Coercive measures in inpatient psychiatry: a look at vulnerable patient groups

In psychiatric inpatient settings, coercive measures should be used only as a last resort. To reduce coercion, it is necessary to identify the factors that promote the use of coercive measures and those which prevent them. Numerous studies have addressed this question, but the findings are heterogeneous and the methodological quality of some of the studies is weak. Further research that includes a broad range of relevant confounders and applies robust study designs is needed.
In this dissertation, I investigated two factors that have been previously shown to be associated with coercive measures: open-door policies and the COVID-19 pandemic. While it was reported that coercive measures overall increased during the pandemic, previous studies demonstrated that open-door policies are accompanied by a reduction in coercive measures. However, to date, experiences of door policies during previous stays have not yet been investigated.
Paper 1 aimed to answer the question of whether the door policies during the previous and the current inpatient stay are related to the risk of coercive measures during the current inpatient stay. In line with previous research, our findings showed that the ward type (open- versus closed-door policy) to which a person is admitted is associated with the use of coercive measures. The admission to a ward with an open-door policy decreased the risk for coercive measures during this inpatient stay. However, the ward type in previous inpatient stays appears to be unrelated to future coercive measures. Patients who were admitted to a ward with an open-door policy, but then had to be transferred to a ward with a closed-door policy, had almost three times higher odds to experiencing coercive measures than patients who were admitted to a ward with a closed-door policy from the start. This finding highlights the need to identify at risk groups, as well as investigate the emergence of high risk situations in acute mental health settings.
In papers 2 and 3, we addressed the association between the COVID-19 pandemic and coercive measures for diagnostic groups separately as previous research has not addressed these groups individually. The occurrence rate of coercive measures increased in four patient groups, namely organic mental disorders, substance use disorders, schizophrenia and other psychotic disorders (paper 3) and personality disorders (paper 2). In the other groups, we did not find any change within the context of the COVID-19 outbreak (paper 3). All diagnostic groups exhibited unique progression in the use of coercive measures, both before and after the COVID-19 outbreak.
The findings of this doctoral thesis support the claim for flexible mental healthcare, with flexible meaning that treatment is adapted to each person, to each situation individually. The COVID-19 pandemic revealed the fragility and structural weaknesses of our healthcare system. In future, we will need to pay special attention to vulnerable populations, in particular in the context of national or global dynamics, in research as well as in clinical settings.