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Im Zusammenhang mit der UN-Konvention uber die Rechte von Menschen mit Behinderungen konzentriert sich die Diskussion uber psychiatrische Versorgungskonzepte auf die Vermeidung von Gewalt und Zwangsmasnahmen. Offen gefuhrte psychiatrische Kliniken berichten uber weniger Gewalt und weniger haufige Zwangsmasnahmen. Dadurch kann eine spezifische Milieugestaltung gelingen, die soziale Ressourcen fordert und institutionelle Exklusion minimiert. Das Konzept geht uber das Offnen von Stationsturen hinaus, wenn die Klinik intensiv und aufsuchend in der Gemeinde tatig wird. Die Modellvorhaben nach § 64b Sozialgesetzbuch V zur sektorubergreifenden Versorgung ermoglichen flexible bedarfsorientierte Behandlung und Home-Treatment.

ZusammenfassungAusgehend von der Situation der Heidenheimer Klinik beschreiben wir die notwendigen Veränderungen, um völlig auf Fixierungen in der Allgemeinpsychiatrie einschließlich Gerontopsychiatrie und Suchtbehandlung zu verzichten, ohne auf andere Zwangsmaßnahmen wie Isolierung oder Zwangsmedikation zurückzugreifen. Dabei werden die bisherigen Fixierungen durch 2:1- oder 3:1-Betreuungen ersetzt. Die Klinik erfasst die Fixierungshäufigkeit und -dauer minutengenau. Dies erlaubt die Bestimmung der Zeiten für intensive Einzelbetreuungen. Die Anlässe für die bislang durchgeführten Fixierungen und individuelle Besonderheiten bei der Begleitung erlauben eine Einschätzung der Betreuungsintensität und damit des erforderlichen Personalaufwands. Die Personalressourcen und dafür erforderlichen Kosten werden mit den üblichen Ausfallzeiten und Personalkosten für qualifiziertes Pflegepersonal errechnet und ergeben einen zusätzlichen Bedarf von 4 % des jährlichen Klinikbudgets. Problematisch für die Umsetzung erscheint der Fachkräftemangel in der Krankenpflege in Deutschland.

In August 2019, a manuscript was published in this journal that aimed at imagining a mental health care system that renounces the judicial control to better focus on the will and preferences of those who require support. Alternative scenarios for dealing with risk, inpatient care, and police custody were presented that elicited strong and emotionally laden reactions. This article adds further reflections to this debate, aiming at contributing explanations for this unsettlement. A productive notion of criticism is discussed, and ways to achieve change toward a more human rights-oriented psychiatric practice are outlined., publishedVersion

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

Social values and concepts have played a central role in the history of mental health care. They have driven major reforms and guided the development of various treatment models. Although social values and concepts have been important for mental health care in the past, this Personal View addresses what their role might be in the future. We (DG, PH, and SP) did a survey of professional stakeholders and then used a scenario planning technique in an international expert workshop to address this question. The workshop developed four distinct but not mutually exclusive scenarios in which the social aspect is central: mental health care will be patient controlled; it will target people's social context to improve their mental health; it will become virtual; and access to care will be regulated on the basis of social disadvantage. These scenarios are not intended as fixed depictions of what will happen. They could, however, be useful in guiding further debate, research, and innovation.

A simple instrument to record case-related coercive measures was tested as part of a pilot project of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). To assess coercive measures data were collected for 3 months in 8 German hospitals for psychiatry and psychotherapy. The type of measures used, the main diagnosis and the legal basis for the coercive measures were documented. In the sample studied, coercive measures were applied in 8% of cases. Coercive measures were most commonly used in patients with a schizophrenic disorder. The principle of justifiable necessity according to A A 34 of the German Penal Code was used particularly often as the legal basis for justifying the coercive measures. Suitable measurement instruments and reliable data that enable the learning of best practices represent the basis for a reduction of coercive measures.

Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes.In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data.In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63).Locked doors might not be able to prevent suicide and absconding.None.

Based on the UN Convention on the Rights of Persons with Disabilities (CRPD), several UN bodies, among them the High Commissioner for Human Rights, have argued for a complete ban of all coercive interventions in mental health care. The authors conceptualize a system for mental health care based on support only. Psychiatry loses its function as an agent of social control and follows the will and preferences of those who require support. The authors draw up scenarios for dealing with risk, inpatient care, police custody, and mental illness in prison. With such a shift, mental health services could earn the trust of service users and thereby improve treatment outcomes.

Coercive treatment with antipsychotic drugs was commonly used in German psychiatric institutions until it became a topic of substantial medical, legal and ethical controversy. In 2011 and 2012, several landmark decisions by Germany’s Constitutional Court and Federal Supreme Court challenged this practice in all but life-threatening emergencies. In March 2013, the new legal provisions governing coercive treatment took effect allowing coercive medication under stricter criteria. While mainstream psychiatry in Germany resumed the use of coercive medication, although less frequently than before 2012, there are examples where clinicians put an even greater emphasis on consensual treatment and did not return to coercive treatment. Data from a case study in a local mental health service suggest that the use of coercive medication could be made obsolete.

We welcome Newton-Howes & Ryan's plea for a more restrictive use of community treatment orders (CTOs).[1][1] They have a heavy impact on patients' rights, are largely ineffective[2][2] and are likely to damage the trust between patients and treatment teams, which is vital for sustained success in

Aims and MethodWe review the prescribing rates for clozapine among all mental health trusts in England and explore whether it has changed with the introduction of NICE guidelines, generic clozapine and the Healthcare Commission ratings. Data were collected from mental health trusts in 2005–2006 and compared with a previous study from 2000. Mental health star ratings of 2004–2005 were taken from the Healthcare Commission.ResultsWe found a reduced inter-trust variability from 34-fold variation in 2000 to 5-fold variation in 2005–2006. There was a significant inverse relationship between star rating and clozapine prescribing.Clinical ImplicationsNICE guidelines and generic clozapine seem to have improved access to gold standard therapy for treatment-resistant schizophrenia. Star ratings have little bearing on the implementation of NICE guidelines.

Aims and MethodDialectical behaviour therapy is an evidence-based treatment for people with borderline personality disorder. We describe implementation and outcomes of a new service.ResultsHospital use and frequency of self-harm were reduced dramatically with dialectical behaviour therapy. Moreover, the therapy can be implemented successfully in a relatively short time at modest costs.Clinical ImplicationsDialectical behaviour therapy provides a useful model of treatment for people with borderline personality disorder and/or self-harm in community mental health settings.