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The article discusses the key aspects of the guidance of the European Psychiatric Association (EPA) on forensic psychiatry and the required actions to implement guidance into clinical practice. The authors pay attention to the discrepancies between the recommendations resulting from the guidance and clinical practice and current systemic solutions. The basic difficulties were discussed in relation to the implementation of the guidelines in the clinical practice in Poland as regards providing services as an expert by psychiatrists and psychologists, risk assessment and management, psychiatric therapy in detention centers, implementation of protection measures in inpatient and outpatient treatment conditions, efficiency of pharmacological and non-pharmacological interventions. We hope that discussing the content of the guidance will help to deepen the knowledge of clinicians in the field of work as court expert witnesses and persons responsible for the implementation of the preventive measure. Based on the clinical experience measures were proposed that enable implementation of the guidance, and thus improvement of the quality of care exercised over the mentally ill criminal offenders.

This article focuses on the preferred disposition for an individual charged with a serious crime against another person, adjudicated incompetent to stand trial and not restorable to competence, whose original criminal charges are dismissed without prejudice, and who is regarded by the state as dangerous to the general public. Three current models used today in California, Oregon, and Ohio are described. All three rely on modifications of various aspects of civil commitment law. We then propose a fourth model based on a modified version of the 1989 American Bar Association (ABA) Criminal Justice Mental Health Standards, in which individuals who are found incompetent to stand trial and not restorable to competence and are considered dangerous would be committed under the same special procedures governing the management and treatment of insanity acquittees., (© 2020 American Academy of Psychiatry and the Law.)

Objective: To assess the impact of a 2015 reform to the Mental Health Act 2007 (NSW) ( MHA ) that was interpreted as requiring a reference to decision-making capacity (DMC) in reports to the NSW Mental Health Review Tribunal (MHRT)., Method: A sample of reports to the MHRT were audited for references to the MHA 's treatment criteria and DMC in periods before and after the reforms, and the frequency of references between the two periods was compared., Results: The frequency of references to DMC did not change significantly after the reforms. (However, references to the 'least restriction' criterion increased markedly between the two periods)., Conclusion: Despite legislative reforms and a supporting education campaign promoting the importance of consideration of DMC, references to DMC did not increase after the reforms.

Objectives: The aim of the study was to prepare the Polish adaptation of the SACS. The scale is a self-assessment tool designed to measure staff attitudes towards direct coercion of psychiatric wards patients., Methods: The sample consisted of 120 adults, staff from 7 psychiatric wards. The SACS is a tool created in Norway by Tonje Husum, comprising of 15 items describing psychiatric healthcare professionals attitudes towards direct coercion. The validation procedure incorporated three basic methods to be applied in the reliability analysis - the comparison of double tests with the same method, the analysis of statistical properties of test items as well as analysis of the relation of test items and subscales with the general test result., Results: After a "think aloud" type pilot study and a language validation, the internal consistency was assessed. The Cronbach's alpha ranged from 0.57 to 0.81 in the subscales, and it was 0.82 for the total score. The best solution obtained in exploratory factor analysis was a three-factor model, almost identical to the original one, confirming the division into three subscales: coercion as offending (critical attitude), as care and security (pragmatic attitude) and as treatment (positive attitude)., Conclusions: The psychometric characteristics of the Polish adaptation of the SACS are similar to those reported in the original version. The results allow to recommend the method for scientific research. However, further analyses are necessary to assess validity and discriminative power in larger settings.

Restraint and seclusion (R&S) measures in psychiatric settings are applied worldwide, despite poor scientific evidence to back up their effectiveness. The medical, ethical and medico-legal implications of coercive interventions are broad-ranging and multifaceted. The review aims to shed a light on the most relevant and meaningful standards that have been laid out by international treaties, supranational institutions (United Nations, Council of Europe, World Health Organization), scientific institutions (American Medical Association, Australian Department of Health), legislative bodies and courts of law. Several court cases are herein expounded upon, with a close focus on meaningful analysis, decisions and conclusions that have laid the groundwork for a different, more restrictive and more clearly defined approach towards R&S imposed upon psychiatric patients. It is reasonable to assume that changing norms, civil rights enforcement, court rulings and new therapeutic options have influenced the use of R&S to such an extent that such measures are among the most strictly regulated in psychiatric practice; health care providers should abide by a strict set of cautionary rules when making the decision to resort to R&S, which must never be put in place as a substitute for patient-centered therapeutic planning. Case law shows that R&S should only be weighed in terms of their effectiveness towards therapeutic goals. Being able to prove that R&S was employed as part of a therapeutic path rather than used to maintain order or to exact punishment may go a long way towards shielding operators against negligence lawsuits and litigation.

