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Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

  • D. Wasserman (a1) (a2), G. Apter (a3) (a4), C. Baeken (a5) (a6), S. Bailey (a1) (a7), J. Balazs (a8) (a9), C. Bec (a2), P. Bienkowski (a10) (a11), J. Bobes (a12) (a13), M. F. Bravo Ortiz (a14) (a15), H. Brunn (a1) (a16) (a17), Ö. Bôke (a18) (a19), N. Camilleri (a20) (a21), B. Carpiniello (a22) (a23) (a24), J. Chihai (a25) (a26), E. Chkonia (a27) (a28), P. Courtet (a29) (a30) (a31), D. Cozman (a32) (a33), M. David (a3) (a34), G. Dom (a35) (a36), A. Esanu (a25) (a37), P. Falkai (a38) (a39), W. Flannery (a40) (a41), K. Gasparyan (a42) (a43), G. Gerlinger (a38), P. Gorwood (a29) (a44), O. Gudmundsson (a45) (a46), C. Hanon (a1) (a47), A. Heinz (a38) (a48), M. J. Heitor Dos Santos (a49) (a50), A. Hedlund (a51) (a52), F. Ismayilov (a53) (a54), N. Ismayilov (a53) (a55), E. T. Isometsä (a56) (a57), L. Izakova (a58) (a59), A. Kleinberg (a60) (a61), T. Kurimay (a22) (a62), S. Klæbo Reitan (a62) (a63) (a64), D. Lecic-Tosevski (a65) (a66) (a67), A. Lehmets (a60) (a68), N. Lindberg (a56) (a69), K. A. Lundblad (a51) (a70), G. Lynch (a71), C. Maddock (a71), U.F. Malt (a63) (a72), L. Martin (a40) (a73), I. Martynikhin (a74) (a75), N. O. Maruta (a76) (a77), F. Matthys (a5) (a78), R. Mazaliauskiene (a79) (a80), G. Mihajlovic (a65) (a81), A. Mihaljevic Peles (a82) (a83), V. Miklavic (a84) (a85), P. Mohr (a86) (a87), M. Munarriz Ferrandis (a14), M. Musalek (a1) (a88) (a89), N. Neznanov (a74) (a90), G. Ostorharics-Horvath (a8), I. Pajević (a91) (a92), A. Popova (a1) (a93) (a94), P. Pregelj (a84) (a95), E. Prinsen (a96), C. Rados (a97) (a98), A. Roig (a14) (a99), M. Rojnic Kuzman (a82) (a100), J. Samochowiec (a10) (a22) (a101), N. Sartorius (a1) (a102), Y. Savenko (a103), O. Skugarevsky (a104) (a105), E. Slodecki (a71), A. Soghoyan (a42) (a106), D. S. Stone (a2), R. Taylor-East (a20) (a21), E. Terauds (a107) (a108), C. Tsopelas (a66) (a109), C. Tudose (a32) (a110), S. Tyano (a1), P. Vallon (a111), R. J. Van der Gaag (a1) (a112), P. Varandas (a49) (a113), L. Vavrusova (a1) (a58), P. Voloshyn (a76) (a114), J. Wancata (a97) (a115), J. Wise (a1) (a116), Z. Zemishlany (a117), F. Öncü (a18) (a118) and S. Vahip (a22) (a119)...

Abstract

Background.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

Methods.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

Results.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

Conclusions.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

D. Wasserman, E-mail: danuta.wasserman@ki.se

References

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Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

