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Uwe B Schirmer,1 Tilman Steinert,1,2 Erich Flammer,1,2 Raoul Borbé1,2 1Centre for Psychiatry South-Wuerttemberg, Ravensburg, Germany; 2Ulm University, Department Psychiatry I, Ravensburg, Germany Background: The long-term course of schizophrenia is often characterized by relapses, induced by poor medication adherence. Early nonadherence after discharge is frequent. Objective: To evaluate a skills-based inpatient training program for medication intake. Methods: We developed a manual-based inpatient medication training program to be carried out by nurses and focusing on practical skills enabling autonomous intake of medication. Medication adherence was measured by three different methods: pill count, determination of serum levels, and self-assessment by the patient. The raters were blinded. Results: Four weeks after discharge, 98% of the patients in the intervention group (N=52) were rated as adherent by pill count versus 76% in the control group (N=50; P

Abstract 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.

Objective: No evidence is available on the relative restrictiveness of seclusion and mechanical restraint, although guidelines recommend use of the least restrictive intervention. This study compared the restrictiveness of these interventions from patients' point of view.Methods: Data were collected from three general psychiatric admission units in South Germany. A total of 102 patients with schizophrenia, an affective disorder, or a personality disorder were included in a comprehensive cohort study with optional randomization. Restrictions of human rights as measured by the Coercion Experience Scale (CES) were the primary outcome variable. Possible total scores range from 1 to 5, with higher scores indicating a higher level of restriction.Results: Twenty-six patients were randomly assigned to seclusion (N=12) or mechanical restraint (N=14). A total of 76 were excluded from randomization and included in the cohort arms (48 experienced seclusion, and 28 experienced mechanical restraint). No difference in mean CES total scores was found between the randomly assigned patients after they experienced seclusion or mechanical restraint (seclusion median score=1.88 [range 1.24-4.24]; restraint median score=2.14 [range 1.28-4.00]). When randomly assigned patients and patients in the cohort arms were considered as a group, no significant difference in CES scores was found (seclusion median score=.40, [range 1.1-4.2]; restraint median score=2.59 [range 1.1-4.0]).Conclusions: The results do not provide evidence for using one intervention rather than the other. Clinical decisions should take into account patients' preferences. Randomized controlled trials of coercive interventions are feasible. Such studies contribute to the development of ethical and evidence-based guidelines. [ABSTRACT FROM AUTHOR]

Zusammenfassung.Von 193 Untersuchungen zur Bestimmung der Wirksamkeit von Hypnose, die bis Ende 1998 veröffentlicht wurden, konnten 43 randomisierte, klinische Studien, in denen eine ausschließlich mit Hypnose behandelte Patientengruppe mit einer unbehandelten (bzw. mit medizinischer Standardversorgung behandelten) Gruppe verglichen wurde, in eine Meta-Analyse integriert werden. Für die hypnotische Behandlung von ICD-10 kodierbaren Störungen wurde bei einem durchschnittlichen Behandlungszeitraum von 5,1 Wochen eine gewichtete, “Post-treatment-Effektstärke” von d=0,60 (mittlere Effektstärke) gefunden (24 Studien), für die Verwendung von Hypnose zur Unterstützung medizinischer Maßnahmen (19 Studien) ein d=0,38 (schwacher Effekt). Es handelt sich hierbei um konservative Schätzungen, da alle Variablen einer Studie zur Berechnung der mittleren Effektstärke verwendet wurden. Die meisten Studien verwendeten Methoden der klassischen Hypnose. Um abzuschätzen, in welchem Ausmaß nichtklinische Faktoren (Designqualität, Art des Messwertvergleichs) die Größe der Effektstärke beeinflussen, wurden für die Studien der ursprünglich 193 Untersuchungen, die die erforderlichen statistischen Angaben enthielten, Effektstärken berechnet. Für diese insgesamt 89 Studien mit einer Effektstärke von d=0,80 zeigte sich ein gravierender Einfluss nichtklinischer Faktoren auf die gewichteten Effektstärken, die von 0,51 für randomisierte Studien mit Gruppenvergleich bis zu d=2,0 für nichtrandomisierte Studien mit Prä-, Post-Vergleich reichten.Abstract.From 193 studies published until 1998 that investigated the efficacy of hypnosis 43 randomized clinical studies were selected that compared a patient group treated exclusively by hypnosis with an untreated control group (or with a group of patients treated by conventional medical procedures). The 43... [ABSTRACT FROM AUTHOR]

