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To examine whether the pandemic in 2020 caused changes in psychiatric hospital cases, the percentage of patients exposed to coercive interventions, and aggressive incidents. We used the case registry for coercive measures of the State of Baden-Wuerttemberg, comprising case-related data on mechanical restraint, seclusion, physical restraint, and forced medication in each of the State's 31 licensed hospitals treating adults, to compare data from 2019 and 2020. The number of cases in adult psychiatry decreased by 7.6% from 105,782 to 97,761. The percentage of involuntary cases increased from 12.3 to 14.1%, and the absolute number of coercive measures increased by 4.7% from 26,269 to 27,514. The percentage of cases exposed to any kind of coercive measure increased by 24.6% from 6.5 to 8.1%, and the median cumulative duration per affected case increased by 13.1% from 12.2 to 13.8 hrs, where seclusion increased more than mechanical restraint. The percentage of patients with aggressive incidents, collected in 10 hospitals, remained unchanged. While voluntary cases decreased considerably during the pandemic, involuntary cases increased slightly. However, the increased percentage of patients exposed to coercion is not only due to a decreased percentage of voluntary patients, as the duration of coercive measures per case also increased. The changes that indicate deterioration in treatment quality were probably caused by the multitude of measures to manage the pandemic. The focus of attention and internal rules as well have shifted from prevention of coercion to prevention of infection.

In a meta-analysis of international studies, 17% of admitted patients in psychiatric hospitals had exhibited violent behavior toward others. Reported data from studies in Germany were considerably lower until recent years. However, studies examining only single hospitals, as well as the quality of the data itself, have raised questions as to the validity of these findings. Indeed, a debate currently exists as to whether there has, in fact, been an increase of violent incidents in German mental institutions. In a group of 10 hospitals serving about half the population of the Federal State of Baden-Wuerttemberg with 11 million inhabitants, the Staff Observation Aggression Scale-Revised (SOAS-R) was introduced into patients' electronic charts as part of routine documentation. Data recording was strongly supported by staff councils and unions. A completed data set is now available for the year 2019. For one hospital, data are available since 2006. Due to some doubts with respect to fully covering self-directed aggression, we restricted the analysis to aggression toward others and toward objects. In 2019, 17,599 aggressive incidents were recorded in 64,367 admissions (1,660 staying forensic psychiatric inpatients included). 5,084 (7.90%) of the admitted cases showed aggressive behavior toward others. Variation between hospitals was low to modest (SD = 1.50). The mean SOAS-R score was 11.8 (SD between hospitals 1.20%). 23% of the incidents resulted in bodily harm. The percentage of patients showing violent behavior was highest among patients with organic disorders (ICD-10 F0) and lowest among patients with addictive or affective disorders (F1, F3, F4). Forensic psychiatry had the highest proportion of cases with aggressive behavior (20.54%), but the number of incidents per bed was lower than in general adult psychiatry and child and adolescent psychiatry (indicating a lower risk for staff). In the hospital with longer-term recordings available, an increase could be observed since 2010, with considerable variation between years. This is the most robust estimate of the frequency of violent incidents in German psychiatric hospitals thus far. The incidence is about half of what has been reported internationally, probably due to sample selection bias in previous studies and a relatively high number of hospital beds in Germany. Available data suggest an increase of violent incidents over the last ten years; however, it is unclear to which extent this is due to increased reporting.

PurposeThe present study investigates perceived coercion in psychiatric inpatients under prescribed antipsychotic medication without a court order. The objective of this study was to investigate whether and to what extent involuntary and voluntary inpatients feel coerced to take their medication and which factors affect perceived coercion.MethodsVoluntarily and involuntarily admitted patients (55 and 36, respectively) were interviewed about the extent of perceived coercion. In addition, socio-demographic and clinical data were collected. The Admission Experience Scale (aAES) was used to assess perceived coercion concerning medication. To measure insight into illness, attitude towards medication, and symptom severity, we used a questionnaire on insight into illness (FKE-10), the Drug Attitude Inventory (DAI-10), and the Brief Psychiatric Rating Scale (BPRS-24), respectively.ResultsVoluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients. The experience of coercion was not related to socio-demographic or clinical variables nor to the BPRS-24 score, but to insight into illness and attitude towards medication. Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion.ConclusionPerceived coercion related to medication is dependent on insight into illness and experience of previous coercive interventions rather than on the severity of psychopathological symptoms. These findings are very similar to a previous study in a forensic psychiatric sample. Having experience of at least one coercive measure seems to be a decisive aspect of the extent of the patients’ perceived coercion.

Many interventions to reduce the use of seclusion and restraint have been suggested in the last decades. Evidence-based interventions in old age psychiatry are different from those in general psychiatry. A common database for psychiatric hospitals introduced in 2004 allowed to examine the use of seclusion and restraint over 16 years under routine conditions. A registry for coercive measures in the Federal State of Baden-Wuerttemberg has been available since 2015, and comprises all 32 hospitals licensed to admit involuntary patients. A study group had collected data prospectively since 2004 from a subsample of these hospitals. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2004 to 2019 among a total of 1,038,239 admissions. The proportion of cases affected by coercive measures dropped significantly from 28.4 to 10.5% in patients with ICD-10 F0 disorders, while rates in patients with other diagnoses decreased insignificantly from 7.0 to 5.4%. The cumulated duration of coercive measures per affected case also dropped significantly among patients with F0 disorders, while changes in patients with other diagnoses remained insiginficant. The use of coercive measures in patients with organic disorders could be reduced by about 50% in a State of 11 million inhabitants within 15 years, while in contrast no substantial reduction occurred among all other diagnostic groups. Specific interventions to reduce coercive interventions seem to be particularly successful for this patient group.