Objectives: The UHSA (UHSA) are French psychiatric units for inmates which admit detainees suffering from a psychiatric disorder requiring full-time hospital care. Non-psychiatric pathologies are overrepresented in patients with psychiatric disorders but also in detainees. As a result, patients hospitalized in UHSA are largely exposed to non-psychiatric conditions, and exploring the organization of general medical care for these patients appears very relevant. The aim of this study is to review the general medical care in all French UHSA., Methods: A descriptive study was carried out through a survey of the nine facilities., Results: All UHSA benefit from the intervention of a general practitioner. The physical clinical examination, the biological assessment and the electrocardiogram are systematically performed at the patient's admission in 7, 5 and 9 establishments, respectively. However, the offer of general medical care in UHSA seems disparate and sometimes insufficient. Specialized consultations are regularly requested during hospitalizations, but no establishment benefits from a telemedicine system or specialized consultations on site. The extraction of the patient to the general hospital is therefore systematic when such a consultation is needed. But the number of penitentiary escorts per day is limited. In 6 UHSA, medical extractions are thus regularly canceled by the penitentiary administration, sometimes without a medical opinion. Finally, the patient's regular physician is only contacted in 3 UHSA during hospitalizations., Conclusion: Based on these results, ways of improving the organization of general medical care in UHSA are proposed through four main axes: the structure and general organization; the general medical care; the link with the healthcare partners and the articulation with the penitentiary administration., (Copyright © 2018 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Outpatient civil commitment (OCC) provisions, community treatment orders (CTOs) in Australia and Commonwealth nations, are part of mental health law worldwide. This study considers whether and by what means OCC provides statutorily required "needed-treatment" addressing two aspects of its legal mandate to protect the safety of self (exclusive of deliberate-self-harm) and others., Method: Over a 12.4-year period, records of hospitalized-psychiatric-patients, 11,424 with CTO-assignment and 16,161 without CTO-assignment were linked to police-records. Imminent-safety-threats included perpetrations and victimizations by homicides, rapes, assaults/abductions, and robberies. "Need for treatment" determinations were validated independently by Health of the Nations Scale (HoNOS) severity-score-profiles. Logistic regressions, with propensity-score- adjustment and control for 46 potential confounding-factors, were used to evaluate the association of CTO-assignment with occurrence-risk of perpetrations and victimizations., Results: CTO-assignment was associated with reduced safety-risk: 17% in initial-perpetrations, 11% in initial-victimizations, and 22% for repeat-perpetrations. Each ten-community-treatment-days in interaction with CTO-assignment was associated with a 3.4% reduced-perpetration-risk. CTO-initiated-re-hospitalization was associated with a 13% reduced-initial-perpetration-risk, a 17% reduced-initial-victimization-risk, and a 22% reduced-repeat-victimization-risk. All risk-estimates appear to be the unique contributions of the CTO, CTO-initiated-re-hospitalization, or the provision of ten-community-treatment-days-i.e. after accounting for the influence of prior crimes and victimizations, ethnic-bias, neighborhood disadvantage and other between-group differences in the analysis., Conclusions: CTO assignment's association with reduced criminal-victimization and perpetration-risk, in conjunction with requiring participation in needed-treatment via re-hospitalization and community-service, adds support to the conclusion that OCC is to some extent fulfilling its legal objectives related to protecting safety of self (exclusive of deliberate-self-harm), and others., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data., Methods and Analysis: Four years of data from the Mental Health Services Dataset (MHSDS) will be analysed using multilevel models. Models based on all patients eligible for CTOs will be used to explore variation in their use. A subset of CTO-eligible patients comprising a treatment group (CTO patients) and a matched control group (non-CTO patients) will be used to examine variation in the association between CTO use and study outcomes. Primary outcome will be total time in hospital. Secondary outcomes will include time to first readmission and mortality. Outputs from these models will be used to populate predictive models of healthcare resource use., Ethics and Dissemination: Ethical approval has been granted by the National Health Service Data Access and Advisory Group and Warwick University. To ensure patient confidentiality and to meet data governance requirements, analyses will be carried out in a secure microdata laboratory using de-identified data. Study findings will be disseminated through academic channels and shared with mental health policy-makers and other stakeholders., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication., Methods: The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document., Results: Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times., Conclusion: The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: This study examined whether psychiatric patients assigned to community treatment orders (CTOs), outpatient commitment in Victoria, Australia, have a greater need for treatment to protect their health and safety than patients not assigned to CTOs. It also considered whether such treatment is provided in a least restrictive manner-that is, in a way that contributes to reduced use of psychiatric hospitalization., Methods: The sample included 11,424 patients first placed on a CTO between 2000 and 2010, and 16,161 patients not placed on a CTO. Need for treatment was independently assessed with the Health of the Nation Outcome Scales (HoNOS) at hospital admission and at discharge. Ordinary least-squares and Poisson regressions were used to assess savings in hospital days attributable to CTO placement., Results: HoNOS ratings indicated that at admission and discharge, the CTO cohort's need for treatment exceeded that of the non-CTO cohort, particularly in areas indicating potential dangerous behavior. When analyses adjusted for the propensity to be selected into the CTO cohort and other factors, the mean duration of an inpatient episode was 4.6 days shorter for the CTO cohort than for the non-CTO cohort, and a reduction of 10.4 days per inpatient episode was attributable to each CTO placement., Conclusions: CTO placement may have helped patients with a greater need for treatment to experience shorter hospital stays. Whether the CTO directly enabled the fulfillment of unsought but required treatment needs that protected patient health and safety is a question that needs to be addressed in future research.