Abstract 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

Abstract: Psychotic experiences have been shown to be comparable in borderline personality disorder (BPD) and schizophrenia. Preliminary evidence suggests differences in the impact of psychotic experiences on daily functioning. Therefore, in this study, we aimed to investigate the role of psychotic experiences in daily functioning in BPD compared with schizophrenia. We performed post hoc analyses on data from 23 inpatients with BPD and 21 inpatients with schizophrenia, for whom results from the Psychotic Symptom Rating Scales were available. No differences were found in frequency, intensity, and disruption of life in relation to auditory verbal hallucinations and the amount of preoccupation and conviction with regard to delusions. Significant differences were found in the disruption of life due to delusions. The results emphasize that the quality of psychotic experiences in BPD and schizophrenia is comparable, but the impact of delusions on daily life is different, which may improve differential diagnosis., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In 2018, the German Federal Constitutional Court decided that mechanical restraint is the most intrusive coercive measure and its use requires a judge's decision after bedside assessment if lasting longer than 30 min. Subsequently, legal changes were realized. The objective of our study was to determine the number of saved coercive episodes and saved hours in seclusion or restraint in 2019 compared to the average of the previous years, 2015-2017, as well as costs per saved episode, hour, and case saved from any coercive measure., Methods: We used data from the Baden-Wuerttemberg case registry for coercive measures, covering all 32 psychiatric hospitals of the Federal State and 435,767 admissions in the study period. Time expenditure was calculated as 3.5 h with an average of 51.95 € per working hour on the side of the justice system and 1.5 h (45.94 €/h) on the side of the hospital per case., Results: The number of coercive episodes decreased by 10.0% from 28,181 (average 2015-2017) to 25,371 (2019). The number of hours in seclusion or restraint decreased by 17.9% from 321,956 (2015-2017) to 264,423 (2019). This resulted in the cost of 872.33 € per saved episode and 42.61 € per saved hour in seclusion or restraint., Conclusion: Given the correctness of our estimations, saving 1 h in coercion by less than 1 h of an expert's work might be justified from an ethical and economic perspective., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Hirsch, Flammer and Steinert.)

