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Objective: Identification of predictors that contribute to explaining regional variance of involuntary admission (IA) in Switzerland., Methods: Multiple regression analysis including potential predictors and regional rates of IA at the level of utilisation-based care regions., Results: Authorisation to issue involuntary admission, assistance/guardianship, outpatient consultation rate in psychiatric practices, hospitalisation rate and urbanisation are significantly related to regional variation in IA rates., Conclusion: Restrictive regulation of the authority to issue IA and voluntary outpatient psychosocial and administrative support measures can contribute to a reduction in the rates of IA., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Small area analysis is a health services research technique that facilitates geographical comparison of services supply and utilization rates between health service areas (HSAs). HSAs are functionally relevant regions around medical facilities within which most residents undergo treatment. We aimed to identify HSAs for psychiatric outpatient care (HSA-PSY) in Switzerland., Methods: We used HSAr, a new and automated methodological approach, and comprehensive psychiatric service use data from insurances to identify HSA-PSY based on travel patterns between patients' residences and service sites. Resulting HSA-PSY were compared geographically, demographically and regarding the use of inpatient and outpatient psychiatric services., Results: We identified 68 HSA-PSY, which were reviewed and validated by local mental health services experts. The population-based rate of inpatient and outpatient service utilization varied considerably between HSA-PSY. Utilization of inpatient and outpatient services tended to be positively associated across HSA-PSY., Conclusions: Wide variation of service use between HSA-PSY can hardly be fully explained by underlying differences in the prevalence or incidence of disorders. Whether other factors such as the amount of services supply did add to the high variation should be addressed in further studies, for which our functional mapping on a small-scale regional level provides a good analytical framework., (© 2022 The Authors. International Journal of Methods in Psychiatric Research published by John Wiley & Sons Ltd.)

Background: Coercive measures continue to be an important topic in psychiatry. However, there is no proof of the effectiveness of the use of coercive measures, especially with suicidal people. For many years, attempts have been made to replace such measures with alternative noncoercive intervention options. This paper aims to clarify the situation of coercive measures, more precisely seclusions, in a general psychiatric hospital in Switzerland. It focuses on compulsory measures in patients with suicidal tendencies., Method: In this single-centre retrospective cohort study, we used routinely collected medical data and performed qualitative analyses of medical histories to examine whether alternative measures to seclusion had been offered and/or provided to patients who had been secluded solely because of suicidality. Patients were aged 18-65 years and had received inpatient treatment at one of five adult acute care units at a general psychiatric hospital in Switzerland between September 2016 and December 2019., Results: There were 5,935 inpatient treatment cases during the study period. Suicidality was rated as "acute" or "very high" at least once during the hospitalization in 219 (3.7%) cases. Of these, 60 were excluded from further analyses as they involved seclusion, but suicidality was not the exclusive indication for this measure. Coercive seclusion was imposed exclusively due to suicidality in 53 (33.3%) of the remaining 159 cases, whereas 106 (66.7%) cases were not secluded. The rates of seclusion among suicidal patients varied considerably between the hospital wards (13.0% to 55.3%). Suicidal patients with non-Swiss residence status and/or lacking language skills were particularly prone to be secluded. Additionally, alternative interventions were offered and provided significantly more frequently in the nonsecluded patients., Conclusions: To avoid seclusion due to suicidal tendencies, it is necessary to have a general attitude of avoiding coercive measures at all costs. It is also important for qualified staff to be able to deal with challenging sociodemographic characteristics of patients such as foreign-language, which may require translators and intercultural interpreters., (© 2022. The Author(s).)

We aimed at determining differential characteristics of patients treated by a home treatment (HT) team compared to patients treated on hospital wards. Of 412 consecutively admitted patients, 194 (47.1%) were at least partially treated at home, whereas 218 (52.9%) received inpatient treatment only during an episode of acute illness. A multivariate logistic regression model identified current employment to increase the odds of HT (p < 0.001). A primary diagnosis of anxiety or stress-related disorder (p < 0.001), other rare primary diagnoses such as personality disorders (p < 0.001), and more pronounced clinician-rated social problems (p = 0.041) decreased the odds of HT. Overall, it remained difficult to clearly specify suitability for HT based on available sociodemographic and clinical characteristics. This might indicate that responsible clinicians consider HT to be a viable alternative to hospital care and hence initiate HT for a relatively broad spectrum of patients., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Home treatment (HT) has been proposed as an alternative to inpatient treatment for individuals in acute mental crises. However, there is limited evidence concerning the effectiveness of HT to date. The aim of this study was to investigate which patients benefit most from HT. The concept and utilization of two HT services in Switzerland were retrospectively compared based on routine medical data of all patients who were treated in one of the two HT services between July 2016 and December 2017. We examined which patient characteristics were related to successful replacement of hospital care by HT based on a calculated success score using binary regression analyses. The whole sample included 408 individuals with an average age of 43 years and of whom 68% were female. As a result of conceptual similarities, in both HT settings, the typical patient was middle-aged, female and having an affective disorder as the main diagnosis. Half of the treatment cases met the criteria of successful replacement of hospital care (> 50% of the total treatment episodes in HT, treatment duration < 40 days and treatment terminated by mutual agreement). The results of the regression analyses indicated that patients with a lower symptom severity at admission (lower HoNOS score) and those who were employed had more likely a successful replacement of hospital care.The findings suggest that patients with acute mental disorders who have a certain level of functioning and social support might benefit most from HT in the sense of successful replacement of hospital care.