This article focuses on the development of a Forensic Mental Health Services Census (FMHSC), proposed to differentiate between five different patient populations institutionalized in state facilities. The FMHSC would comprise patients who are civilly committed for mental illness or sexual dangerousness, those found incompetent to stand trial, those committed after a verdict of not guilty by reason of insanity, and those voluntarily committed. The census would be performed by state mental health authorities for each of these populations within the particular jurisdiction and then would be reported to a national coordinating organization. These data are important because of the large number of persons involved and the significant resources devoted to the management and treatment of each involuntary group. The census is necessary for clinical, research, and policy purposes, to provide more rational management of these populations, both within and across jurisdictions., (© 2017 American Academy of Psychiatry and the Law.)

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

Severely mentally ill jail detainees require an adequate spectrum of mental health services during detainment. For some this means a limited period of treatment in a mental hospital, just as some mentally ill individuals in the community occasionally require hospital treatment. Unfortunately, this appropriate level of treatment is often denied or neglected for jail detainees with adverse consequences for them. Among the reasons for this neglect, may be standards for hospital transfer that are no longer practical and can be easily skirted by policymakers and administrators with little interest in ensuring this level of care for mentally ill jail inmates. A more realistic standard and justification would recognize the need for hospitalization for the mentally disordered detainee who because of psychotic anosognosia refuses appropriate treatment including medications and/or whose severely decompensated condition is worsening or failing to improve despite attempts at treatment in the jail., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective The study aimed to evaluate the applicability of a set of quality indicators to assess models of integrated care for patients with a diagnosis of schizophrenia. We report first values for these indicators in routine care in Germany. Methods The study is based on a cohort of adult patients with schizophrenia insured by one large German statutory health insurance company, which were assessed two times and gave consent to evaluate their routine claims data. The study tried to use 12 basic and 22 quality indicators from claims data. Results It was possible to estimate most structural indicators using available data, but only half of the quality indicators. This means that while assessment of quality indicators is feasible in general, routine claims data needs to be supplemented by additional (primary) data. Four of the calculated quality indicators had clear targets or red-flag values, which were not met in our cohort in all four indicators. None of the patients had an outpatient mental health related contact within one week (target > 90 %). The readmission rate within 30 days (21 %) was twice as high as the proposed red-flag value of 10 %. Similar figures were seen for antipsychotic polypharmacy (25 %, red-flag value > 10 %) and the proportion of patients with compulsory treatment (15 %) exceeded the red-flag value by 5 %. Conclusion The study shows that it is possible to measure quality indicators, but also demonstrates considerable limitations. There is a need to validate indicators in routine care., (© Georg Thieme Verlag KG Stuttgart · New York.)