Background: Interventions to prevent the use of coercion in psychiatric hospitals have been summarized in the 2018 German Association for Psychiatry, Psychotherapy, and Psychosomatic's comprehensive guidelines. Twelve recommendations for implementation of these guideline on psychiatric wards have been deducted and their feasibility has been tested in a pilot study, using external implementation consultants as facilitators. The objective of the PreVCo study was to test their effect in a randomised clinical trial., Methods: Fifty-four psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to either an intervention or to a waiting list condition. The intervention consisted of the implementation of three out of 12 suggested recommendations as selected by the ward teams, supported by external study workers. As the primary outcome measure, the number of coercive measures used per bed and month in the final 3 months of the intervention period was determined. Secondary outcomes were the cumulative duration of coercive measures used per bed and months and assaults per bed and month. Achieved guideline adherence was measured by a fidelity scale developed for this purpose during a pilot study for the PreVCo Rating Tool. After a 3-month baseline collection period under routine conditions, randomisation was done after matching wards pairwise according to frequency of coercive measures used and scores on the PreVCo Rating Tool at baseline. The duration of the intervention period was 12 months; control wards received only an initial workshop presentation of the study and completed their PreVCo ratings. We used the Wilcoxon signed rank test and the paired t-test and conducted sensitivity analyses for different periods of observation., Findings: Neither the number of coercive measures used per month and bed nor their cumulative duration nor the number of assaults per bed and months differed significantly between the 27 intervention wards and the 27 control wards in the final 3 months of the intervention period. The median number of coercive measures used decreased by 45% (median 0.96 (IQR 1.34)-0.53 (IQR 0.59) from baseline until the end of the intervention period on the intervention wards and by 28% (median 0.98 (IQR 1.71)-0.71 (IQR 1.08) on waiting list wards. The PreVCo Rating Tool showed a significant improvement in intervention wards compared to control wards, indicating a successful implementation., Interpretation: The study demonstrated that guideline adherence could be significantly improved by the intervention. However, there was no evidence for an effect on the frequency or duration of coercive measures used. Spill-over effects and the impact of the COVID-19 pandemic on in-patient care might have limited the effect of the intervention. Further research from robust randomised controlled trials are necessary to identify effective interventions to reduce the use of coercion in psychiatric hospitals., Funding: The study was funded by the German Innovationsfonds beim Gemeinsamen Bundesausschuss (project no. 01VSF19037). The funder had no role in study design or data collection., Competing Interests: TS declared that he had received funding for other research projects from government bodies and for the development of the guideline from the German Association for Psychiatry and Psychotherapy (DGPPN). All other authors declared that they had no conflicts of interests., (© 2023 The Authors.)

Introduction: The PreVCo study examines whether a structured, operationalized implementation of guidelines to prevent coercion actually leads to fewer coercive measures on psychiatric wards. It is known from the literature that rates of coercive measures differ greatly between hospitals within a country. Studies on that topic also showed large Hawthorne effects. Therefore, it is important to collect valid baseline data for the comparison of similar wards and controlling for observer effects., Methods: Fifty five psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to an intervention or a waiting list condition in matched pairs. As part of the randomized controlled trial, they completed a baseline survey. We collected data on admissions, occupied beds, involuntarily admitted cases, main diagnoses, the number and duration of coercive measures, assaults and staffing levels. We applied the PreVCo Rating Tool for each ward. The PreVCo Rating Tool is a fidelity rating, measuring the degree of implementation of 12 guideline-linked recommendations on Likert scales with a range of 0-135 points covering the main elements of the guidelines. Aggregated data on the ward level is provided, with no patient data provided. We performed a Wilcoxon signed-rank-test to compare intervention group and waiting list control group at baseline and to assess the success of randomization., Results: The participating wards had an average of 19.9% involuntarily admitted cases and a median 19 coercive measures per month (1 coercive measure per occupied bed, 0.5 per admission). The intervention group and waiting list group were not significantly different in these measurements. There were 6.0 assaults per month on average (0.3 assaults per occupied bed and 0.1 per admission). The PreVCo Rating Tool for guideline fidelity varied between 28 and 106 points. The percentage of involuntarily admitted cases showed a correlation with coercive measures per month and bed (Spearman's Rho = 0.56, p < 0.01)., Discussion: Our findings that coercion varies widely within a country and mainly is associated with involuntarily admitted and aggressive patients are in line with the international literature. We believe that we included a sample that covers the scope of mental health care practice in Germany well. Clinical trial registration : www.isrctn.com, identifier ISRCTN71467851., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hirsch, Baumgardt, Bechdolf, Bühling-Schindowski, Cole, Flammer, Mahler, Muche, Sauter, Vandamme, PreVCo Study Group and Steinert.)

