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SummaryThis study examines whether ward atmosphere, aggressive behavior, and sexual molestation will change after severely disturbed patients have been distributed over several wards determined by their place of residence, instead of concentrating them in locked single-sex wards. Four wards for predominantly psychotic patients were investigated with the German version of the Ward Atmosphere Scale (WAS), and some further questions about the observation of aggressive behavior and sexual molestation once before and twice after internal sectorisation, partial ward opening, and mixing the sexes were asked. Questionnaires (345: 162 staff members, 183 patients) were evaluated. After the structural changes, a significant improvement of ward atmosphere and a reduction of aggressive behavior was found on average in all wards, whereas the impact on sexual molestation remained unclear. Internal sectorisation and sex integration policy, resulting in distributing rather than concentrating severely disturbed patients, have beneficial effects on the social climate of acute wards.

SummaryEpidemiological studies, animal studies, and clinical studies yielded conflicting results concerning a supposed association between increased risk for suicide and violence, and low serum cholesterol levels. Until now, no data has been available for patients with schizophrenia, a disorder with a well-known increased risk of violence. Correlations of serum cholesterol levels at admission and measures of violence were investigated in 103 consecutively admitted patients (44 males, 59 females) of a general psychiatric admission unit. Seventy subjects were diagnosed as suffering from schizophrenia or schizoaffective disorder (ICD-10 F 20, F25), and 33 were diagnosed as suffering from non-psychotic disorders (mainly personality disorders). The level of total exhibited violence during the inpatient treatment period was measured in each patient by the Modified Overt Aggression Scale (MOAS), the Social Dysfunction and Aggression Scale (SDAS), the Staff Observation Aggression Scale (SOAS), and the Violence Scale (VS). Correlations of all violence measures were high (0.75–0.90), but no correlation was found with cholesterol levels, neither for psychotic nor for non-psychotic subjects, neither for men nor for women. The hypothesis of associations of violence and cholesterol levels is not supported by the data.

We report on a 27-year-old woman with previously therapy-resistant obsessive-compulsive disorder and emotionally unstable personality disorder, borderline type, which improved considerably on treatment with clozapine. Previous treatment attempts with paroxetine, clomipramine and various classic and atypical neuroleptics, as well as extensive psychotherapeutic treatment, had proved ineffective.

The ELAN study is a prospective multi centre observational trial on the effectiveness and safety of long-term antipsychotic treatment of people with schizophrenia or schizoaffective disorders with quetiapine in comparison to olanzapine and risperidone under real world treatment conditions.374 adult persons with schizophrenia or schizoaffective disorder prescribed antipsychotic maintenance therapy with quetiapine, olanzapine or risperidone were included at discharge from inpatient treatment. Psychotropic regimen, psychopathological symptoms, general and cognitive functioning, negative side-effects and quality of life were assessed before discharge and at 6, 12, 18 and 24 month follow-up assessments. Intention-to-treat analyses and crossover analyses were conducted by mixed-effects regression models including random linear time effects and time x treatment effects, controlling for baseline differences and additional psychotropic medication and using propensity scores to control for selection bias.As indicated by significant linear time effects the patients improved with regard to psychopathological symptoms, general functioning, subjective quality of life and cognitive processing speed. No change of extrapyramidal motor side-effects, body mass index or waist circumference was obtained. The lack of any significant time x treatment interaction effects indicated no differences in the safety or effectiveness between the three antipsychotics. Nevertheless, the average hospital admission rate of patients receiving olanzapine was lower in comparison to patients receiving quetiapine or risperidone.