The author discusses a pragmatic approach to decisions about coercive treatment that is based on four principles from principle-based ethics: respect for autonomy, nonmaleficence, beneficence, and justice. This approach can reconcile psychiatry's perspective with the U.N. Convention on the Rights of Persons With Disabilities. Coercive treatment can be justified only when a patient's capacity to consent is substantially impaired and severe danger to health or life cannot be prevented by less intrusive means. In this case, withholding treatment can violate the principle of justice. In the case of danger to others, social exclusion and loss of freedom can be seen as harming psychosocial health, which can justify coercive treatment. Considerable efforts are required to support patients' informed decisions and avoid allowing others to make substitute decisions. Mental disorder alone without impaired capacity does not justify involuntary treatment, which can be considered a misuse of psychiatry. Involuntary detention without treatment can be justified for short periods for assessment and to offer treatment options.

Background Measuring patient satisfaction in mental health care potentially provides valuable information, but studies in acutely admitted psychosis patients are scarce. Aims The aims were to assess satisfaction among patients acutely admitted with psychosis, to compare satisfaction in voluntarily versus involuntarily admitted patients, and to assess the influence of symptom load and insight. Methods The UKU Consumer Satisfaction Rating Scale (UKU-ConSat) was used. A total of 104 patients completed the UKU-ConSat at discharge/follow-up (between 6-11 weeks after admittance if not discharged earlier) (mean duration of stay 4 weeks), thus corresponding to the end of the acute treatment phase. Results A total of 88.4% had total scores above zero (satisfied). Only three of the eight single items were statistically significantly different among patients admitted voluntarily versus involuntarily, and only the information item score remained significantly different in adjusted analyses. Insight level at admittance, and an increasing level of insight during the acute phase were positively associated with patient satisfaction, whereas levels and changes in positive and negative psychosis symptoms were indirectly related to satisfaction via this process of insight. Conclusions The vast majority of the acutely admitted patients were satisfied with treatment. There were few differences between the involuntarily and voluntarily admitted patient groups, except that the involuntary care group was clearly less satisfied with the information provided. Poor insight had a major negative impact on treatment satisfaction in psychosis. The provision of sufficient and adequate information is an important target for mental health care service improvement.

Objectives: To determine the appropriateness and utility of the certificates issued under the New South Wales Mental Health Act (MHA) and compliance with the requirements of the MHA. The analysis also compares MHA documentation by different groups of health professionals and police., Methods: The MHA certificates associated with 100 consecutive involuntary Emergency Department presentations were audited., Results: Considerable variability exists between professional groups in the level of detail, appropriateness, clinical utility and compliance of MHA certificates. Over 10% of Schedule 1s failed to meet the requirements of the MHA, potentially invalidating the involuntary detention of these patients. Information provided by police was typically superior in informing initial risk assessment and emergency management., Conclusions: A number of patients are presently being detained under incomplete MHA certificates. Educational initiatives that aim to improve awareness of the MHA's requirements, and the potential uses of the information contained in MHA certificates, could encourage professionals to complete these certificates in a more appropriate and clinically useful manner., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