Epidemiological registers on the burden of disease and adverse events (deaths, serious side effects, etc.) play an important role in the management, evaluation, and improvement of healthcare treatment for the population. This also applies to coercive measures in the psychiatric healthcare system. Such registers only became feasible on a broad basis due to the availability of electronic medical records and steadily increasing computing capacities; however, in most German states, registers have not been implemented. Data protection problems must be taken into account in the collation of person-related data but can be solved by appropriate pseudonymization procedures taking the prerequisites of data parsimony into account. Extensive data are now available from the Baden-Wuerttemberg register for coercive measures, which has been in existence since 2015 and which enabled, for instance, evaluating the consequences of the changes to the law following the 2018 ruling of the Federal Constitutional Court on mechanical restraint and the consequences of the coronavirus pandemic. In the meantime, there are also state-wide data collections in some other German states; however, unlike in Baden-Wuerttemberg, these registers do not include measures under guardianship law. A nationwide register for coercive measures, compulsory treatment and involuntary detention has justifiably repeatedly been demanded for a long time. A major obstacle is the historically developed separation between the responsibility of the German states for the detention regulated by public law and the Federal State for the scope of application of the guardianship law., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Robust evidence exists for the link between dissociation and psychotic positive symptoms. The extent to which various dissociative phenomena may contribute to this relationship is still unknown. This study aimed to investigate the association between different dissociative phenomena and psychotic experiences. For this purpose, we analyzed data from 118 consecutively admitted patients of an acute care unit for trauma-related disorders who completed the Childhood Trauma Questionnaire, the German version of the Dissociative Experiences Scale and the Symptom Check-List-90-Revised. Stepwise regression analyses revealed that derealization/depersonalization in combination with amnesia accounted for 44.5% of the variance of the psychoticism subscale of the Symptom Check-List-90-Revised. Absorption in combination with emotional abuse accounted for 24.9% of the variance of the paranoid ideation subscale of the Symptom Check-List-90-Revised. The results reveal that pathological and non-pathological types of dissociation that alter the perception of reality or memory procession may contribute to the development of psychotic experiences.

Objective: To examine whether the pandemic in 2020 caused changes in psychiatric hospital cases, the percentage of patients exposed to coercive interventions, and aggressive incidents., Methods: 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., Results: 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., Conclusions: 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., Competing Interests: The authors have declared that no competing interests exist.

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/ )., (© 2022. The Author(s).)

On 23 July 2018 the German Constitutional Court decided that mechanical restraint in psychiatric patients with 5 or 7‑point mechanical restraint lasting longer than 30 min requires a judicial authorization. On the same day, the German Association for Psychiatry and Psychotherapy (DGPPN) published guidelines on the prevention of coercion and violence. Together, this can be considered as the strongest intervention to reduce coercion on a national level worldwide. The registry for coercive measures in the Federal State of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change. 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 2015 to 2017 compared to 2019 among a total of 438,003 admissions. The percentage of patients subjected to any kind of freedom-restricting coercion (restraint or seclusion) decreased from 6.7% (average 2015-2017) to 5.8% in 2019 (p < 0.001). Effects were strongest in patients with organic (F0) and schizophrenic disorders (F2). The percentage of patients subjected to mechanical restraint decreased from 4.8% to 3.6% in 2019, and the percentage of mechanical restraints less than 30 min increased from 1.8% to 10.5%. Vice versa, the percentage of patients subjected to seclusion increased from 2.9% to 3.3%. The median cumulated duration of restraint and seclusion per affected case decreased from 12.7h to 10.9 h (median). The intervention was probably responsible for a reduction of the percentage of cases subjected to coercive measures by about 13% and a reduction of the duration of these measures per affected case by about 14%., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Research in recent years has demonstrated that the use of coercive measures such as seclusion and restraint differs very much between hospitals within a country. In 2015, a central register for all coercive measures in the German federal state of Baden-Wuerttemberg has been established for 32 hospitals treating involuntary patients. The objective of the present study was to identify factors that determine the differences between these hospitals., Methods: Data on coercive measures and diagnoses from the central register in 2015-2017 were linked with structural data of the 32 hospitals and their supply areas., Results: On average, coercive measures were applied in 6.7% of cases ( SD = 2.8%; Min-Max = 0.35-12.0%). The proportion of affected cases was significantly correlated with the proportion of involuntary patients ( r = 0.56), the proportion of cases with affective or neurotic, stress-related and somatoform disorders ( r = -0.42), number of hospital beds ( r = 0.44), a sheltered home associated with the hospital ( r = 0.43) and number of addiction counseling centers per 100,000 inhabitants in the service area ( r = -0.39). The final regression model only included the proportion of involuntary cases as a significant predictor (standardized beta = 0.55, adjusted R 2 = 0.27)., Conclusions: The predominating part of the considerable variance observed between hospitals could not be explained by structural variables. The proportion of involuntary patients had a significant impact, but a considerable amount of unexplained variance due to different practices within psychiatric hospitals remains., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Flammer, Hirsch, Thilo and Steinert.)

