Non-coercive techniques for the management of crises in mental health settings in Germany-a narrative review.

Coercion is common in mental health care settings in Germany. At the same time, considerable efforts are undertaken to reduce and ultimately abolish coercive interventions. Need adapted treatment, open door policies, and moving away from the biomedical model of mental illness can contribute to non-coercive care. WHO's QualityRights Training can be used to advance knowledge about and adherence to human rights standards in institutions, and to transform institutions to a non-coercive approach. Advance care decisions can make sure that will and preferences prevail in situations when capacity is questioned. However, a radical overhaul of legislation would be required to abolish coercive mental health care in Germany.

The WHO QualityRights initiative: building partnerships among psychiatrists, people with lived experience and other key stakeholders to improve the quality of mental healthcare.

Psychiatrists have an essential role to play in promoting human rights in mental healthcare. The World Health Organization's QualityRights initiative, in partnership with different stakeholders, is improving the quality of psychiatric care in different countries.

[Open-door psychiatry and community mental health work]. / Offene Psychiatrie und gemeindepsychiatrische Arbeit.

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

[Inpatient Mental Health Care without Mechanical Restraint, Seclusion or Compulsory Medication]. / Auf Fixierungen kann in der klinischen Praxis verzichtet werden ­ ohne dass auf Zwangsmedikation oder Isolierungen zurückgegriffen wird.

Mechanical restraint is a common occurance in Germany's mental health care facilities; less common though not unusual are seclusion and compulsory medication. The authors describe a model to calculate additional resources required to provide mental health care without any of these forms of coercive measures. An analysis of actual clinical situations that led to mechanical restraint provides information of the 1:1, 2:1 or 3:1 intensive support necessary to cope with crises in inpatient mental health care. The additional resources required to provide inpatient mental health care without mechanical restraint, seclusion or compulsory medication would be at 4 % of the annual hospital budget. A national shortage of skilled nursing staff appears to be a limiting factor in moving towards a human-rights based mental health care.

Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study.

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

Scenarios for the future of mental health care: a social perspective.

Social values and concepts have played a central role in the history of mental health care. They have driven major reforms and guided the development of various treatment models. Although social values and concepts have been important for mental health care in the past, this Personal View addresses what their role might be in the future. We (DG, PH, and SP) did a survey of professional stakeholders and then used a scenario planning technique in an international expert workshop to address this question. The workshop developed four distinct but not mutually exclusive scenarios in which the social aspect is central: mental health care will be patient controlled; it will target people's social context to improve their mental health; it will become virtual; and access to care will be regulated on the basis of social disadvantage. These scenarios are not intended as fixed depictions of what will happen. They could, however, be useful in guiding further debate, research, and innovation.

[What is a "Considerable Damage to One's Health" in the Sense of German Guardianship Law?] / Was ist ein "erheblicher gesundheitlicher Schaden" im Sinne des § 1906 BGB?

The term of a "considerable damage to one's health" is central in German guardianship law with respect to judge's decisions on involuntary commitment and coercive treatment. A legal definition has not been provided, and up to now no explanations from the part of medicine have been available what a "considerable damage to one's health" is in the case of mental illness and how it can be determined. A consensus paper of the German Association of Psychiatry and Psychotherapy (DGPPN) explains four possible scenarios of manifestation of such kind of damage, corresponding to somatic illnesses: evidence of structural brain lesions (rare), subjective suffering (sufficient, but not necessary), impairment of functioning in important areas of life, and severe impairment of social participation (e. g. by dangerous behaviour against others). This view corresponds with the WHO's bio-psycho-social concept of health.

Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study.

BACKGROUND: Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes. METHODS: In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data. FINDINGS: In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p<0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63). INTERPRETATION: Locked doors might not be able to prevent suicide and absconding. FUNDING: None.

[Long-Term Tendencies in the Use of Seclusion and Restraint in Five Psychiatric Hospitals in Germany]. / Langzeittendenzen in der Anwendung von Fixierungen und Isolierungen in fünf psychiatrischen Kliniken.