The Forensic Monitoring System (FMS) of the Missouri Department of Mental Health considers and approves consumers committed under not guilty by reason of insanity (NGRI) status for release. The system extends to the outpatient sector to ensure that such persons maintain their mental stability and do not pose a danger to the community. The process of conditional release and the organization of the FMS are outlined, reasons for the low recidivism rate are discussed, and paternalism in requiring treatment compliance as a condition of individual liberty is explored. Case examples illustrate the success, in terms of revocation and rearrest rates, of the Missouri system, which typically sees an annual return to inpatient custody of only 7%, and a still lower rate of criminal recidivism. Cost-effectiveness is discussed in terms of resources spent so that recovered persons with dangerous mental illnesses may live in safety outside of an institution. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Several states currently have enacted laws that allow for civil commitment for individuals diagnosed with severe substance use disorders. Civil commitment or involuntary commitment refers to the legal process by which individuals with mental illness are court-ordered into inpatient and/or outpatient treatment programs. Although initially civil commitment laws were intended for individuals with severe mental illness, these statutes have been extended to cover individuals with severe substance use disorders. Much of the recent legislation allowing for civil commitment of individuals with substance use disorders has come about in response to the heroin epidemic and is designed to provide an alternative to the unrelenting progression of opioid use disorders. Civil commitment also provides an opportunity for individuals with opioid use disorders to make informed decisions regarding ongoing or continued treatment. However, civil commitment also raises concerns regarding the potential violation of 14th Amendment rights, specifically pertaining to abuses of deprivation of liberty or freedom, which are guaranteed under the 14th Amendment to the United States Constitution. This commentary examines these issues while supporting the need for effective brief civil commitment legislation in all states.

Objective: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness., Method: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies., Results: The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion., Conclusion: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs., (© The Author(s) 2016.)

Outcomes for individuals with psychosis remain far from acceptable. Recently, prominent psychiatrists have called for an improved understanding of the impact of social contexts, and how social contexts might influence the development and maintenance of mental health problems. A key social context for individuals with psychosis is the therapeutic relationship. As part of a trial of joint crisis planning in England, this qualitative study aimed to determine the mechanism through which joint crisis planning might affect the therapeutic relationship. Results suggest that routine processes in mental health care are affected by policy and organizational requirements for risk mitigation-aspects that undermine person-centered approaches. In contrast, strong therapeutic relationships are characterized by individualized care and reliable and respectful treatment. The Joint Crisis Plan intervention partially succeeded in reducing contextual influences on routine role enactments, facilitating the demonstration of respect and improving the therapeutic relationship., (© The Author(s) 2015.)

Background: In Norway, doctors may make the decision to refer patients to involuntary psychiatric treatment. This is a difficult decision, as it involves a range of medical, legal and ethical challenges. The decision to commit is presumed based on an independent assessment of the patient and whether a set of medico-legal criteria is met., Aims: To examine characteristics of GPs that admitted patients involuntarily to a psychiatric hospital, and to examine how the GPs assessed this process., Methods: 74 doctors who had referred patients to involuntary admission at one major Norwegian psychiatric hospital participated in semi-structured interviews. The questions posed were in part factual and in part about the participating doctors' assessments and considerations with respect to the involuntary admission of psychiatric patients., Results: Approximately half of the participating doctors worked at the public out-of-hours clinics, while a fifth were the patients' family doctors. Those working at the out-of-hours clinics had less work experience and fewer had prior knowledge of the patients they committed. About half the doctors felt it was difficult to apply the medico-legal criteria. More than half had felt pressured/advised to refer the patient to hospital and about half had felt pressured/advised to do so involuntarily., Conclusions: While doctors considering the commitment of psychiatric patients are presumed to make independent assessments of patients based on medico-legal criteria, this study suggests that many doctors feel pressured to commit., Clinical Implications: The assessment made by doctors who refer patients involuntarily to psychiatric hospital may be influenced by other parts of the health service, the patient's family and the police. Many doctors feel that it is difficult to apply the medico-legal criteria when referring patients involuntarily.

