European psychiatry in bad shape

*Featured photo by Rosa García from Pixabay / This article is part of the series “Mental Health in crisis“

The use of coercion and force continue to be common practice despite efforts to decrease their use.

Recent studies have looked at the patient’s viewpoints of the mental health services. In one study from 2016 retrospective views of patients towards their admission and length of psychiatric hospital stay were analyzed. The study includes an analysis conducted of involuntarily detained inpatients across 10 European countries, of whom 770 were subject to one or more coercive measures while deprived of their liberty.

The findings indicated the damaging effects of the use of coercion in terms of hospital treatment efficacy.

The study’s main investigator Paul McLaughlin of the Unit for Social & Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development in England noted: “The use of coercion in mental health care remains common practice in jurisdictions across the world. As well as involuntary admission to hospital under statutory powers of detention, the most obvious forms of coercive practice are those referred to as ‘coercive measures’–forced administration of psychotropic medication against the patient’s will, involuntary confinement of the patient in isolation or seclusion, and manual or mechanical restraint of the patient’s limbs or body to prevent free movement. Despite the widespread use of coercive measures, however, there is a remarkable lack of empirical evidence as to their association with treatment outcomes.”

The use of coercive measures would only be justified where their use would cause an improvement of a treatment situation for the person subjected to the intervention or alternatively other persons in treatment that would suffer negative effects from the actions of that person. This however seems to not be the case according to several expert studies.

Paul McLaughlin and his co-investigators based on their study’s findings concluded: “Given their widespread use, the association between coercive measures and treatment outcomes is clearly important. Quite apart from the physical risks that go with the use of force, qualitative studies consistently show that coercive measures can be experienced by patients as humiliating and distressing, and consideration has started to be made of the psychological risks of their use.”

Coercion result in longer hospital stay

The study included a total of 2030 involuntary patients from 10 countries. It was found that 770 (37.9%) were subject to one or more coercive measures in the first four weeks of their admission or less, if they were released from the psychiatric hospital earlier. The 770 patients experienced 1462 recorded instances of use of coercive measures.

From this finding Paul McLaughlin concluded that the: “Use of forced medication was associated with patients being significantly less likely to justify their admission when interviewed after three months. All coercive measures were associated with patients staying longer in hospital.”

When considering different variables, it was found that seclusion was a significant predictor of longer hospital stay, adding about 25 days to the average admission.

When reviewing if certain types of coercion were having a stronger impact than others, it was found that forced medication appears to have an extraordinary strong effect. The use of this type of force is strongly contributing to patient disapproval of the psychiatric treatment.

Increasing involuntary commitments

An editorial published in the British Medical Journal in 2017, reviewed the increasing rate of involuntary psychiatric hospital admission in England. It has increased by more than a third in six years. In Scotland, the number of detentions increased by 19% in five years.

Shockingly the scene has deteriorated to a degree that more than half of the admissions to psychiatric hospitals in England now are involuntary. This is the highest rate recorded since the 1983 Mental Health Act.

Germany has also experienced a worsening. A study presented to the World Psychiatric Association’s (WPA) Thematic Conference: Coercive Treatment in Psychiatry held in 2007 reviewed civil commitment rates in Germany. The study found that excluding those commitments which were allowing physical restraint, these more than doubled. The increase is from 24 to 55 per 100,000 inhabitants in the period 1992 to 2005. And when looking at the public commitment rates these increased from 64 to 75. Summarizing the different types, the total of all commitments increased by 38 per cent in Germany.

In addition to the type of deprivations of liberty through civil commitments another form of restraints is also used in Germany. Persons are increasingly being taken before a legal court. The court decision rates with regard to physical restriction, which have been obligatory since 1992, increased more than seven-fold from 12 to 90 per 100,000 inhabitants.

In Denmark the increasing use of the possibility to deprive people of their liberty through involuntary commitment in to psychiatry is even more significant. A nearly linear increase has taken place from 1998 when 1522 persons were committed to 2020 when 5165 persons were involuntary committed.