OBJECTIVE: To evaluate multiple efforts of the last decade to reduce the use of coercive measures in psychiatric hospitals. METHOD: A working group for the prevention of violence and coercion in psychiatric hospitals has compared several outcome indicators since the year 2000 and repeatedly has provided evidence-based recommendations for clinical practice. We present data from those 5 hospitals with complete data sets recorded by an identical method over 9 years. RESULTS: The percentage of admissions exposed to any kind of coercive measure decreased from 8.2 % in 2004 to 6.2 % in 2012. The standard deviation of outcomes between hospitals decreased by 20 %. Changes in the duration of measures were mostly insignificant. CONCLUSIONS: Measures to reduce the use of coercion are effective in clinical practice, but to less extent than in clinical studies. A ban on all forced and non-consensual medical interventions, as being stipulated by the UN Special Rapporteur on Torture, has so far not materialized in the participating psychiatric institutions.

Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial.

BACKGROUND: A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder. METHODS: Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care. RESULTS: Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89-0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI -603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76-0.80, p < 0.001). CONCLUSIONS: DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.

[Fatal aspiration following polydipsia in schizophrenia]. / Polydipsie bei paranoider schizophrenie mit tödlichem ausgang.

OBJECTIVE AND METHODS: Polydipsia with hyponatraemia commonly occurs with chronic psychosis and is associated with a reduced life expectancy for individuals diagnosed with schizophrenia. We describe a 51 years old man who presented with polydipsia during a relapse of paranoid schizophrenia. While treated with Clozapine, and despite regular observation and daily control of creatinine and electrolytes, the man suddenly collapsed and died after drinking huge amounts of water. No sedation from psychotropic medication or drugs and alcohol was present in this case. Sodium levels on the day of death and the day before were within normal range. A post-mortem revealed aspiration of water and gastric content as the cause of asphyxiation and death. A literature search in Medline and Embase did not yield a description of a similar case. RESULTS AND CONCLUSIONS: This case highlights the risk of aspiration associated with polydipsia in chronic schizophrenia. Daily control of electrolytes to identify hyponatremia and regular observation are recommended but may not be sufficient to prevent sudden death from drinking huge amounts of water.

Mental healthcare reform in the Republic of Moldova.

Mental healthcare in the countries of the former Soviet Union faces considerable challenges as result of the socio-economic transition. In this article we look at the changes in the Republic of Moldova. We identify weaknesses and strengths in the traditional hospital-based system and describe examples of the successful implementation of modern mental health services. We follow the reform process in mental health law and service provision in view of the recommendations from the Council of Europe (2004) for the protection of human rights of persons with mental disorder. Some of the information in this article was gathered during official visits to mental healthcare institutions in the Republic of Moldova in 2006.

A typology of advance statements in mental health care.

Advance statements documenting mental health service consumers' preferences for treatment during a future mental health crisis or period of incapacity have gained currency in recent years in the United States and some European countries. Several kinds of advance statements have emerged -- some as legal instruments, others as treatment planning methods -- but no formal comparison has been made among them. This article reviews the literature in English and German to develop a comparative typology of advance statements: joint crisis plans, crisis cards, treatment plans, wellness recovery action plans, and psychiatric advance directives (with and without formal facilitation). The features that distinguish them are the extent to which they are legally binding, whether health care providers are involved in their production, and whether an independent facilitator assists in their production. The differing nature of advance statements is related to the diverse models of care upon which they are based and the legislative and service contexts in which they have been developed. However, there is recent convergence between the United Kingdom and the United States with respect to research interventions that facilitate the production of advance statements, as evidence emerges for the effectiveness of facilitated psychiatric advance directives and joint crisis plans. Different types of advance statements can coexist and in some cases may interact in complementary ways. However, the relationship of advance statements to involuntary treatment is more problematic, as is their effective implementation in many mental health service settings.