Objective: Despite widespread use internationally, there is no convincing evidence that community treatment orders (CTO) (legal regimes making out-patient treatment compulsory), reduce readmission rates or have wider patient benefit. The primary and secondary outcomes of the Oxford Community Treatment Order Evaluation Trial (OCTET) (hospitalisation) showed no benefit. This article will, first, test the effect of community compulsion on wider clinical and social outcomes and on patients' experiences of services and the use of treatment pressure and second, explore differential effects in different groups of patients., Method: OCTET is a RCT of CTO effectiveness. Three hundred and thirty-six patients were randomised and data for the 333 eligible patients were collected from interviews and medical records at baseline, 6 and 12 months., Results: There was no significant difference at 12 months between the two arms in any of the reported outcomes, except a small difference in patients' view of the effectiveness of treatment pressure, which is unlikely to be clinically meaningful. Two statistically significant interactions were found in the subgroup analysis: symptoms interacted with age and with education, but no pattern was demonstrated., Conclusion: CTOs do not have benefit on any of the tested outcomes, or for any subgroup of patients. Their continued use should be carefully reconsidered., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use or improves clinical outcome and social functioning. To examine the effectiveness of CCT for people with SMI. We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, 2012, and 2013). We obtained all references of identified studies and contacted authors where necessary. All relevant randomized controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another preexisting form of compulsory community treatment such as supervised discharge. We found 3 trials with a total of 752 people. Two trials compared a form of CCT called 'Outpatient Commitment' (OPC) versus standard voluntary care, whereas the third compared Community Treatment Orders with intermittent supervised discharge. CCT was no more likely to result in better service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care. However, people receiving CCT were less likely to be victims of crime than those on voluntary care. Further research is indicated into the effects of different types of CCT as these results are based on 3 relatively small trials., (© The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: For many years, it has been an objective of national public health policy in Norway to reduce the number of compulsory hospitalisations under the Norwegian Mental Health Care Act. Uncertain data quality and inadequate reporting have made it difficult to obtain reliable measurements of hospitalisation trends. We have examined changes in psychiatric emergency admissions and compulsory hospitalisations under the Mental Health Care Act between 2000 and 2010 in the county of Østfold., Material and Method: The material on which the study is based was gathered during two three-month periods – from 1 September to 30 November in the years 2000 and 2010 respectively. We compared emergency admissions in accordance with the national care quality indicator for compulsory hospitalisation in mental health care and examined whether there were changes in the diagnostic composition., Results: The number of emergency admissions per 1,000 population in Østfold increased from a rate of 7.05 in 2000 to 8.86 in 2010 (p < 0.001). There was no significant change in the rate of compulsory hospitalisation during this period, being 2.48 and 2.24 per 1,000 population, respectively. There was a sharp increase in the number of admissions for mental disorders related to alcohol and illicit drug abuse., Interpretation: The study material showed that there was a significant increase in psychiatric emergency admissions between 2000 and 2010. The rate of compulsory hospitalisation, measured among the population over the age of 18, remained unchanged during the period. The Norwegian Board of Health Supervision's care quality indicator for compulsory hospitalisation in mental health care can contribute to providing information and a basis of comparison for the use of compulsory hospitalisation, provided that the data submitted is quality assured. The highest increase was seen in the group of emergency admissions for mental disorders related to alcohol and illicit drug abuse as the principal diagnosis.

To elucidate disparities in clinical and legal documentation for patients admitted involuntarily to a county psychiatric hospital in Texas. The study sample comprised of 89 randomly selected patients, involuntarily hospitalized to our facility in September 2011. All patients met criteria for involuntary detention based on the legal documents filed by admitting psychiatrists. Electronic medical records were reviewed to assess if the clinical documentation from the same date when legal documents were filed; demonstrated criteria for involuntary detention (harm to self, harm to others, inability to care for self). A logistic regression model was used to assess the predictors of concordance between legal and clinical documentation of involuntary detention criteria. Of 89, 6 patients were made voluntary, while two were discharged within 24 h, thus removed from the analysis pool. Of 81, 31(38.2 %) patients lacked sufficient clinical documentation on medical records required for involuntary hospitalization. Patients, for whom detention was justified in clinical notes, were more likely to have single marital status, longer duration of hospitalization and they were more likely to undergo commitment for further inpatient mental health treatment. Our study found that involuntary detention of many patients based on the legal documents filed by admitting psychiatrists was not justified by the clinical documentation. This indicates that appropriate standards are not maintained when completing the medical certificates for involuntary detention. Maintaining appropriate standards may reduce the need for involuntary hospitalization, increase patient autonomy, and reduce resource utilization.