Background: In line with previous findings, in a recent randomized controlled trial (RCT), we found that home treatment (HT) for acute mental health care can reduce (substitute) hospital use among severely ill patients in crises. This study examined whether the findings of the RCT generalize to HT services provided under routine care conditions., Methods: We compared patients who received HT during the RCT study phase with patients who received the same HT service after it had become part of routine mental health services in the same catchment area. Sociodemographic and clinical characteristics as well as service use (HT and hospital bed days) were compared between the RCT and the subsequent routine care study period., Results: Compared to patients who received HT during the RCT, routine care HT patients were more often living with others, less often admitted compulsorily, more often diagnosed with anxiety and stress-related disorders (ICD-10 F4) and less often diagnosed with schizophrenia spectrum disorders (F2). When compared to patients who were exclusively treated on hospital wards, involvement of the HT team in patients' care was associated with a clear-cut reduction of hospital bed days both during the RCT and under routine care conditions. However, unlike during the RCT study period, involvement of HT was associated with longer overall treatment episodes (inpatient + HT days) under routine care conditions., Conclusions: HT seems to reduce the use of hospital bed days even under routine care conditions but is at risk of producing longer overall acute treatment episodes.

Background: Home treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment., Aims: To test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use., Method: A total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2-F6, F8-F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437)., Results: The mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242)., Conclusions: Home treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.

Objective: To identify effective components of home treatment (HT) and to evaluate the implementation of a new HT team from a service user perspective., Methods: Experiences of patients, relatives and staff were assessed using semi-structured interviews and an online questionnaire. Thematic analysis was applied to determine key themes., Results: 25 interviews and 70 questionnaires were analysed. Four key themes emerged: individualisation, proximity to daily life, conceptual aspects, and requirements (for patients and for the service model). Major challenges for the implementation of HT were the suitability for HT, time of referral to HT, and handing over of responsibility from hospital staff to the HT team., Conclusion: Essential requirements for HT are no-harm agreements, patients' ability to maintain daily routines, and shared responsibility between patients and staff. Implementing HT within an existing care system should be accompanied by sufficient information on the new service model for other service providers involved. This may be achieved through HT team members visiting hospital wards and outpatient facilities, illustrating functioning and limitations of HT using case reports., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Previous research suggested a distance decay effect in health services systems, with people living closer to service facilities being more likely to use them., Method: In this ecological cross sectional study, we conducted spatial and statistical analyses in a Swiss mental health services system being legally bound to provide primary mental health care to approximately 620,000 inhabitants. We examined a cohort of all patients who were over 18 years old and who were treated in the mental health services system between January and December 2011., Results: There were 5574 treatment cases during the 12-month period, 2161 inpatient cases and 3413 outpatient cases. Travel time by public transportation between patients' residence and the closest mental health service facility negatively predicted the utilization of outpatient services for all mental disorders, even after controlling for variability in ecological (e.g. socioeconomic) characteristics of the communities in the service provision area. For utilization of inpatient wards no geographical distance decay effect was observed, except for organic mental disorders., Conclusions: Based on these findings, outpatient clinics should be most effectively located decentralized and in the largest communities to meet the needs of the population as close as possible to where people live and to avoid remote areas being insufficiently supplied with mental health care. For mental hospitals and inpatient services decentralized location seems to be less important.

