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      Freedom Restrictive Coercive Measures in Forensic Psychiatry

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          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.

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          Most cited references 16

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          Cluster-randomized controlled trial of reducing seclusion and restraint in secured care of men with schizophrenia.

          This randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence.
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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.
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              Patients’ Preference and Experiences of Forced Medication and Seclusion

              This study examined patients’ preferences for coercive methods and the extent to which patients’ choices were determined by previous experience, demographic, clinical and intervention-setting variables. Before discharge from closed psychiatric units, 161 adult patients completed a questionnaire. The association between patients’ preferences and the underlying variables was analyzed using logistic regression. We found that patients’ preferences were mainly defined by earlier experiences: patients without coercive experiences or who had had experienced seclusion and forced medication, favoured forced medication. Those who had been secluded preferred seclusion in future emergencies, but only if they approved its duration. This suggests that seclusion, if it does not last too long, does not have to be abandoned from psychiatric practices. In an emergency, however, most patients prefer to be medicated. Our findings show that patients’ preferences cannot guide the establishment of international uniform methods for managing violent behaviour. Therefore patients’ individual choices should be considered.

                Author and article information

                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                05 March 2020
                : 11
                1Center for Psychiatry Suedwuerttemberg, Clinic for Psychiatry and Psychotherapy I, Ulm University , Ravensburg, Germany
                2Center for Psychiatry Suedwuerttemberg , Ravensburg, Germany
                Author notes

                Edited by: Athanassios Douzenis, National and Kapodistrian University of Athens, Greece

                Reviewed by: Martin Zinkler, Kliniken Landkreis Heidenheim gGmbH, Germany; Ioannis Michopoulos, National and Kapodistrian University of Athens, Greece

                *Correspondence: Erich Flammer erich.flammer@

                This article was submitted to Forensic Psychiatry, a section of the journal Frontiers in Psychiatry

                Copyright © 2020 Flammer, Frank 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) and the copyright owner(s) 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: 6, Equations: 0, References: 17, Pages: 7, Words: 5365
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