Background: On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion., Methods: We analysed 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 2017 compared to 2019 among a total of 233,0273 admissions., Findings: The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001)., Interpretation: There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions ., Funding: The registry is funded by the Ministry of Social Welfare and Integration., Competing Interests: All authors have no conflicting interests to disclose., (© 2021 The Authors.)

Objective: We investigated treatment pathways after discharge from in-patient treatment and their predictors., Methods: Within a prospective naturalistic study, 320 adult inpatients treated in four settings were examined at admission, discharge, and two follow-up time points. In addition to sociodemographic and clinical data, standardized instruments have been employed to collect data on pathways within the mental care system a half year before and one year after index treatment, respectively. Descriptive analyses and logistic regression models were applied., Results: Inpatient admissions in the first half of the follow-up year were common in psychiatric inpatients as planned aftercare. The majority of participants received outpatient aftercare. Main predictors of both inpatient readmission and outpatient psychotherapy after discharge were the setting of the index-treatment (psychiatry versus psychosomatics) as well as previous and planned forms of care., Conclusion: Though according to plan, the pathways of aftercare in psychiatry and psychosomatics are predominantly disconnected and show little overlap., Competing Interests: Da die Hauptautorin und Prof. Dr. Tilman Steinert in den untersuchten Settings der Psychiatrie tätig sind, kann sich eine Tendenz ergeben, bestimmte Ergebnisse für wünschenswert zu halten und andere weniger. Die anderen Co-Autoren sind ausschließlich in der Forschung tätig., (Thieme. All rights reserved.)

Background: Inclusion in terms of personal mobility (§ 20 of the UN Convention on the Rights of Persons with Disabilities) should be investigated in a sample of people with alcohol dependency and additional mental disability., Methods: Interviews with N = 153 individuals, recruited from specific community services for people with alcohol-related disorders and co-morbidity of mental disorders, patients in in-patient treatment, day clinics, and in out-patient treatment., Results: 54.1 % reported loss of their driver's licence due to alcohol, 43.3 % indicated to own a motor vehicle. Personal mobility was realized much more frequently by bicycle or on foot than in the general population., Conclusion: The expansion of public transport and the bicycle network is desirable not only on the background of climate change but also in favour of the inclusion of people with mental disability., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: The 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., Methods: Voluntarily 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., Results: Voluntarily 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., Conclusion: Perceived 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., (© 2021. The Author(s).)

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.

Abstract: Both borderline personality features and dissociative symptoms have been associated with different types of childhood trauma. The aim of this investigation was to analyze to what extent emotional, physical, and sexual child maltreatment predict borderline personality features and dissociative symptoms. For this purpose, we analyzed data from 86 consecutively admitted patients who completed the Borderline Symptom List, the Childhood Trauma Questionnaire, and the German version of the Dissociative Experiences Scale for differential diagnosis of a borderline personality disorder. Hierarchical regression analyses revealed that borderline features were mainly predicted by emotional abuse, whereas pathological dissociation was best predicted by sexual and physical abuse. This evidence supports the hypothesis that different kinds of maltreatment may lead to different psychopathological symptoms in adulthood and should be taken into account in the therapy., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: 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., Methods: 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., Results: 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., Conclusions: 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., Competing Interests: The authors have declared that no competing interests exist.

Background: 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., Methods: 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., Results: 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., Conclusions: 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.