Aim: To examine the validity of diagnoses obtained by clinicians during routine clinical examination on acute psychiatric inpatient wards., Methods: N=100 inpatients with a broad spectrum of major mental disorders were randomly selected in a mental hospital's department of general psychiatry. Patients were diagnosed by independent assessors within Md = 5 (Range: 1-18) days of admission using the SCID I in order to examine the validity of the diagnoses given by the clinical staff based on routine assessments., Results: The commonly used clinical examination technique had good overall agreement with the SCID I assessments regarding primary diagnoses at the level of ICD-10 main categories (F2, F30-31, F32-F33, F4; κ = 0.65). However, agreement between routine clinical diagnoses and the SCID I diagnoses tended to be low for some specific mental disorders (e.g., depressive disorders) and for secondary diagnoses., Conclusions: The validity of routine clinical diagnoses established in acute inpatient settings is limited and should be improved., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Home treatment has been proposed as an alternative to acute psychiatric inpatient treatment. Health insurance systems in Germany and in Switzerland hinder the nationwide implementation of home treatment teams into mental health systems, although the German S3 guidelines for psychosocial treatments of severe mental illnesses recommend provision of acute care at home. Evidence for home treatment is positive, yet there are only few up-to-date studies from Europe and differential indication criteria are lacking. The aim of home treatment is to reduce inpatient bed-days by nonadmission or early discharge. Home treatment teams are mobile, interdisciplinary, and provide 24 h services. The average treatment length in home treatment should not exceed the duration of the inpatient treatment. The home treatment team usually takes the responsibility for the gatekeeping for inpatient treatment. Future research should focus on precise definitions of the structures and interventions of home treatment teams. Home treatment for severely mental ill patients should be distinguished from assertive community treatment and case management, which offer continuing rather than acute crises care.

We analyzed the dispositional decisions taken in a unit for clinical decision making (UCDM) which was set up to examine all emergency inpatient referrals to a psychiatric hospital. Hospitalization proved unnecessary for at least 17 % of the N = 2,026 inpatient referrals over a one year period. Instead, these patients were admitted to day-hospitals or outpatient treatments, resulting in annual cost savings of approximately 3.3 million. Merely 8 % of those non-admitted patients had to be hospitalized within 28 days of the decision for non-admission being taken. Thus, a specialized UCDM run by clinical experts can help identify cost-effective alternatives to hospitalization.

Psychiatric emergencies are stressful and time-consuming for physicians. Comprehensive diagnostic assessment is often not feasible in psychiatric emergency situations. Primary interventions target symptoms and syndromes. Treatments for psychiatric emergencies often lack an evidence base and rely on expert opinions and good clinical practice. Target symptoms for interventions in emergency situations are agitation, aggressive behavior, delirious states, psychotic symptoms and anxiety (psychotic or non-psychotic). Pharmacological treatments are indicated due to their sedative, antipsychotic, and anxiolytic effects. It is important to look for possible medical causes and comorbidity (differential diagnosis). The treatment of delirium should always focus on any underlying medical conditions. Psychiatric emergencies require immediate action by a physician, although the options available are often limited. If an emergency situation can be converted into a crisis situation by means of a successful intervention, additional time is gained and the range of options for action may be widened.

Objective: To identify user groups of inpatient psychiatry., Methods: Retrospective cohort study over two years (n = 1295). Identification of patient subgroups based on the number of inpatient admissions and inpatient days by means of latent class analysis., Results: Two patient groups were identified: 28 % heavy users and 72 % ordinary users. Heavy users were often diagnosed with schizophrenia and they also showed increased use of outpatient services., Conclusions: Integrated service models should be developed and tested for patients with schizophrenia and HU., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Despite being recognized as an important prognostic factor for the outcome in gender identity disorder (GID), psychiatric comorbidity has rarely been assessed by means of standardized diagnostic instruments. The aim of this study was to assess current and lifetime psychiatric comorbidity in patients with GID., Methods: A cross-sectional sample of 31 patients who were treated for GID was assessed by the structured clinical interview for Axis I and II (SCID-I/II) and the Hospital Anxiety and Depression Scale (HADS)., Results: Twenty-nine percent of the patients had no current or lifetime Axis I disorder; 39% fulfilled the criteria for current and 71% for current and/or lifetime Axis I diagnosis. Forty-two percent of the patients were diagnosed with one or more personality disorders., Conclusions: Lifetime psychiatric comorbidity in GID patients is high, and this should be taken into account in the assessment and treatment planning of GID patients.

Objective: This study analyzes how sociodemographic and clinical characteristics influence the treatment decision for patients referred to a university hospital emergency room (ER) owing to attempted suicide., Method: Using a cross-sectional design, we monitored all patients admitted to a university hospital ER after attempting suicide, over a 3-year period (n = 404). Treatment decisions were categorized into 3 groups: inpatient treatment, outpatient treatment, and no further treatment., Results: Older patients were more likely to be hospitalized, while women and patients with regular occupational activity were more likely to receive outpatient treatment. In logistic regression analysis, attempted suicide using aggressive methods, history of psychiatric inpatient treatment, and psychotic disorders were associated with inpatient treatment. Adjustment and neurotic disorders were related to outpatient treatment., Conclusions: The decision to hospitalize can be satisfactorily predicted by means of sociodemographic and clinical characteristics, while the number of patients assigned to outpatient treatment is underestimated. A triage that relies only on sociodemographic and clinical data as well as risk factors could result in too frequent admissions of patients after attempted suicide.