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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.

AimTo evaluate the associations between refraining from buying prescribed medications and selected factors among older persons.MethodsA total of 4467 people aged 60–84 years from seven European cou ...

Few studies have evaluated the impact of lifetime abuse on quality of life (QoL) among older adults. By using a multinational study authors aimed to assess the subjective perception of QoL among people who have reported abuse during the course of their lifetime. The respondents (N = 4,467; 2,559 women) were between the ages of 60 and 84 years and living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, and Sweden). Lifetime abuse was assessed by using a structured questionnaire that allowed to assess lifetime experiences of abuse. QoL was assessed with the World Health Organization Quality of Life–Old module. After adjustment for potential confounders, authors found that to have had any abusive experience decreased the score of sensory abilities. Psychological abuse was associated with lower autonomy and past, present, and future activities. Physical abuse with injuries significantly decreased social participation. Intimacy was also negatively associated with psychological abuse, physical abuse with injury, and sexual abuse. The results of this study provide evidence that older people exposed to abuse during their lifetime have a significant reduction in QoL, with several QoL domains being negatively affected. ABUEL

Aims: Describing alcohol use by abuse type (e.g. psychological) and considering other factors (e.g. depression).Methods: The respondents were 4467 (2559 women, 57.3%) randomly selected elders (60–8 ...

Aim: To evaluate the association between somatic complaints and education level among elders in selected European countries. Methods: Cross-sectional study among randomly selected community dwelling persons aged 60–84 years from seven cities in Europe: Ancona (Italy), Athens (Greece), Granada (Spain), Kaunas (Lithuania), Stuttgart (Germany), Porto (Portugal) and Stockholm (Sweden). Somatic complaints were measured with the 24-item version of the Giessen Complaint List (GBB-24). A regression analysis was done to investigate the association between education and somatic complaints. Results. The mean GBB-24 scale was 16.3±14.9. The most common complaints were pain in joints and limbs (29.6%), back-pain (24.1%), heaviness or tiredness in the legs (19.1%) and general tiredness (15.7%). Respondents with less than primary education reported higher levels of somatic symptoms compared to those with university degree. A regression analysis showed that higher education (OR=0.69) and being male (OR=0.48) were associated with a decreased risk for high levels of somatic complaints, and the opposite for older age (OR=1.03) and being single/divorced/window (OR=1.28). Conclusions: The results indicate that less educated elders are more likely to expressed somatic complaints.

Objective: Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, the ...

Background Several studies on elder abuse indicate that a large number of victims are women, but others report that men in later life are also significantly abused, especially when they show symptoms of disability and poor health, and require help for their daily activities as a result. This study focused on the prevalence of different types of abuse experienced by men and on a comparison of male victims and non-victims concerning demographic/socio-economic characteristics, lifestyle/health variables, social support and quality of life. Additionally, the study identified factors associated with different types of abuse experienced by men and characteristics associated with the victims. Methods The cross-sectional data concerning abuse in the past 12 months were collected by means of interviews and self-response during January-July 2009, from a sample of 4,467 not demented individuals aged between 60–84 years living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain and Sweden). We used a multilevel approach, within the framework of an Ecological Model, to explore the phenomenon of abuse against males as the complex result of factors from multiple levels: individual, relational, community and societal. Results Multivariate analyses showed that older men educated to higher levels, blue-collar workers and men living in a rented accommodation were more often victims than those educated to lower levels, low-rank white-collar workers and home owners, respectively. In addition, high scores for factors such as somatic and anxiety symptoms seemed linked with an increased probability of being abused. Conversely, factors such as increased age, worries about daily expenses (financial strain) and greater social support seemed linked with a decreased probability of being abused. Conclusions Male elder abuse is under-recognized, under-detected and under-reported, mainly due to the vulnerability of older men and to social/cultural norms supporting traditional male characteristics of stoicism and strength. Further specific research on the topic is necessary in the light of the present findings. Such research should focus, in particular, on societal/community aspects, as well as individual and family ones, as allowed by the framework of the Ecological Model, which in turn could represent a useful method also for developing prevention strategies for elder abuse.