The management of mentally disordered offenders varies widely across countries. Given the high prevalence of individuals with mental disorders throughout the criminal justice system, it is not always clear why some people receive forensic treatment and others a prison sentence. This project investigated trends in criminal justice sentencing practices in Germany from 1995 to 2009. We analysed officially recorded data taken from 14,100,329 court rulings to describe differences in the index offences committed by individuals sentenced to prison of at least two years and those given a forensic treatment order. The distribution of offence types differed substantially. Forensic patients committed 6.6% of all severe crimes. There was a 50% increase in the number of forensic treatment orders compared to a 11.6% increase in the group of individuals sentenced for crimes of a similar severity. Forensic patients were more likely to have committed a serious offence. This paper provides key epidemiological data and offers a basis for future comparative research. It also concludes that these trends are indicative of a moderate penal policy, without a drift towards penal populism arguably visible in other jurisdictions. Instead, it is argued that the findings are consistent with actuarial social control policies oriented towards risk prediction and crime prevention of high-risk offender groups., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: After the decisions of the German Federal Constitutional Court in 2011 and the Federal Supreme Court in 2012, involuntary treatment was not approvable for a period of seven months in the State of Baden-Wuerttemberg. Previous analyses of routine data had demonstrated that at that time in a rather small group of patients, aggressive incidents and coercive interventions had significantly increased and then decreased to the previous level after the new legislation came into force. The changes concerned a relatively small group of involuntary patients. Based on an analysis of medical charts in 6 hospitals, this study aimed to investigate 1) whether refusal of prescribed medication became more frequent in that period and 2) how frequently antipsychotic medication was administered without coercion., Method: We conducted a longitudinal intra-individual comparison and included all of the patients with schizophrenic and manic disorders who had been admitted in the period without the option of involuntary treatment and in a defined control period one year before as well (N = 174). Thus, study group and control group were identical., Results: In the period without the option of involuntary treatment, patients remained involuntarily committed significantly more frequently (+ 26 %) but only insignificantly longer. Length of stay and number of mechanical restraints remained unchanged, number of seclusions doubled, and some patients could not leave the ward for long periods of time and had frequent readmissions. Persistent refusal of prescribed medication was significantly more frequent (+ 130 %, p < .001). However, the percentage of patients who received an antipsychotic drug during their hospital stay did not differ (96.0 vs. 96.6 %). The dosage at discharge as calculated in chlorpromazine units tended to be even higher during the period without option of involuntary treatment (+ 7.9 %, p = .06). All differences concerned both voluntary and involuntary patients., Conclusions: Without the option of involuntary treatment, persistent refusal of medication and different forms of deprivation of liberty increased. Nevertheless, oral antipsychotic treatment was realized in nearly all cases until discharge., Competing Interests: T. Steinert und E. Flammer erhalten Mittel des Bundesministeriums für Gesundheit im Rahmen des Forschungsprojekts ZIPHER (Zwangsmaßnahmen im psychiatrischen Hilfesystem: Erfassung und Reduktion). T. Steinert hat Mittel der DGPPN für die Erstellung der S3 Leitlinie „Vermeidung von Zwang: Therapie aggressiven Verhaltens“ erhalten., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In Germany, people suffering from severe mental illness who have committed serious offenses and have considerably reduced or suspended criminal responsibility can be detained and treated in forensic psychiatric hospitals. In the German federal state of Baden-Wuerttemberg, all psychiatric hospitals including forensic psychiatric hospitals are obliged to record data on every coercive intervention and to submit them to a central registry. The objective of this study was to determine key measures for the use of seclusion and restraint and to compare them with data from the same registry on the use of coercion in general inpatient mental health care. Methods: Data on the main psychiatric diagnosis according to ICD-10, type and duration of each coercive measure and number of treated cases according to diagnoses, and cumulated number of days of treatment from all 8 forensic facilities in the state of Baden-Wuerttemberg covering a catchment area with about 11 million inhabitants were collected at the treated-case-level for 3 years. Results: 22.6% of the cases treated in 2017 in forensic psychiatric hospitals were subjected to seclusion, and 3.8% were subjected to mechanical restraint. The mean cumulated duration of seclusion episodes per affected case was 343.9 h and the mean cumulated duration of restraint episodes was 261.7 h. 13.2% of the treated cases were subjected to room confinement with a mean cumulated duration of 539.1 h per affected case. Involuntary medication was applied in 1.9% of the cases. In general psychiatry, 2.9% of the treated cases were subjected to seclusion, and 4.7% were subjected to mechanical restraint. The mean cumulated duration per affected case amounted to 32.2 h for seclusion episodes and to 37.6 h for restraint episodes. Involuntary medication was applied in 0.6% of cases. Conclusion: Compared to general psychiatry, mechanical restraint is used in forensic psychiatry substantially less frequently and seclusion substantially more frequently. Room confinement is used only in forensic psychiatric hospitals. Use of involuntary medication is rare. On the one hand, recorded involuntary medication comprises only clear actions against the patient's expressed will as defined by law. Psychological pressure to take medication to avoid other forms of coercion and to achieve higher levels of freedom within the facility is not recorded. On the other hand, the low numbers of clear involuntary medication probably reflect the high legal threshold for such interventions, and, consequently, efforts by staff to motivate voluntary acceptance. The long duration of freedom-restricting coercive measures in forensic psychiatry probably reflects the selection of patients at high risk of violence., (Copyright © 2020 Flammer, Frank and Steinert.)