Objective The aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions. Methods Combined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas. Results There are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries. Conclusions Databases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the use of coercion in patients lacking mental capacity. The committee’s recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols.

Background The aim of the study was to investigate functional impairment and its relationship to illness severity in a sample of patients with a diagnosis of mood or anxiety disorder during inpatient treatment and 1 year after discharge. Methods Two hundred thirty-nine inpatients with primary diagnoses of mood or anxiety disorders were assessed at baseline and at follow-up by a range of validated instruments. Mini-ICF-APP was used for the assessment of functional impairment, BDI-II for the assessment of clinical symptoms and remission. Sample characteristics and measures of impairment at baseline and at follow-up were analysed descriptively. Symptomatically remitted and non-remitted patients were compared with regard to capacity limitations. Results Initially, the sample showed considerable impairment in many capacities, particularly endurance, spontaneous activities, structuring of tasks, competency and flexibility. After 1 year, all capacities significantly improved. The level of impairment was correlated with employment status and severity of clinical symptoms. About 50% of the patients remitted in clinical symptomatology. Retrospectively, the remitted and the unremitted did not differ in functional impairment at baseline but there were considerable differences at follow-up. Conclusions Mini-ICF-APP is a useful instrument to monitor functional status and change in psychiatric samples, complementing the usual focus on symptom reduction.

Background Cognitive dysfunction has been reported in acute psychiatric patients for a long time. The detection of cognitive deficits is crucial both for clinical treatment and for predicting the psychosocial functional level in the further course of the disease. The SCIP is a well-evaluated screening instrument for the examination of cognitive performance in psychiatric patients. We recently integrated the SCIP into our routine admission and discharge assessments on two inpatient wards, and we examined the cognitive profiles of patients with psychotic and affective disorders over the course of their admission. Methods Shortly after admission, and prior to discharge, patients were routinely referred for examination with the SCIP. A total of 529 assessments were completed on admission, and 227 returned for SCIP at the time of discharge. After standardization of the test results against a normative sample, we examined the normalized test values in terms of percentages of pathological cognitive performance based on the total SCIP score, and each of the SCIP subscale scores. We conducted cluster analysis to identify cognitive subgroups within the clinical sample. Results More than 70% of the SCIP results on admission were pathological. At discharge, improvements were observed, especially on tests with attention and speed components. Cluster analysis identified two groups. The cluster with chronic patients showed poorer results at admission, but greater improvement and reached the level of the others at discharge. Conclusions The SCIP appears to have value in routine diagnostic assessments, and in the quantification of improvements in cognitive performance during an inpatient stay. The greatest benefit was observed in chronically ill patients with many previous stays. Trial registration DRKS00019825 (retrospectively registered on 03.12.2019).

Background Psychiatric wards treating involuntarily admitted patients are traditionally locked to prevent absconding. However, on the basis of observational evidence, the necessity for locked units in psychiatric hospitals has increasingly been questioned. Updated Mental Health Laws in several Federal States of Germany legitimate involuntary commitment without generally locked doors. Methods We examined the effects of an open-door policy in a quasi-experimental, prospective design. For the first time, at each of two locations, two identical wards serving as control and intervention could be compared. After a baseline period of three months, one ward at each location started the 12 month intervention period with the implementation of an open-door policy, while the respective control ward, as before, used open doors only facultatively. Primary outcomes were average opening times of the four wards between 8 a.m. and 8 p.m., and the number of involuntary treatment days with the doors open. Secondary outcomes were adverse events including aggressive incidents, absconding, suicide attempts and coercive measures. Results Overall, door-opening times increased significantly at both sites´ intervention wards. The number of adverse events did not increase during intervention period. Frequencies of coercive measures decreased in Friedrichshafen and remained unchanged in Tuebingen. In case of the intervention ward in Friedrichshafen, doors were open in up to 91% of all involuntary treatment days, whereas in the control ward, this was only the case in 67% of all involuntary treatment days ( p  < .001). In case of the intervention ward in Tuebingen, 45% of involuntary treatment days had open doors, compared to 30% in the control ward ( p  < .001). Conclusions It is possible to manage psychiatric wards with open doors without taking inappropriate risks. The extent to which open-door policies are achievable is be dependent on staffing and patient characteristics. Further research is necessary to explore the role of staff attitudes. Trial registration Our trial \"Open Doors by Fair Means\" is retrospectively registered with DRKS ( DRKS00015154 ) on Sept. 10 th 2018 and displayed on the public web site. It is searchable via its meta-registry ( http://apps.who.int/trialsearch/ ).

This study explores the relationship between temperature and the number of aggressive incidents and coercive interventions in the years 2007–2019 in six psychiatric hospitals in the south of the Germany with a total of 1007 beds. The number of aggressive incidents among 164 435 admissions was significantly higher on ‘heat days’ (≥30°C). Furthermore, there was a dose–response relationship between the number of aggressive incidents and increasing temperature. In contrast, the number of coercive interventions was not related to temperature. Considering the background of global warming, rising temperature could result in more frequent aggressive behaviour during in-patient treatment of psychiatric patients.