BackgroundPatient–clinician communication is central to mental healthcare but neglected in research.AimsTo test a new computer-mediated intervention structuring patient–clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care.MethodIn a cluster randomised controlled trial, 134 keyworkers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction.ResultsOf 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months.ConclusionsStructuring patient–clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction.

Objective To establish whether reinstitutionalisation is occurring in mental health care mid, if so, with What variations between Western European countries.Design Comparison of data on changes in service provision.Setting Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s - England, Germany, Italy, the Netherlands, Spain, mid Sweden.Outcome measures Changes in die number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 mid 2002-3.Results Forensic beds and places in supported housing have increased in all countries, whereas changes in it involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds h is been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing The general prison population has substantially increased in all countries.Conclusions Reinstitutionalisation is taking place in European countries with different, traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more Important than changing morbidity and new methods of mental healthcare delivery.

SUMMARYThree issues characterise the background to the MECCA study: A) Throughout Europe, most patients with severe forms of psychotic disorders are cared for in the community. The challenge now is to make processes in community mental health care more effective. B) There are widespread calls to implement regular outcome measurement in routine settings. This, however, is more likely to happen, if it provides a direct benefit to clinicians and patients. C) Whilst user involvement is relatively ?" easy to achieve on a political level, new mechanisms may have to be established to make the views of patients feed into individual treatment decisions. The MECCA study is a cluster randomised controlled trial following the same protocol in community mental health teams in six European countries. In the experimental group, patients' subjective quality of life, treatment satisfaction and wishes for different or additional help are assessed in key worker-patient meetings every two months and intended to inform the therapeutic dialogue and treatment decisions. The trial tests the hypothesis that the intervention – as compared to current best standard practice – will lead to a better outcome in terms of quality of life and other criteria in patients with psychotic disorders over a one year period. This more favourable outcome is assumed to be mediated through different treatment input based on more appropriate joint decisions or a more positive therapeutic relationship in line with a partnership model of care or both. Moreover, the study will hopefully reveal new insights into how therapeutic processes in community mental health care work and how they can be optimised.

To evaluate the associations between refraining from buying prescribed medications and selected factors among older persons.A total of 4467 people aged 60-84 years from seven European countries answered a questionnaire (response rate 45.2%). Refraining from buying prescribed medications was measured with the question: 'Have you ever refrained from buying prescribed medication and care?'About 11.9% of older people refrained from buying prescribed medications. The multiple regression analysis showed that ages 60-64 (odds ratio (OR) = 2.08; 95% confidence interval (95%CI): 1.38-3.13) and 65-69 (OR = 1.73; 95%CI: 1.16-2.57) years, experience of financial strain (OR = 1.59; 95%CI: 1.27-2.01), as well as exposure to abuse (OR = 1.64; 95%CI: 1.31-2.06) when taking into account country of participant were independently associated with refraining from buying medications, while an opposite association was observed for being male (OR = 0.72; 95%CI: 0.58-0.91).The study found that refraining from buying prescription medications is a problem among older people and identified a number of factors associated with this.