  • D. Wasserman (a1) (a2), G. Apter (a3) (a4), C. Baeken (a5) (a6), S. Bailey (a1) (a7), J. Balazs (a8) (a9), C. Bec (a2), P. Bienkowski (a10) (a11), J. Bobes (a12) (a13), M. F. Bravo Ortiz (a14) (a15), H. Brunn (a1) (a16) (a17), Ö. Bôke (a18) (a19), N. Camilleri (a20) (a21), B. Carpiniello (a22) (a23) (a24), J. Chihai (a25) (a26), E. Chkonia (a27) (a28), P. Courtet (a29) (a30) (a31), D. Cozman (a32) (a33), M. David (a3) (a34), G. Dom (a35) (a36), A. Esanu (a25) (a37), P. Falkai (a38) (a39), W. Flannery (a40) (a41), K. Gasparyan (a42) (a43), G. Gerlinger (a38), P. Gorwood (a29) (a44), O. Gudmundsson (a45) (a46), C. Hanon (a1) (a47), A. Heinz (a38) (a48), M. J. Heitor Dos Santos (a49) (a50), A. Hedlund (a51) (a52), F. Ismayilov (a53) (a54), N. Ismayilov (a53) (a55), E. T. Isometsä (a56) (a57), L. Izakova (a58) (a59), A. Kleinberg (a60) (a61), T. Kurimay (a22) (a62), S. Klæbo Reitan (a62) (a63) (a64), D. Lecic-Tosevski (a65) (a66) (a67), A. Lehmets (a60) (a68), N. Lindberg (a56) (a69), K. A. Lundblad (a51) (a70), G. Lynch (a71), C. Maddock (a71), U.F. Malt (a63) (a72), L. Martin (a40) (a73), I. Martynikhin (a74) (a75), N. O. Maruta (a76) (a77), F. Matthys (a5) (a78), R. Mazaliauskiene (a79) (a80), G. Mihajlovic (a65) (a81), A. Mihaljevic Peles (a82) (a83), V. Miklavic (a84) (a85), P. Mohr (a86) (a87), M. Munarriz Ferrandis (a14), M. Musalek (a1) (a88) (a89), N. Neznanov (a74) (a90), G. Ostorharics-Horvath (a8), I. Pajević (a91) (a92), A. Popova (a1) (a93) (a94), P. Pregelj (a84) (a95), E. Prinsen (a96), C. Rados (a97) (a98), A. Roig (a14) (a99), M. Rojnic Kuzman (a82) (a100), J. Samochowiec (a10) (a22) (a101), N. Sartorius (a1) (a102), Y. Savenko (a103), O. Skugarevsky (a104) (a105), E. Slodecki (a71), A. Soghoyan (a42) (a106), D. S. Stone (a2), R. Taylor-East (a20) (a21), E. Terauds (a107) (a108), C. Tsopelas (a66) (a109), C. Tudose (a32) (a110), S. Tyano (a1), P. Vallon (a111), R. J. Van der Gaag (a1) (a112), P. Varandas (a49) (a113), L. Vavrusova (a1) (a58), P. Voloshyn (a76) (a114), J. Wancata (a97) (a115), J. Wise (a1) (a116), Z. Zemishlany (a117), F. Öncü (a18) (a118) and S. Vahip (a22) (a119)...

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Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

  • D. Wasserman (a1) (a2), G. Apter (a3) (a4), C. Baeken (a5) (a6), S. Bailey (a1) (a7), J. Balazs (a8) (a9), C. Bec (a2), P. Bienkowski (a10) (a11), J. Bobes (a12) (a13), M. F. Bravo Ortiz (a14) (a15), H. Brunn (a1) (a16) (a17), Ö. Bôke (a18) (a19), N. Camilleri (a20) (a21), B. Carpiniello (a22) (a23) (a24), J. Chihai (a25) (a26), E. Chkonia (a27) (a28), P. Courtet (a29) (a30) (a31), D. Cozman (a32) (a33), M. David (a3) (a34), G. Dom (a35) (a36), A. Esanu (a25) (a37), P. Falkai (a38) (a39), W. Flannery (a40) (a41), K. Gasparyan (a42) (a43), G. Gerlinger (a38), P. Gorwood (a29) (a44), O. Gudmundsson (a45) (a46), C. Hanon (a1) (a47), A. Heinz (a38) (a48), M. J. Heitor Dos Santos (a49) (a50), A. Hedlund (a51) (a52), F. Ismayilov (a53) (a54), N. Ismayilov (a53) (a55), E. T. Isometsä (a56) (a57), L. Izakova (a58) (a59), A. Kleinberg (a60) (a61), T. Kurimay (a22) (a62), S. Klæbo Reitan (a62) (a63) (a64), D. Lecic-Tosevski (a65) (a66) (a67), A. Lehmets (a60) (a68), N. Lindberg (a56) (a69), K. A. Lundblad (a51) (a70), G. Lynch (a71), C. Maddock (a71), U.F. Malt (a63) (a72), L. Martin (a40) (a73), I. Martynikhin (a74) (a75), N. O. Maruta (a76) (a77), F. Matthys (a5) (a78), R. Mazaliauskiene (a79) (a80), G. Mihajlovic (a65) (a81), A. Mihaljevic Peles (a82) (a83), V. Miklavic (a84) (a85), P. Mohr (a86) (a87), M. Munarriz Ferrandis (a14), M. Musalek (a1) (a88) (a89), N. Neznanov (a74) (a90), G. Ostorharics-Horvath (a8), I. Pajević (a91) (a92), A. Popova (a1) (a93) (a94), P. Pregelj (a84) (a95), E. Prinsen (a96), C. Rados (a97) (a98), A. Roig (a14) (a99), M. Rojnic Kuzman (a82) (a100), J. Samochowiec (a10) (a22) (a101), N. Sartorius (a1) (a102), Y. Savenko (a103), O. Skugarevsky (a104) (a105), E. Slodecki (a71), A. Soghoyan (a42) (a106), D. S. Stone (a2), R. Taylor-East (a20) (a21), E. Terauds (a107) (a108), C. Tsopelas (a66) (a109), C. Tudose (a32) (a110), S. Tyano (a1), P. Vallon (a111), R. J. Van der Gaag (a1) (a112), P. Varandas (a49) (a113), L. Vavrusova (a1) (a58), P. Voloshyn (a76) (a114), J. Wancata (a97) (a115), J. Wise (a1) (a116), Z. Zemishlany (a117), F. Öncü (a18) (a118) and S. Vahip (a22) (a119)...
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Reduction of Seclusion and Forced Medication by an Open Door Strategy

