mean 0.76, SD 1.14) nor anxiety (mean 0.70, SD 1.03). The employees reported minor psychosocial stressors (mean 2.83, SD 2.92). The number of reported stress factors varied significantly across groups with different levels of home office use (χ42=9.72, P=.04). CONCLUSIONS: In general, home office implementation appears to be feasible for large psychiatric hospitals, however, it is not equally feasible for all professional groups. Professional groups that require personal contact with patients and technical or manual tasks must work onsite. Further evaluation of home office use in psychiatric hospitals up to the development of clinics that function merely online will follow in future research. The situation created by the COVID-19 pandemic served as a stepping stone to promote home office use and should be used to improve employees' work-life balance, to save employers costs and foster other benefits.

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization.

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion. Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization. Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization. Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval. Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Opening the Doors of a Substance Use Disorder Ward-Benefits and Challenges From a Consumer Perspective.

Open doors in psychiatry have been a subject of controversy in recent years. While some studies postulate the clinical necessity of closed doors, others challenge the theoretical advantages of this setting, mention numerous drawbacks of closed wards, and focus on the advantages of open-door settings. With regard to patients diagnosed with substance use disorders (SUD), other standards may apply. Very little research has been done on this topic. Some studies adopted a consumer perspective (i.e. asking involved parties about their experience of the door status). To the authors' knowledge, no study has so far addressed the ideal setting for the treatment of SUD. With our data from the opening of a specialized SUD ward, we take one step to closing this knowledge gap. Applying a qualitative design, we asked patients and health care professionals (HCP) to report changes following the opening of the ward. The results are mainly in line with the literature on the general psychiatric population. The newly introduced open-door setting was mostly perceived as positive, but some disadvantages were mentioned (e.g. less protection of patients, less control over who enters/leaves the ward, the theoretically increased risk of patients absconding). Moreover, HCP (but not patients) mentioned potentially increased substance use on the ward as an additional disadvantage that could arise. Opening a previously closed ward was generally perceived as a positive and progressive decision. These findings support the trend towards an overall open-door policy in psychiatry.

Compulsory Admission to Psychiatric Wards-Who Is Admitted, and Who Appeals Against Admission?

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with "involuntary admission" and "appeal against compulsory admission order." Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.

Nonadherence with ambulatory saliva sampling is associated with biased salivary testosterone estimates.

OBJECTIVE: Nonadherence with scheduled saliva sampling, as encountered in ambulatory settings, can bias the estimation of salivary cortisol concentrations. This study is the first to estimate if such nonadherence is also associated with biased salivary testosterone concentration estimates. METHODS: Using a standard ambulatory saliva-sampling protocol, we instructed pregnant women to collect saliva samples on two consecutive days at awakening, 1100h, 1500h, 2000h, and 2200h. We estimated testosterone concentrations in the saliva samples and participants' actual sampling times with an electronic medication event-monitoring system. We classified a saliva sample as adherent if it was sampled within a specific time window relative to its scheduled sampling time. We used a mixed-model analysis to distinguish between trait (number of adherent saliva samples per participant) and state (adherence status of a specific sample) adherence. RESULTS: We included 60 pregnant women in this study. Seventy-five percent (448 of 600) of the scheduled samples indicated adherence with the sampling schedule. Participants' trait adherence was associated with their diurnal profiles of salivary testosterone estimates; that is, adherent participants had higher salivary testosterone estimates compared with nonadherent participants, F(1,58)=5.41, p=0.023, Cohen's d=0.67. The state adherence of a sample was associated with the salivary testosterone estimate of the related sample, F(1,469)=4.48, p=0.035, Cohen's d=0.20, with delayed sampling associated with lower salivary testosterone estimates. CONCLUSIONS: The results suggest that common ambulatory nonadherence with scheduled saliva sampling is associated with biased salivary testosterone estimates. They will inform further studies estimating salivary testosterone with ambulatory saliva-sampling designs and highlight the relevance of strategies to improve or confirm adherence, beyond routinely used instructions.

Improving ambulatory saliva-sampling compliance in pregnant women: a randomized controlled study.

OBJECTIVE: Noncompliance with scheduled ambulatory saliva sampling is common and has been associated with biased cortisol estimates in nonpregnant subjects. This study is the first to investigate in pregnant women strategies to improve ambulatory saliva-sampling compliance, and the association between sampling noncompliance and saliva cortisol estimates. METHODS: We instructed 64 pregnant women to collect eight scheduled saliva samples on two consecutive days each. Objective compliance with scheduled sampling times was assessed with a Medication Event Monitoring System and self-reported compliance with a paper-and-pencil diary. In a randomized controlled study, we estimated whether a disclosure intervention (informing women about objective compliance monitoring) and a reminder intervention (use of acoustical reminders) improved compliance. A mixed model analysis was used to estimate associations between women's objective compliance and their diurnal cortisol profiles, and between deviation from scheduled sampling and the cortisol concentration measured in the related sample. RESULTS: Self-reported compliance with a saliva-sampling protocol was 91%, and objective compliance was 70%. The disclosure intervention was associated with improved objective compliance (informed: 81%, noninformed: 60%), F(1,60)  = 17.64, p<0.001, but not the reminder intervention (reminders: 68%, without reminders: 72%), F(1,60) = 0.78, p = 0.379. Furthermore, a woman's increased objective compliance was associated with a higher diurnal cortisol profile, F(2,64)  = 8.22, p<0.001. Altered cortisol levels were observed in less objective compliant samples, F(1,705)  = 7.38, p = 0.007, with delayed sampling associated with lower cortisol levels. CONCLUSIONS: The results suggest that in pregnant women, objective noncompliance with scheduled ambulatory saliva sampling is common and is associated with biased cortisol estimates. To improve sampling compliance, results suggest informing women about objective compliance monitoring but discourage use of acoustical reminders.