Purpose – Elder abuse is an issue of great concern world-wide, not least in Europe. Older people are increasingly vulnerable to physical, psychological, financial maltreatment and sexual coercion. However, due to complexities of measurement, psychological abuse may be underestimated. The purpose of this study is to investigate the prevalence of psychological abuse toward older persons within a 12 month period.Design/methodology/approach – The study design was cross-sectional and data were collected during January-July 2009 in the survey “Elder abuse: a multinational prevalence survey, ABUEL”. The participants were 4,467 randomly selected persons aged 60-84 years (2,559 women, 57.3 per cent) from seven EU countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, Sweden). The sample size was adapted to each city according to their population of women and men aged 60-84 years (albeit representative and proportional to sex-age). The participants answered a structured questionnaire either through a face-to-face interview or a mix of interview/self-response. The data were analysed using descriptive statistics and regression methods.Findings – The prevalence of overall psychological abuse was 29.7 per cent in Sweden, followed by 27.1 per cent in Germany; 24.6 per cent in Lithuania and 21.9 per cent in Portugal. The lowest prevalence was reported in Greece, Spain and Italy with 13.2 per cent, 11.5 per cent and 10.4 per cent, respectively. Similar tendencies were observed concerning minor/severe abuse. The Northern countries (Germany, Lithuania, Sweden) compared to Southern countries (Greece, Italy, Portugal, Spain) reported a higher mean prevalence (across countries) of minor/severe abuse (26.3 per cent/11.5 per cent and 12.9 per cent/5.9 per cent, respectively). Most perpetrators (71.2 per cent) were spouses/partners and other relatives (e.g. children). The regression analysis indicated that being from Greece, Italy, Portugal and Spain was associated with less risk of psychological abuse. Low social support, living in rented housing, alcohol use, frequent health care use, and high scores in anxiety and somatic complaints were associated with increased risk of psychological abuse.Social implications – Psychological abuse was more prevalent in Northern than Southern countries and factors such as low social support and high anxiety levels played an important role. Further studies are warranted to investigate the prevalence of psychological abuse and risk factors among older persons in other EU countries. Particular attention should be paid to severe abuse. Such research may help policy makers and health planers/providers in tailoring interventions to tackle the ever growing problem of elder abuse.Originality/value – The paper reports data from the ABUEL Survey, which collected population based data on elderly abuse.

Background: Elder abuse and its effects are a serious public health issue. However, little is known about the relation between psychological abuse, other factors (e.g. social support) and quality of life (QoL) by domain. This study addressed differences in QoL by domain between psychologically abused and non-abused. While considering other factors such as social support. Methods: The respondents were 4,467 (2,559 women) randomly selected persons aged 60-84 years living in 7 European cities. The mean response across countries was 45.2%. The cross-sectional data were analyzed with bivariate/multivariate methods. Results: Abused respondents contrasted to non-abused scored lower in QoL (autonomy, 67.42 ± 21.26 vs. 72.39 ± 19.58; intimacy, 55.31 ± 31.15 vs. 67.21 ± 28.55; past/present/future activities, 62.79 ± 19.62 vs. 68.05 ± 18.09; social participation, 65.03 ± 19.84 vs. 68.21 ± 19.77). Regressions showed that abuse was negatively associated with autonomy, intimacy and past/present/future activities, and positively with the social participation. All QoL dimensions were negatively associated with country and depressive/anxiety symptoms, and positively with social support. Further, variables such as age, sex and somatic symptoms were negatively associated with some of the QoL dimensions and others such as family structure, education, health care use and drinking positively. The regression model “explained” 32.8% of the variation in autonomy, 45.6% in intimacy, 44.8% in past/present/future activities and 41.5% in social participation. Conclusions: Abuse was linked to lower QoL in most domains, but other factors such as depressive symptoms also carried a negative impact. Social support and to some extent family structure had a “protective” effect on QoL. Abuse, health indicators (e.g. depressive symptoms) and social support should be considered in addressing the QoL of older persons. However, QoL was influenced by many factors, which could not be firmly disentangled due to the crosssectional approach, calling for longitudinal research to address causality.

