BUDAPEST — Changing the way that psychiatric care is delivered can significantly reduce the use of coercive measures, experts said at the 32nd European Congress of Psychiatry.
"It's really important to reduce coercion in psychiatry," Julian Beezhold, MD, a consultant in emergency psychiatry for Norfolk and Suffolk NHS Foundation Trust in England, told Medscape Medical News. Not only is coercion unpleasant for all concerned, but it also entails risks for harm.
Beezhold, the current chair of the European Psychiatric Association's (EPA's) Section on Emergency Psychiatry, noted that examining how to reduce coercive practices in psychiatry is a priority for the Association and patient advocacy groups.
"It starts at the top," he said, which is why the EPA, the Global Alliance of Mental Illness Advocacy Network ( GAMIAN-Europe), and the European Federation of Associations of Families of People with Mental Illness, are working together to see how coercive practices can be avoided.
It's not necessarily about having more funding or resources, Beezhold stressed. "E ven with more limited resources, you can do better."
Types of Coercion
Coercion in psychiatry can take many forms, pointed out Péter Kéri, the president GAMIAN-Europe, during the Coercion in Psychiatry: Epidemiology and Prevention session at EPA 2024. It can be physical, such as admitting a patient to a hospital involuntarily, administering medication without consent, isolating someone, or using physical restraints. It can also be more subtle and informal such as pressuring or threatening someone to obtain compliance with psychiatric care.
Coercion also includes social and emotional pressure from family or friends and economic pressure to manipulate people into accepting treatment they may not want. Finally legal coercion can be used to order a person to undergo and comply with psychiatric care.
"We know that there are differences throughout the world concerning coercion, frightening differences," said Kéri. "But if you do not talk about it, and we do not understand why the differences occur, those patients will not be heard."
Kéri added that patients who have experienced coercion must be empowered to speak out, share their stories, and advocate for change.
Avoiding Involuntary Hospitalization
In 2019, The Lancet published data on the annual number of involuntary hospitalizations in selected European countries, Australia, and New Zealand. These data showed that the median rate of involuntary hospitalization was 106.4 per 100,000 people. The highest rate of involuntary hospitalization was reported in Austria (282 per 100,000 people), and the lowest in Italy (14.5 per 100,000 people).
The findings highlight the variation in involuntary hospital admissions across Europe, said Jorun Rugkåsa, adjunct professor of nursing and health sciences at the University of South-Eastern Norway. While involuntary hospitalization does not mean that other coercive practices are going to be used, it perhaps increases the chances that they might, she said.
"In many countries, policy aims to reduce the level of coercion and have more appropriate use of coercive interventions," said Rugkåsa at EPA 2024. "In Norway, for example, all the health trusts are instructed to reduce the use of compulsion."
The problem is that most of the measures being enacted to address coercion focus on the time of the involuntary hospital admission: a time when the individual is in crisis. The problem might instead be addressed earlier in the process, for example, while the patient is still being treated by a general practitioner or by community mental health services.
"We are thinking that maybe there is a better way, and that's the premise for the ReCoN [Reducing Coercion in Norway] intervention," said Rugkåsa.
The ReCoN Study
ReCoN is a comprehensive intervention that consists of six strategy areas and more than 50 actionable points that aim to help primary mental health care services avoid involuntary hospital admission. It was created by stakeholders from some of Norway's many municipalities so that it would work anywhere within the country's existing healthcare systems.
Rugkåsa is the principal investigator for a randomized controlled study examining whether the intervention makes a difference. The ReCoN study involved 10 mid-size Norwegian municipalities where high levels of involuntary admissions have been reported. Five of the municipalities helped create the ReCoN intervention and implemented all or some of the actions from it between 2019 and 2020. The other municipalities were not involved and did not implement any of the actions.
Unpublished data show that implementation of the intervention is feasible and that it might have had a positive impact on involuntary admission rates between 2020 and 2022.
Norway is a well-resourced country, Rugkåsa told Medscape Medical News. Whether the principles of the intervention could be applied to other European healthcare systems remains to be seen. "The principles are translatable, but if you're going to shift responsibility for coercion reduction, then you need the resources there," she said.
Reducing the Need
In England, Beezhold and colleagues have examined how coercive practices in their acute hospital ward might be reduced through simple changes to how the ward is run.
"We had the opportunity to do a quasi-experimental study," said Beezhold, explaining the rationale for the Psychiatrist Hospitalist Norwich Evaluation Study (PHoNES). "Alongside us was another ward that did not make changes at the same time, so we were able to compare data from before and after we changed things with data from that ward."
PHoNES collected data on all admissions to the two wards over a 4-year period, including 2 years before and after changes to the wards were or were not made. The two wards had similar patient populations but different geographic catchment areas.
The intervention was a reduction in the number of psychiatrists on the ward at any given time from 13 to one. Weekly ward rounds were changed to daily multidisciplinary team reviews with the same psychiatrist.
As a result of these changes, referrals to the Crisis Resolution and Home Treatment Team were halved compared with the time before the implementation period, said Beezhold. In addition, assessments and detainments according to the UK's Mental Health Act were reduced, and admissions to the ward were reduced.
Patient accidents and injuries per admission, the use of restraints, and need for constant supervision were also down. There was a significant reduction in violence per admission in the intervention ward, compared with the control wards, and patients were less likely to cause deliberate self-harm or abscond without being discharged.
The intervention used in PHoNEs may not be the solution for everyone, said Beezhold. "It depends on local circumstances. But for us, it led to a big change and a big reduction in coercive practices."
PHoNES was an independently conducted study. ReCoN was funded by the Research Council of Norway. Beezhold, Kéri, and Rugkåsa reported no relevant financial relationships.
Sara Freeman is a freelance medical journalist based in London, England.