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      Involuntary Medication, Seclusion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013

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          Involuntary medication in psychiatric treatment of inpatients is highly controversial. While laws regulating involuntary medication have been changed in Germany, no data have been available to date on how often involuntary medication is actually applied. Recently, our hospital group introduced specific routine documentation of legal status and application of involuntary medication in the patients’ electronic records, which allows the assessment of the frequency of involuntary medication.


          For the year 2014, we extracted aggregated data from the electronic database on age, sex, psychiatric diagnosis, legal status during admission, kind of coercive measure (mechanical restraint, seclusion, and involuntary medication) applied, and the number and duration of seclusion and restraint episodes for seven study sites.


          A total of 1,514 (9.6%) of 15,832 admissions were involuntary. At least one coercive measure was applied in 976 (6.2%) admissions. Seclusion was applied in 579 (3.7%) admissions, mechanical restraint was applied in 529 (3.3%) admissions, and involuntary medication was applied in 78 (0.5%) admissions. Two-thirds of involuntary medications were applied in cases of emergency; the remainder was applied after a formal decision by a judge. In 55 (70.5%) of the admissions with involuntary medication, at least one other coercive measure (seclusion, restraint, or both) was applied as well.


          Involuntary medication is rarely applied and less frequent than seclusion or mechanical restraint, possibly as a consequence of recent legal restrictions.

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          Most cited references 14

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          Reversing hard won victories in the name of human rights: a critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons with Disabilities.

          The UN Convention on the Rights of Persons with Disabilities (CRPD) is a major milestone in safeguarding the rights of persons with disabilities. However, the General Comment on Article 12 of the CRPD threatens to undermine critical rights for persons with mental disabilities, including the enjoyment of the highest attainable standard of health, access to justice, the right to liberty, and the right to life. Stigma and discrimination might also increase. Much hinges on the Committee on the Rights of Persons with Disabilities' view that all persons have legal capacity at all times irrespective of mental status, and hence involuntary admission and treatment, substitute decision-making, and diversion from the criminal justice system are deemed indefensible. The General Comment requires urgent consideration with the full participation of practitioners and a broad range of user and family groups.
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            Legal provisions and practice in the management of violent patients. a case vignette study in 16 European countries.

            To compare the clinical management of typical scenarios by using three case vignettes in a substantial number of European countries. Three case vignettes and an associated questionnaire, filled in and finalised by at least two experts from each country. Legislation and clinical practice varies widely across the 16 included countries. No specific pattern emerged. Certain practices (intravenous medication, mechanical restraint, net beds and forensic transfers, respectively) only exist in few countries. Legislation for involuntary medication is most restrictive in the Netherlands. There is little harmonisation and a lack of consistent standards within and across European countries regarding treatment and management of violent patients.
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              Diagnosis-related frequency of compulsory measures in 10 German psychiatric hospitals and correlates with hospital characteristics.

              To investigate the incidence of coercive measures in standard psychiatric care in different psychiatric hospitals. We developed a common documentation of mechanical restraint, seclusion, and medication by coercion, and introduced it in 10 participating hospitals. We developed software able to process the data and to calculate four key indicators for routine clinical use. 9.5% of 36,690 cases treated in 2004 were exposed to coercive measures with the highest percentage among patients with organic psychiatric disorders (ICD-10 F0) (28.0%). Coercive measures were applied a mean 5.4 times per case and lasted a mean 9.7 h each. The incidence and duration of coercive measures varied highly between different diagnostic groups and different hospitals. Use of detailed guidelines for seclusion and restraint was associated with a lower incidence of coercive measures. Data interpretation should consider numerous confounding factors such as case mix and hospital characteristics. Suggestions on how to cope with ethical and technical problems in the processing of large multi-site data sets in routine clinical use are made.

                Author and article information

                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                28 October 2015
                : 6
                1Clinic for Psychiatry and Psychotherapy I, Centers for Psychiatry Suedwuerttemberg, Versorgungsforschung Weissenau, Ulm University , Ravensburg, Germany
                Author notes

                Edited by: Samantha Battams, Torrens University Australia, Australia

                Reviewed by: Matthias Jaeger, University Hospital of Psychiatry Zürich, Switzerland; Charles Bonsack, Université de Lausanne, Switzerland

                *Correspondence: Erich Flammer, erich.flammer@

                Specialty section: This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry

                Copyright © 2015 Flammer and Steinert.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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                Figures: 0, Tables: 3, Equations: 0, References: 18, Pages: 5, Words: 3391
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