IntroductionThe number of beds in forensic psychiatry has increased more than two-fold since 1990 in many countries, mostly due to an increasing number of admitted male patients with psychotic disorders. Most of these patients had previous admissions to general psychiatric units.AimsTo develop a manual for interventions aiming on the prevention of violence based on cognitive behavioural therapy and to test its feasibility.MethodsA manual comprising of 11 different domains of possible interventions was developed. For each patient, the three most relevant domains should be identified. A pilot study was conducted in two psychiatric hospitals. Included patients should receive two sessions as in-patients and consecutively three more as out-patients.ResultsOut of 368 male patients with a diagnosis of a schizophrenic or schizoaffective disorder, 89 (24.2%) had a relevant history of violence. Only 15 (17%) could be recruited for the study, 13 (14.6% of eligible patients) completed the intervention. A considerable proportion refused to participate. The manual was considered to be applicable and relevant. Domains used most frequently were anger management, substance abuse, and medication adherence.ConclusionsThe intervention based on a flexible manual and five sessions was feasible and well accepted by participating patients. However, it turned out to be difficult to recruit this group of patients for an intervention programme and for a study. To conduct a randomised controlled trial, a screening of about 4.000 patients with schizophrenia will be necessary.

Papers p 1093 Two years ago, Munk-Jorgensen initiated a continuing debate about the development of psychiatric care for severely mentally ill people in a paper entitled “Has deinstitutionalization gone too far?”1 He pointed out that the reduction in numbers of psychiatric hospital beds had been accompanied by a continuing increase in the number of forensic psychiatric patients as well as an increase in suicides and readmissions in Denmark. Similarly, Webster et al reported a doubling of the number of forensic patients within the past decade in Canada.2 In the USA, meanwhile, a considerable proportion of severely mentally ill people do not live within the community but are imprisoned3 or homeless.4 The study by Walsh et al in this issue (p 1093) is the …

ObjectivesCollecting prospective data on medication adherence, course of illness, course of treatment, cost effectiveness and quality of life among patients with schizophrenia under the German health system.MethodsThe ELAN study was conducted as a multi-centre, non-interventional observation study. 374 patients with a diagnosis of schizophrenia or schizoaffective disorder (ICD-10 F2) who had been discharged with a medication of quetiapine (N=183), olanzapine (N=91) or risperidone (N=100) were included. Follow-up interviews were conducted after 6,12,18 and 24 months. Applied instruments comprised PANSS, MARS-S, EPS-M, AIMS-S, GAF, ZST and a questionnaire for quality of life.ResultsFor each follow-up, at least 80% of the original sample could be included. After two years, between 39% and 43% of patients continued to take the drug prescribed at discharge. Only between 4% and 7% of patients received no neuroleptic treatment in the last 6 months, respectively. The variety of drugs used increased during the course. Only small differences could be found regarding the defined outcome measures (PANSS, GAF, rehospitalisation rate) and side effects. Changes in medication were mostly due to insufficient efficacy or side effects. Doctor's recommendations had an important influence on patients’ decisions.ConclusionsUnder conditions of routine treatment, medication adherence was much greater and differences between drugs were smaller than reported in randomised controlled clinical trials. Taking into account the low sample selection bias and the small percentage of lost-to-follow-up subjects, this study provides some new insight into routine clinical treatment and outcomes in patients with schizophrenia.

ObjectiveAssessment of patients’ subjective experiences is an important approach of qualitative research in mental health care. It also strengthens the patient-centred view on mentally ill people. Here we focus on the admission to a psychiatric hospital.MethodsSubjective experiences of psychiatric admissions were recorded with a semi-structured interview in 72 fairly representative in-patients. Patients’ satisfaction with treatment was recorded with the ZUF-8 questionnaire. Additionally, 52 in-patients on nine wards were interviewed in focus groups.ResultsFrom the patients’ point of view, the most important aspects of the admission were staff, ward atmosphere and fellow patients. Violence and coercion played only a minor role. In the face-to-face interviews, assessments were generally positive. The results of the patient-satisfaction-questionnaire (ZUF-8) showed a tendency to positive ratings as well. In focus groups, also negative experiences and criticism were reported.ConclusionsPatient's subjective experiences of an admission to a psychiatric hospital could be well assessed. Future surveys should be conducted anonymously to minimize social desirability bias. Focus groups yield an important extension of individual interviews.