It is strongly recommended to establish mental health laws in every state. By these laws, outpatient services have to be dedicated to avoiding involuntary hospitalisations. Community mental health systems need to be enabled to supply low threshold, immediate care services, if necessary at home (home treatment resp. assertive community treatment). To this end, the role of sociopsychiatric services in service coordination has to be strengthened and comprehensive community mental health organisations have to be established in every city or county. At state level, Councils on Mental Health need to be implemented by state government, mental health reporting, especially on rates of involuntary hospitalisations (by federal as well as state law) has to be established and visiting committees need to extend their scope to all institutions and services that play a role in prevention or aftercare of involuntary hospitalisation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patient dignity in involuntary psychiatric hospital care is a complex yet central phenomenon. Research is needed on the concept of dignity's specific contextual attributes since nurses are responsible for providing dignified care in psychiatric care. The aim was to describe nurses' experiences of violation of patient dignity in clinical caring situations in involuntary psychiatric hospital care. A qualitative design with a hermeneutic approach was used to analyze and interpret data collected from group interviews. Findings reveal seven tentative themes of nurses' experiences of violations of patient dignity: patients not taken seriously, patients ignored, patients uncovered and exposed, patients physically violated, patients becoming the victims of others' superiority, patients being betrayed, and patients being predefined. Understanding the contextual experiences of nurses can shed light on the care of patients in involuntary psychiatric hospital care.

Effective case managers in community mental health are successful at forging a working alliance with recipients. This article explores one key aspect of case management practice, serving involuntary clients, specifically those on outpatient commitment orders. In 19 intensive interviews, a subset of a larger study, case managers shared their perceptions of the utility of outpatient commitment with a focus on how such orders impacted the professional relationship. We argue that the use of advance psychiatric directives and shared decision-making processes can reduce the need for coercive practice.

Objectives: Compulsory community treatment has been shown to reduce preventable deaths from physical disorders-these causes being up to 10 times more common than suicide in psychiatric patients. We investigated whether this was mediated by better access to specialized medical procedures., Method: All patients on compulsory community treatment for over 11 years were compared with matched control subjects using linked administrative health data from Western Australia (state population of about 2.24 million). Outcomes were access to revascularization and other specialized procedures at 1-, 2-, and 3-year follow-up. Logistic regression was used to adjust for demographics, prior health service use, diagnosis, and length of psychiatric history., Results: There were 2757 patients and 2687 control subjects (total n = 5444). Sixty-five per cent were males (n = 3522), and the average age was 36 years (SD 13.2). Most had schizophrenia or other nonaffective psychoses (74%), followed by affective disorders (26%). At 2-year follow-up, 2% (n = 53) of patients and 2.6% (n = 69) of control subjects had undergone a specialized intervention. Compulsory community treatment did not result in greater access to specialized procedures at all 3 time points even after adjusting for potential confounders., Conclusions: Greater access to specialized procedures does not explain the reduced mortality from preventable physical illness that had been reported in patients on community treatment orders. There must be other explanations for this finding, such as mental health staff facilitating access to chronic disease management in primary care. This warrants further research.

Objectives: The aim of this study is to compare the historic development of indicators of institutionalized care for the mentally ill in East and West Germany since the political change of 1989., Methods: Data on numbers of psychiatric beds, prison populations, the occupancy in forensic psychiatric institutions, in rehabilitation services, in supported housing units and involuntary admission rates are presented in historic time lines. Changes were calculated as a percentage., Results: After 1989 general psychiatric bed numbers decreased by 61% and the prison population by 77% in East Germany both from initially higher to then lower rates than in West Germany. Since 1993 there has been an approximation of the numbers in East and West Germany. In both parts of Germany the forensic psychiatric bed numbers, supported housing and rehabilitation capacities have increased. Involuntary admission rates into general psychiatry are on the increase in both parts of Germany. They continue to be 3.3 times higher in West Germany than in East Germany., Conclusion: The harmonization of capacities in mental health care institutions between both parts of Germany was realized within a few years after reunification. Continuous differences remain regarding the involuntary admission rates.