Lieselotte Mahler, Charité Universitätsmedizin Berlin
Undine E. Lang, Universitäre Psychiatrische Kliniken Basel
Andreas Heinz, Charité Universitätsmedizin Berlin
21 November 2020

We strongly support the discussion and comparison of coercive treatment routines in Europe as they are central to gain evidence on detrimental and often avoidable coercive measures. We would like to suggest a comparison of best practice models to reduce coercion (1).

According to the UN Convention on the Rights of Persons with Disabilities and the German Federal Constitutional Court treatment decisions should, under any cir-cumstances, respect the patient’s will and preferences and compulsory treatment can only take place with the intention of restoring the patients’ capacity to consent (2).

Following this line of thought, complex and comprehensive interventions are neces-sary in order to create a patient-centred and supportive treatment setting reducing coercive measures to a minimum (2). The so-called Weddinger Model (named after an inner city district of Berlin) is a recovery-oriented and participatory treatment con-cept that has been introduced in the Charité University Department of Psychiatry at the St. Hedwig Hospital in Berlin, Germany, which is responsible for this sector of the city (3). Initial evaluations show significantly fewer and shorter seclusions and restraints accompanied by a significant decrease in coercive medication, and indi-cate that the risk for aggression and therefore following coercive measures can be limited almost exclusively to the first 24 hours after admission (3,4). A close thera-peutic relationship, flexible and individualized treatment settings, as well as trans-parent and participatory decision-making processes, create a setting that enables even severely ill patients to take personal responsibility and strengthens their self-efficacy (2, 3).

Within this framework of a multi-professional and participatory psychiatric treatment setting, a guideline for a standardized post-coercion review session was developed (5). The goal is an open exchange about the circumstances that led to the use of coercion and to make decision-making processes of the team traceable. This type of post-coercion review session in a moderated setting including the patient as well as a team member involved in the coercive measure has already been scientifically evaluated in a major project of the German Federal Ministry of Health (5). The standardized post-coercion review session shows a positive effect on the therapeu-tic relationship and reduces symptoms of posttraumatic stress disorder (5). Further-more, a reduction of future coercive measures is to be expected, however, the sci-entific evaluation is still pending.

In the discussion about modern psychiatry, the question of locked ward doors inevi-tably arises. Psychiatric inpatient treatment is increasingly being performed in set-tings with locked doors and the legal status is not the crucial factor for admission on a locked ward (6). However, locking policies are mainly determined by local tradi-tion and highly variable between countries, hospitals and wards (6).

On the organizational level, an open door strategy demands patients admission to be personalized with the availability of psychotherapeutic and evidence-based treatment for persons who are involuntarily admitted and severely ill. In this context the therapeutic staff-patient contact can replace closed doors policies (6,7). These measures which are necessary to enable an open door strategy lead to an increase of patients’ satisfaction, an improved therapeutic atmosphere, a decreased transfer of patients and thus, better continuity in therapeutic relationships and a decrease of coercive measures (6,7). Moreover, appeals against involuntary admissions de-crease (8) as patients may feel less confined and dependent.

Additionally, suicide rates, absconding, and aggression are not increased in open door psychiatric hospitals (9,10). The change to an open door policy has shown the potential to reduce the incidence of safety and coercive measures in studies exam-ining individual wards, and in a large observational data set from 21 German hospi-tals (9,10). In open door settings, the use of a less restrictive alternative is facilitated and the duration of coercive measures is kept to a minimum, therefore, the patient’s rights might be better granted. Consequently, the official statement of the ethics committee of the German Medical Association recommended the reduction of com-pulsory treatment and the reduction of closed wards in psychiatric settings.

In conclusion, it should be noted that a reduction of coercion in psychiatric settings appears promising if legal procedures are combined with multi-professional, pa-tient-centred, and participatory recovery-oriented clinical work. In line with the find-ings described above indicating that modern psychiatric concepts, transparent and participatory debriefing of coercive measures, and open door policies contribute to the reduction of coercion, we recommend initiation of European studies in different cultural and social conditions to assess such models to gain ethical and evidence-based practice examples to utilise in everyday clinical practice.

(750 words)

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Conflict of interest: None declared

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