Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring

Abstract

BackgroundThe high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples. The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients’ perceived coercion and to increase patient satisfaction, their quality of life and empowerment.Methods/DesignThis paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study. In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge.DiscussionInnovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.Trial registrationCurrent Controlled Trials ISRCTN63162737.

Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness

“…Participants were recruited for a larger controlled trial of an intervention including psychoeducation, crisis cards and preventive monitoring to reduce involuntary psychiatric hospitalizations among people with serious mental illness in the Canton of Zürich, Switzerland (for more details of the study context and design see the study protocol [30] and www.zinep.ch). For the current study, we used the preintervention cross-sectional baseline data provided by 186 participants that were recruited in four psychiatric hospitals in the Canton of Zürich (for details of recruitment procedures, see [30]). In Switzerland, there is no compulsory community treatment, and in the Canton of Zürich, all physicians have the right to mandate compulsory admission to psychiatric inpatient care.…”

“…Participants had to meet the following inclusion criteria: (1) at least one involuntary hospitalization during the past 24 months, (2) between 18 and 65 years of age, (3) residency in the Canton of Zürich and (4) ability to give written informed consent. Exclusion criteria were an organic mental disorder, mental retardation or insufficient German language skills (for details of recruitment, see [30]). The study was approved by the regional ethics committee of Zürich.…”

Coercion in mental healthcare: time for a change in direction

“…Although due legal process and best clinical practice should always be followed (Prinsen & van Delden, 2009), there are substantial disparities internationally in the legal and clinical aspects of care (Newton-Howes, 2010). This may reflect differences in societal and clinical attitudes (Lay et al, 2012). The 'heterogeneity of coercion' remains poorly understood.…”

Factors Associated with Costs of Hospitalization of Severely Mentally Ill Patients

“…The rise of pharmacotherapy has been associated with less frequent and shorter hospitalizations, briefer outpatient visits and less emphasis on lengthy psychotherapies, especially for patients with relatively mild or moderate illnesses [25,26]. Nevertheless, psychiatric hospitalization, especially of the severely mentally ill, has been unavoidable and the costs of hospitalization [and incarceration] remain a leading financial strain to individuals, thirdparty payers, and society [5,12,[27][28][29]. Efforts to manage costs associated with psychiatric illness include increasingly strenuous requirements by insurers tending to limit hospital admissions and days per admission and to reduce per-diem reimbursements for prolonged hospitalization [24,30,31].…”