This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries. Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients’ sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries’ effect. The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20–F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries’ effect, the risk of being coerced was higher in Poland. Patients’ sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model. The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries’ effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

We aimed to investigate the prevalence rate of abuse (psychological, physical, sexual, financial, neglect) of older persons (AO) in seven cities from seven countries in Europe (Germany, Greece, Italy, Lithuania, Portugal, Spain, Sweden), and to assess factors potentially associated with AO. A cross-sectional study was conducted in 2009 (n = 4,467, aged 60–84). Potentially associated factors were grouped into domains (domain 1: age, gender, migration history; domain 2: education, occupation; domain 3: marital status, living situation; domain 4: habitation, income, financial strain). We calculated odds ratios (OR) with their respective 95 % confidence intervals (CI). Psychological AO was the most common form of AO, ranging from 10.4 % (95 % CI 8.1–13.0) in Italy to 29.7 % (95 % CI 26.2–33.5) in Sweden. Second most common form was financial AO, ranging from 1.8 % (95 % CI 0.9–3.2) in Sweden to 7.8 % (95 % CI 5.8–10.1) in Portugal. Less common was physical AO, ranging from 1.0 % (95 % CI 0.4–2.1) in Italy to 4.0 % (95 % CI 2.6–5.8 %) in Sweden. Sexual AO was least common, ranging from 0.3 (95 % CI 0.0–1.1) in Italy and Spain to 1.5 % (95 % CI 0.7–2.8) in Greece. Being from Germany (AOR 3.25, 95 % CI 2.34–4.51), Sweden (OR 3.16, 95 % CI 2.28–4.39) or Lithuania (AOR 2.45, 95 % CI 1.75–3.43) was associated with increased prevalence rates of AO. Country of residence of older people is independent from the four assessed domains associated with AO. Life course perspectives on AO are highly needed to get better insight, and to develop and implement prevention strategies targeted at decreasing prevalence rates of AO.

Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions. (Psychiatric Services 61: 1012-1017, 2010)

Background\ud The effectiveness of psychosocial interventions in community mental healthcare has been shown to depend on the setting in which they are implemented. Recently structured patient–clinician communication was found to be effective in a multi-centre trial in six European countries, the DIALOG trial. In the overall study, differences between centres were controlled for, not studied. Here, we test whether the effectiveness of structured patient–clinician communication varies between services in different countries, and explore setting characteristics associated with outcome.\ud \ud Methods\ud The study is part of the DIALOG trial, which included 507 patients with schizophrenia or related disorder, treated by 134 keyworkers. The keyworkers were allocated to intervention or treatment as usual.\ud \ud Results\ud Positive effects were found on quality of life (effect size 0.20: 95% CI 0.01–0.39) and treatment satisfaction (0.27: 0.06–0.47) in all centres, but reductions in unmet needs for care were only seen in two centres (−0.83 and −0.60), and in positive, negative and general symptoms in one (−0.87, −0.78, −0.87). The intervention was most effective in settings with patient populations with many unmet needs for care and high symptom levels.\ud \ud Conclusions\ud Psychosocial interventions in community mental healthcare may not be assumed to have uniform effectiveness across settings. Differences in patient population served and mental healthcare provided, should be studied for their influence on the effectiveness of the intervention. Structured patient–clinician communication has a uniform effect on quality of life and treatment satisfaction, but on unmet needs for care and symptom levels its effect differs between mental healthcare settings.

Background Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment. Methods Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition. Results At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect. Conclusions Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.

Objective: An intervention to structure patient-key worker communication has been tested in a randomized controlled trial. The aim of this paper was to investigate effectiveness of the intervention in terms of moderators of effectiveness.Method: A total of 507 patients with schizophrenia were included. Moderators of effectiveness were investigated using two-way ANOVAS.Results: Patients with a better relationship with their key worker and a shorter duration of illness at baseline benefited more from the intervention in terms of quality of life. Patients who received the intervention who were in competitive employment or had a shorter duration of illness showed greater reduction of unmet needs. Older patients receiving the intervention had better treatment satisfaction.Conclusion: Outcome of the intervention was moderated by patient characteristics. Moreover, the moderating characteristics varied depending on the specific outcome. Evidence on moderators is very limited, even though, they are significant for understanding, targeting and implementing complex interventions.

Background Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. Methods 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. Results When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. Conclusions Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.