In 2010, a programme intended to increase the number of structured interviews after coercive measures (IC) was implemented in a psychiatric ward. The IC forms were collected before and after the implementation of the programme. The number of ICs was compared to the total amount of compulsion. A significant rise in the number of effectuated ICs was demonstrated. The patients' contentment underwent no change. The majority of the coercive measures were not followed by an IC. At the next audit of the psychiatric legislation we will suggest an adjustment of the paragraphs concerning ICs.

Background: Creative use of legislation can produce positive change in the lives of people with intellectual disabilities. This may be 'bottom-up' or 'top-down' or at multiple levels and with multiple stakeholders., Method: Using a human rights-based approach (HRBA), four initiatives to improve services for people with intellectual disabilities in the UK are described., Results: The first example explains the process of co-producing a DVD and board game to enable people with intellectual disabilities to understand their human rights. The second example considers the impact of organizational culture in the process of embedding a pilot evaluation of practical, human rights-based risk assessment and management tools. A third pilot project examines how the guiding principles of Mental Health Act (MHA) (2007) for England and Wales can be operationalized using an HRBA. Finally, improving equitable access to health care through a 'top-down' process of change involving the Green Light Toolkit is reported., Conclusion: The authors consider how to approach the process and where to focus in the system, to realize meaningful change., (© 2012 Blackwell Publishing Ltd.)

Purpose of Review: Involuntary treatment is burdened by the lack of evidence. One of the challenges is the difference in practice across borders in Europe. While reviewing the current literature, a proposal of monitoring guidelines is discussed., Recent Findings: The field is characterized by a small number of dedicated researchers. A study of violence in first-episode psychosis shows that differences in criteria for involuntary admission lead to different prognosis for the patients. The most recent contributions from the cross-national EUNOMIA study point to great variation across countries, regarding frequencies of involuntary admission as well as outcome. The EUNOMIA study provides suggestions for good quality in involuntary admission. A Cochrane review has examined the evidence of involuntary community treatment compared with standard treatment. The effectiveness of involuntary community treatment is limited. The review concludes that the benefits for a small number of patients are outweighed by the high numbers needed to treat in terms of avoided re-admission., Summary: Despite pioneering work, involuntary treatment is still caught up in tradition. There is a lack of standard and proof of effectiveness. A proposal of monitoring guidelines for involuntary measures is a first step to improve the situation.

Involuntary Outpatient Treatment (IOT) expects to improve treatment compliance and, therefore, prevent the impairment of patients with severe mental illness, as well as the risk for them and others. Besides IOT introduction defenders and opponent's states, scientific literature offers contradictory results. Legislative changes have been taken in the vast majority of our neighbouring countries in order to regulate IOT application. There is no legal regulation in Spain; however, OIT application is possible in certain Spanish cities. This article reviews IOT in Spain and surrounding countries.

Objectives: We sought to determine the level of procedural justice experienced by individuals at the time of involuntary admission and whether this influenced future engagement with the mental health services., Methods: Over a 15-month period, individuals admitted involuntarily were interviewed prior to discharge and at one-year follow-up., Results: Eighty-one people participated in the study and 81% were interviewed at one-year follow-up. At the time of involuntary admission, over half of individuals experienced at least one form of physical coercion and it was found that the level of procedural justice experienced was unrelated to the use of physical coercive measures. A total of 20% of participants intended not to voluntarily engage with the mental health services upon discharge and they were more likely to have experienced lower levels of procedural justice at the time of admission. At one year following discharge, 65% of participants were adherent with outpatient appointments and 18% had been readmitted involuntarily. Insight was associated with future engagement with the mental health services; however, the level of procedural justice experienced at admission did not influence engagement., Conclusions: This study demonstrates that the use of physical coercive measures is a separate entity from procedural justice and perceived pressures., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients' rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)