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Was ist zu diesem Thema bereits bekannt? Die Bestimmungen der UN-Behindertenrechtskonvention (UN-BRK) erfordern eine grundlegende Transformation der Behandlung und Unterstützung im psychosozialen Hilfssystem hin zu einer menschenrechtlichen Praxis. Wie wird eine neue Perspektive eingebracht? Die neuen Leitlinien der Weltgesundheitsorganisation (WHO) stellen eine Reihe von Diensten vor, in denen auf der Grundlage der UN-BRK rechtebasierte, personenzentrierte und recovery-orientierte Versorgungsmodelle ganz oder weitgehend realisiert werden. Was sind die Auswirkungen für die Praxis? Der Blick auf die psychiatrische Praxis und die rechtlichen Rahmenbedingungen in den deutschsprachigen Ländern lässt erkennen, dass diese in weiten Teilen weder der UN-BRK noch den WHO-Leitlinien gerecht werden.

SummaryPsychiatrists have an essential role to play in promoting human rights in mental healthcare. The World Health Organization's QualityRights initiative, in partnership with different stakeholders, is improving the quality of psychiatric care in different countries.

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.

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.

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

Mechanical restraint is a common occurance in Germany's mental health care facilities; less common though not unusual are seclusion and compulsory medication. The authors describe a model to calculate additional resources required to provide mental health care without any of these forms of coercive measures. An analysis of actual clinical situations that led to mechanical restraint provides information of the 1:1, 2:1 or 3:1 intensive support necessary to cope with crises in inpatient mental health care. The additional resources required to provide inpatient mental health care without mechanical restraint, seclusion or compulsory medication would be at 4 % of the annual hospital budget. A national shortage of skilled nursing staff appears to be a limiting factor in moving towards a human-rights based mental health care.Ausgehend 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.

Unterstützte Entscheidungsfindung Bei der Behandlung von psychischen Erkrankungen sind viele Entscheidungen zu treffen. Nicht selten wird dabei Zwang ausgeübt. Spätestens seit der Ratifizierung der UN-Behindertenrechtskonvention sollen Behandelnde, Betreuende und Angehörige jedoch nicht mehr stellvertretend für psychisch erkrankte Menschen entscheiden, sondern bei anstehenden Entscheidungen umfassend informieren und unterstützen, je nach Ausmaß der Behinderung und nach Komplexität der Entscheidung. Dieses Buch lotet die Möglichkeiten unterstützter Entscheidungsfindung in der psychiatrischen Praxis aus. Neben der Darstellung spezifischer Herausforderungen bei bestimmten psychischen Störungen finden sich darin viele praktische Hinweise für die Betreuung, Begleitung und Therapie, insbesondere in kritischen klinischen Situationen. Empfehlenswert für alle Akteure im psychiatrischen Hilfesystem.

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.

Anliegen: Langsschnittbeobachtung der Anwendung von Zwangsmasnahmen in deutschen psychiatrischen Kliniken. Methode: Der Arbeitskreis zur Pravention von Gewalt und Zwang fuhrt seit 2000 Klinikvergleiche zur Anwendung von Zwangsmasnahmen durch und versucht die Anwendung von Zwangsmasnahmen zu reduzieren. Wir verglichen die 5 Kliniken, von denen uber 9 Jahre durchgangig Vollerhebungsdaten mit gleicher Methode vorlagen. Ergebnisse: Der Anteil der betroffenen Patienten sank zwischen 2004 und 2012 von 8,2 % auf 6,2 %. Die Standardabweichung der Ergebnismase der einzelnen Kliniken nahm um 20 % ab. Schlussfolgerungen: Die durchgefuhrten Masnahmen zur Reduzierung von Zwangsmasnahmen sind insgesamt wirksam, aber deutlich weniger als in klinischen Studien.

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.

The term of a "considerable damage to one's health" is central in German guardianship law with respect to judge's decisions on involuntary commitment and coercive treatment. A legal definition has not been provided, and up to now no explanations from the part of medicine have been available what a "considerable damage to one's health" is in the case of mental illness and how it can be determined. A consensus paper of the German Association of Psychiatry and Psychotherapy (DGPPN) explains four possible scenarios of manifestation of such kind of damage, corresponding to somatic illnesses: evidence of structural brain lesions (rare), subjective suffering (sufficient, but not necessary), impairment of functioning in important areas of life, and severe impairment of social participation (e. g. by dangerous behaviour against others). This view corresponds with the WHO's bio-psycho-social concept of health.

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.

Der Beitrag untersucht die Rolle der gemeindepsychiatrischen Pflege in England. Ausbildung, Karrieren und Spezialisierung werden beschrieben, aktuelle Trends und Probleme werden diskutiert. Besondere Beachtung finden Selbstverstandnis, Verhaltnis zu anderen Berufsgruppen und neue Entwicklungen in den Pflegewissenschaften.

Objective: The frequency of compulsory admission varies widely across Europe. Although there has been some research on a nation-wide level, no work has been done to compare mental health legislation in different countries in relation to detention rates and to patients' perception of hospital detention. Method: Databases and government statistics were searched for regional, national and European data. Legal frameworks were compared and reviewed in relation to patients' and professionals' views. Results: Nearly 20-fold variations in detention rates were found in different parts of Europe. Criteria for detention of the mentally ill are broadly similar when it comes to patients at risk to themselves or others. However different rules apply for involuntary treatment in the interest of the patient's health. Conclusion: Variations in detention rates across Europe appear to be influenced by professionals' ethics and attitudes, sociodemographic variables, the public's preoccupation about risk arising from mental illness and the respective legal framework.

OBJECTIVE AND METHODS Polydipsia with hyponatraemia commonly occurs with chronic psychosis and is associated with a reduced life expectancy for individuals diagnosed with schizophrenia. We describe a 51 years old man who presented with polydipsia during a relapse of paranoid schizophrenia. While treated with Clozapine, and despite regular observation and daily control of creatinine and electrolytes, the man suddenly collapsed and died after drinking huge amounts of water. No sedation from psychotropic medication or drugs and alcohol was present in this case. Sodium levels on the day of death and the day before were within normal range. A post-mortem revealed aspiration of water and gastric content as the cause of asphyxiation and death. A literature search in Medline and Embase did not yield a description of a similar case. RESULTS AND CONCLUSIONS This case highlights the risk of aspiration associated with polydipsia in chronic schizophrenia. Daily control of electrolytes to identify hyponatremia and regular observation are recommended but may not be sufficient to prevent sudden death from drinking huge amounts of water.

To evaluate multiple efforts of the last decade to reduce the use of coercive measures in psychiatric hospitals.A working group for the prevention of violence and coercion in psychiatric hospitals has compared several outcome indicators since the year 2000 and repeatedly has provided evidence-based recommendations for clinical practice. We present data from those 5 hospitals with complete data sets recorded by an identical method over 9 years.The percentage of admissions exposed to any kind of coercive measure decreased from 8.2 % in 2004 to 6.2 % in 2012. The standard deviation of outcomes between hospitals decreased by 20 %. Changes in the duration of measures were mostly insignificant.Measures to reduce the use of coercion are effective in clinical practice, but to less extent than in clinical studies. A ban on all forced and non-consensual medical interventions, as being stipulated by the UN Special Rapporteur on Torture, has so far not materialized in the participating psychiatric institutions.

Background: A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder. Methods: Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care. Results: Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89–0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI –603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76–0.80, p < 0.001). Conclusions: DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.