We investigated whether the type of antipsychotic treatment has an impact on patients’ subjective quality of life (QoL).In a prospective naturalistic long-term study, 374 patients meeting ICD-10 criteria for schizophrenia or schizoaffective disorder were examined biannually over a two-year period with regards to QoL, psychopathology, social functioning, use of medical and psychosocial services, compliance, side effects and current neuroleptic treatment. QoL was assessed by the Berliner Lebensqualitätsprofil (BeLP), an adaption of the Lancashire Quality of Life Profile. First examination took place two weeks around discharge from a psychiatric clinic. At study entry, all participants were receiving neuroleptic medication of either quetiapine, risperidone or olanzapine. Mixed regression analysis taking into account the unbalanced panel structure of the data and adjusted for selection bias by means of propensity scores were used for data analysis.Overall quality of life improved continuously during the two years observed period regardless of the type of neuroleptic. A small, but significant difference emerged when comparing quetiapine monotherapy treatment with olanzapine monotherapy or with a combination treatment of conventional and atypical antipsychotics. QoL of patients treated with olanzapine was generally worse than that of patients treated with quetiapine but improved slightly more over the course of time. In total time and type of medication explained only small proportions of variance in QoL.Type of neuroleptic had only marginal impact on the subjective QoL of our sample. In order to explain changes in quality of life, research on social and individual factors seems to be more promising.

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The discussion on the use of coercive interventions such as seclusion and restraint accompanies the history of psychiatry from its beginning. It is the oldest and still topical issue of psychiatric institutions. Nowadays, the political growing together of Europe puts questions of common ethical standards on the agenda. The quality of psychiatric care and particularly the use of freedom-restricting coercive measures for mentally ill people are a challenge for modern civilized societies. There is a wide variety in the use of coercive interventions in different European countries in the past and the presence. An important supra-national institution dealing with the issue of coercive interventions in mental health care is the CPT (Committee for the Prevention of Inhumane or degrading Treatment or Punishment). Available data on the use of coercive interventions in different countries were found by literature review. The percentage of admissions exposed to seclusion or restraint varies from zero (Iceland) to 35% (Austria). The median duration of a coercive measure varies from 15 minutes (physical restraint, UK) to 16 days (seclusion, Netherlands). Recently, in several European countries (Finland, Germany, Netherlands, Norway, Switzerland, UK) initiatives have emerged to reduce seclusion and restraint. Obstacles for decreasing coercion in clinical psychiatry are discussed, suggestions for action are given.

Background Self-directed and other violence as well as subsequent coercive interventions occur in a substantial proportion of patients with personality disorders during in-patient treatment. Different strategies may be required to reduce coercive interventions for patients of different diagnostic groups. Methods We specialised one of our acute admission wards in the treatment of personality disorders and adjustment disorders (ICD-10 F4 and F6). Patients are not transferred to other acute wards in case of suicidal or violent behaviour. Violent behaviour and coercive interventions such as seclusion or restraint were recorded in the same way as in the rest of the hospital. We recorded the percentage of subjects affected by diagnostic group and average length of an intervention in the year before and after the change in organisational structure. Results The total number of coercive interventions decreased by 85% both among patients with an F4 and those with an F6 primary diagnosis. Violent behaviours decreased by about 50%, the proportion of involuntary committed patients decreased by 70%. Conclusion The organisational change turned out to be highly effective without any additional cost of personnel or other resources.

Objective:Seclusion and mechanical restraint are widely used for people with serious mental disorders. In most countries one intervention is preferred while the other is considered as inhuman or not sufficiently safe, but identical arguments refer to different preferences. There is a lack of evidence from well-designed studies on compulsory measures in psychiatry.Methods:We conducted a cohort study with optional randomisation comparing seclusion and mechanical restraint among in-patients with acute psychotic disorders. We determined an ethical aspect as main outcome variable: the restriction of human rights from the patients' point of view, measured by a scale developed for this purpose, Human DIgnity during COercive Procedures, DICOP-Score.Results:102 out of 233 patients exposed to coercive measures within 24 months could be included, 26 could be randomised (12 seclusion, 14 restraint). There were no significant differences between the two interventions referring to DICOP-score and duration of the intervention. The burdens most frequently reported were solitude, loss of dignity, and not having understood why the intervention was done. Watching pictures of several alternatives in the interview, including physical restraint and net bed (not available in Germany), most patients preferred seclusion.Conclusions:Both from ethical and safety aspects the results do not yield evidence to prefer or forbid one of the interventions. Clinical decisions should take into account patients' preferences.