Purpose: Arrangements for the management of mentally disordered offenders vary widely across countries, as do rates of imprisonment and detention in forensic-psychiatric settings of such individuals. This study aims to quantify the characteristics of offenders detained in forensic-psychiatric settings in Germany over a 15 year period from 1995 and compare these with those sentenced to imprisonment over the same period., Methods: Using official national statistical data, the index offences, demographic characteristics and criminal histories for all individuals convicted to forensic-psychiatric detention during the study period are described together with changes over time. This group was then compared with offenders convicted to a prison sentence of at least two years in the same time period for equivalent offences., Results: Relevant differences and similarities between the two treatment groups were identified. Compared to offenders in prison, those in forensic care were older, with a higher proportion of women and a lower proportion of those with foreign backgrounds. Significant previous offending and levels of diminished responsibility were present in both groups., Conclusions: These findings provide data for future comparative research and indicate potential opportunities for earlier intervention to prevent trajectories into more serious offending, particularly in young people and those with mental disorder., (Copyright © 2019. Published by Elsevier Ltd.)

Background: In the federal state of Baden-Wuerttemberg, collecting data on coercive measures in psychiatric hospitals and supplying this data to a central register has been mandatory since 2015, so that statewide comprehensive data is available. This first full survey of the use of coercive measures in German psychiatric hospitals presents data of the year 2016 and allows comparisons with previous smaller samples., Methods: We analyzed the register data. The analysis is based on data provided by 32 facilities with 108,863 treated cases., Results: 10.7 % of admissions were involuntary at least at parts of their stay. 7,321 (6.7 %) cases were affected by any kind of freedom-restrictive measures (5.3 % mechanical restraint, 4.5 % seclusion). 674 cases (0.6 %) were affected by forced medication either as an emergency or after a judge's decision. The mean cumulative duration of freedom-restrictive measures was 45.9 hrs per admission. Time in seclusion or restraint accounted on 0.5 % of total time in hospital., Conclusion: In comparison to previous studies in smaller samples, the use of coercive measures has considerably decreased in patients with delirium and dementia (ICD-10 F0). Coercive medication is rarely used., Competing Interests: Die Autoren sind mit der Einrichtung und dem Betrieb des Melderegisters sowie mit der Auswertung der Daten beauftragt., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The percentage of patients subjected to coercive measures has been proposed as 1 of 10 quality indicators for psychiatric inpatient treatment by the German Association of Psychiatry, Psychotherapy and Psychosomatics (DGPPN). Internationally, there are similar recommendations and corresponding reporting systems., Methods: The registry of coercive measures of psychiatric hospitals in Baden-Württemberg that was established in 2015, yields the possibility to examine the appropriateness of this indicator, based on raw data of 108,863 cases in 2016. This study investigated how the indicator is influenced by patient variables and characteristics of hospital structure., Results: The percentage of cases exposed to coercive measures was strongly (r = 0.6) correlated with the percentage of involuntarily treated cases. With respect to the latter, hospitals varied widely with a range from 0.7% up to 24.1%. Specialized wards serving patients outside the catchment area with a high number of coercive measures also had a strong influence on the results of a benchmarking comparison., Conclusion: The indicator is a good instrument for longitudinal evaluation of an institution; however, due to a high number of known and unknown confounding factors, it is inappropriate for the purpose of comparing psychiatric hospitals.

