Preventing Compulsory Admission to Psychiatric in-patient Care using Psycho-education and Monitoring

Custodial or compulsory measures constitute a drastic encroachment on an individual's personality and autonomy of action. Nonetheless, these measures are essential for the prevention of harm to the patient or to another party when the person affected, and/or their immediate environment, cannot be helped by other means and milder action is not possible. The high ethical relevance of these problems is strengthened even more by the fact that the way mental health services handle custodial measures varies considerably. In Switzerland, in particular, the rate of protective custody (FFE) is relatively high (in the Canton of Zurich: 26% - 30% of psychiatric in-patient admissions).

In spite of the ethical and care-political relevance of this problem, there has been, up until now, a lack of reliable documentation concerning the preventative measures which, applied directly prior to a mental health crisis, would reduce the number of involuntary admissions. Reducing the number of cases of involuntary in-patient treatment by using appropriate preventative measures would lead to a decrease in the amount of constraint the patients experience and to an increase in their autonomy of action. For the health care system this would mean a reduction in health care costs.

In this study, which is being carried out in co-operation with the study group for Care Research at the Central Institute for Mental Health in Mannheim, under the direction of Prof. H.J. Salize and Prof. H. Dressing, an innovative intervention program is being evaluated. The program focuses on the interest of the patient to avoid a loss of autonomy as far as possible. The intervention program consists of problem-specific training, on the one hand, and a personal emergency card filled in together with the patient and issued prior to his or her being discharged from the clinic. In addition, the program provides preventative monitoring of individual risk factors for compulsory admission with the help of a personal checklist. This preventative monitoring extends for a period of two years after a patient’s discharged from the clinic.

The aim of this prospective intervention study is to evaluate the success rate and cost-effectiveness of this intervention programme. In order to do this, a study group of 400 patients with chronic mental disorders and a high risk of being taken into protective custody (FFE) is to be recruited from four psychiatric clinics in the Canton of Zurich. Patients who agree to take part in the study are randomly assigned either to the intervention group or to a control group (which receives the usual, standard treatment). 

In order to document the effectiveness, a baseline assessment is carried out on being discharged from the clinic as well as follow-up assessments 12 months and 24 months later. This involves asking the patient questions in the form of an interview and with the help of questionnaires. Clinical and socio-demographic data will be collected as well as information about the utilization of care services.

The main target criterion for the evaluation is the number and length of involuntary psychiatric in-patient admissions. A significant reduction in the number of involuntary admissions is expected for the patients of the intervention group and consequently a reduction in health care costs. Secondary aims are empowerment, satisfaction with treatment and the patient's quality of life. The hypothesis is that, after 24 months, these should be significantly greater in the intervention group than in the control group, while the constraints experienced should be significantly lower. The whole project, including the recruitment and intervention phases, the 24 month follow-up period, analysis, and the compiling of reports should take approximately 5 years.