The use of coercive measures is an indicator of the quality of psychiatric inpatient treatment. To date, there is no data available to European comparisons on the incidence of such measures. The frequency and duration of mechanical restraint and seclusion on patients with a diagnosis of F2 ICD-10 was analysed in seven German and seven Swiss psychiatric hospitals in the year 2004 using three indicators. Differences between German and Swiss hospitals regarding the indicators were tested for statistical significance using Mann-Whitney-U-tests. 6.6 % (Switzerland) and 10.4 % (Germany) of admissions respectively were affected by mechanical restraint and 17.8 % (Switzerland) and 7.8 % (Germany) respectively by seclusion. Seclusion as well as mechanical restraint per case were applied significantly more often in German than in Swiss hospitals and were of significantly longer duration in Swiss than in German hospitals. The results showed different patterns in the use of seclusion and mechanical restraint across Swiss and German hospitals. For future European research on the use of compulsory measures in routine psychiatric care, there is a need for uniformed definitions, reliable documentation of coercive measures as well as for an identical way of data analysis. To meet these conditions is the first step to achieve European standards for the use of coercive measures.

Background Although the authors of a Cochrane Review on seclusion and mechanical restraint concluded that "there is a surprising and shocking lack of published trials" on coercive interventions in psychiatry, there are only few instruments that can be applied in trials. Furthermore, as main outcome variable safety, psychopathological symptoms, and duration of an intervention cannot meet the demand to indicate subjective suffering and impact relevant to posttraumatic stress syndromes. An instrument used in controlled trials should assess the patients' subjective experiences, needs to be applicable to more than one intervention in order to compare different coercive measures and has to account for the specific psychiatric context. Methods The primary version of the questionnaire comprised 44 items, nine items on restrictions to human rights, developed on a clinical basis, and 35 items on stressors, derived from patients' comments during the pilot phase of the study. An exploratory factor analysis (EFA) using principal axis factoring (PAF) was carried out. The resulting factors were orthogonally rotated via VARIMAX procedure. Items with factor loadings less than .50 were eliminated. The reliability of the subscales was assessed by calculating Cronbach. Results Data of 102 patients was analysed. The analysis yielded six factors which were entitled "Humiliation", "Physical adverse effects", "Separation", "Negative environment", "Fear" and "Coercion". These six factors explained 54.5% of the total variance. Cronbach alpha ranged from .67 to .93, which can be interpreted as a high internal consistency. Convergent and discriminant validity yielded both highly significant results (r = .79, p < .001, resp. r = .38, p < .001). Conclusions The "Coercion Experience Scale" is an instrument to measure the psychological impact during psychiatric coercive interventions. Its psychometric properties showed satisfying reliability and validity. For purposes of research it can be used to compare different coercive interventions. In clinical practice it can be used as a screening instrument for patients who need support after coercive interventions to prevent consequences from traumatic experiences. Further research is needed to identify possible diagnostic, therapeutic or prognostic implications of the total score and the different subscales. Trial registration Current Controlled Trials ISRCTN70589121

Aims.Attempts to reduce high utilisation of mental health inpatient care by targeting the critical time of hospital discharge are rare. In this study, we test the effect of a needs-oriented discharge planning intervention on number and duration of psychiatric inpatient treatment episodes (primary), as well as on outpatient service use, needs, psychopathology, depression and quality of life (secondary).Methods.Four hundred and ninety-one adults with a defined high utilisation of mental health care gave informed consent to participate in a multicentre RCT carried out at five psychiatric hospitals in Germany (Düsseldorf, Greifswald, Regensburg, Ravensburg and Günzburg). Subjects allocated to the intervention group were offered a manualised needs-led discharge planning and monitoring intervention with two intertwined sessions administered at hospital discharge and 3 months thereafter. Outcomes were assessed at four measurement points during a period of 18 months following discharge.Results.Intention-to-treat analyses showed no effect of the intervention on primary or secondary outcomes.Conclusions.Process evaluation pending, the intervention cannot be recommended for implementation in routine care. Other approaches, e.g. team-based community care, might be more beneficial for people with persistent and severe mental illness.