Therapeutic leave and coercive measures in inpatient psychiatry a clinical and health economic viewpoint

In inpatient psychiatric care, readmissions and coercive measures can be problematic in various
aspects. More research on treatment variables is needed to improve the quality of care and reduce
readmission and coercive measures. Inpatient care is also a large cost driver of healthcare
systems. With a global increasing economic burden of mental ill health, health economic analyses
are warranted to promote policy change according to scientific evidence. This dissertation,
therefore, integrates a clinical and health-economic perspective to examine two treatment
variables in inpatient care: therapeutic leave and staff resources relating them to readmission,
direct inpatient costs, and coercive measures. Therapeutic leave (TL) is an established practice
in inpatient psychiatry. However, research on its association with readmission and inpatient costs
is scarce. Studies have addressed the association between staff resources and coercion but yield
limited and heterogeneous results.
Study 1 assessed the readmission risk of patients with TL during their inpatient stay compared to
patients without TL applying a survival analysis. The results showed a significantly longer
cumulative survival and a reduced hazard of readmission for patients with TL compared to patients
without TL. Study 2 was a follow-up study of Study 1 and examined whether there is an association
between TL and direct inpatient costs in the months following discharge. We applied a Tweedie
regression model. Study 2 showed TL is associated with lower direct inpatient costs after
discharge. Study 3 examined how efficiently psychiatric clinics maximize inpatient cases without
seclusion and restraint with their given staff number of full-time equivalents. The results suggest
that clinics are relatively efficient at maximizing cases without coercion. However, changes in
management and careful consideration of team composition are necessary to further increase
cases without seclusion and restraint.
In conclusion, Study 1 and Study 2 add to the limited knowledge of TL in relation to readmission
risk and direct healthcare costs. In addition, Study 3 sheds more light on staff-related factors in
reducing coercive methods. By integrating a clinical and health-economic perspective, this
dissertation considers an ever-present and growing conflict between economic motives and a
patient-oriented psychiatry lead in line with ethical principles. This dissertation's results imply a
link between TL during inpatient treatment, a lower readmission risk, and lower direct inpatient
costs after discharge. Regarding TL, randomized controlled trials are needed to assess the
causality of our results. We still need to better understand the underlying mechanisms of TL. More
health economic analyses, especially including indirect costs, are required. TL might be a suitable
intervention to improve the quality of care. Whilst our results of Study 3 show that clinics are
relatively efficient at maximizing cases without coercion, economic and ethical considerations
regarding staff numbers in psychiatric clinics need to be balanced out. Coercive measures should
never, even implicitly, be driven by monetary factors. When it comes to the integrity of human
beings, ethical considerations must outweigh economic motives.