Purpose: Dissociation is a common symptom in Borderline Personality disorder (BPD) and its consideration is important for the therapeutic outcome. The aim of this cross-sectional study was to scrutinize the co-occurrence of BPD symptoms and dissociative experiences. In particular, we were interested in the occurrence of specific symptom clusters characterizing qualitatively different patient groups in a clinical sample of BPD patients., Basic Procedures: We analyzed the data of 103 patients in a specialized acute inpatient care crisis intervention unit. Measures were the Borderline Symptom List (BSL-95), a German adaption of the Dissociative Experience Scale (FDS), and the Symptom Checklist SCL-90-R. We applied a Latent Profile Analysis (LPA) using the subscales of BSL-95 and FDS to investigate the existence of distinct latent classes of symptom profiles. Afterwards, we related the obtained profiles to other clinical and demographic characteristics., Main Findings: Dissociative experiences of moderate to severe intensity were common among patients with BPD. LPA revealed that a model of three classes fitted the data best: one class was characterized by co-occurrence of severe borderline symptoms and frequent dissociative experiences, one class showed low symptom burden in both measures, and one class showed considerable borderline symptoms but only moderate dissociative experiences. The classes were closely related to the severity of other self-rated psychological problems and showed significantly different occurrences of stress-related comorbid disorders., Principal Conclusions: The results underline that dissociation is an important factor in many (but not all) BPD patients. This should be addressed by increased attention to dissociative symptoms in the diagnostic process and the adjustment of treatment plans., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Objective: A simple instrument to record case-related coercive measures was tested as part of a pilot project of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)., Methods: To assess coercive measures data were collected for 3 months in 8 German hospitals for psychiatry and psychotherapy. The type of measures used, the main diagnosis and the legal basis for the coercive measures were documented., Results: In the sample studied, coercive measures were applied in 8% of cases. Coercive measures were most commonly used in patients with a schizophrenic disorder. The principle of justifiable necessity according to § 34 of the German Penal Code was used particularly often as the legal basis for justifying the coercive measures., Conclusion: Suitable measurement instruments and reliable data that enable the learning of best practices represent the basis for a reduction of coercive measures.

Objective To examine the understanding of and attitudes towards ward rules among patients and staff on 5 wards for treatment of alcohol addiction in 5 hospitals. 4 wards were specialized, one was a general psychiatric ward. Methods Development of a questionnaire, measurement of patient satisfaction (ZUF-8), ward atmosphere (SBB), and hospital admission experience (FEA-P). Results For 24 previously identified areas, patients (N = 134) and staff (N = 41) reported 18.7 rules on average. Contentment with rules was generally high without significant differences between patients and staff. On the general ward, fewer rules were reported than on the specialized wards. Patient satisfaction, ward atmosphere and hospital admission experience were similar between normal and specialized wards. Conclusions Ward rules are common and detailed, and are highly valued by staff and patients. Rules can be considered as an important element of treatment for patients with alcohol addiction. There was no evidence of a superiority of the disorder-specific wards., (© Georg Thieme Verlag KG Stuttgart · New York.)