Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice.

To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required.

PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed.

Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored.

Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement.

To examine the impact of this intervention on people with lived experience, carers and staff.

People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed.

Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored.

This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

The World Psychiatric Association recently emphasised that the protection of human rights in mental healthcare was a ‘central concern’. This paper examines recent literature on human rights and mental healthcare.

To (a) outline how international human rights law distinguishes between the protection and promotion of human rights; and (b) explore the literature on promoting human rights in mental healthcare which avoids what has been termed the ‘Geneva impasse’ between those who argue that compulsory care and treatment can never comply with human rights law and those who argue that they can if certain conditions are met.

The following doctrinal methodology was used: (a) identification and detailed analysis of international human rights conventions and commentaries; (b) identification of key literature on human rights and mental healthcare; and (c) critical analysis of key issues emerging from the literature.

Much of the literature on human rights and mental healthcare focuses on whether restrictions on compulsory care are required to meet the requirements of United Nations Conventions. There is an emerging literature identifying measures to promote the right to the enjoyment of the highest attainable standard of mental health.

There has been a focus on protecting the rights to liberty and equality before the law for mental health patients. The nascent literature on promoting human rights in mental healthcare could mark a way forward beyond the ‘Geneva impasse’ that has dominated public debate in recent years.

Compulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical.

To report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis.

Data for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis.

A total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14–1.45; P < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23–2.42; P < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07–1.40; P < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81–2.12; P = 0.22).

Increased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.

Peer Support Work can be an effective way to support patients and their participation also in psychiatric populations. Unlike in general psychiatry there is less experience with peer support work in forensic mental health inpatient settings. Characteristics different from general psychiatry, e.g., regarding safety, might be a reason for the delay of their implementation.

We aim to present the implementation of a peer support worker in a forensic mental health setting for addicted offenders. We address reservations of staff before the implementation and their development during the first year. The perspective of patients about their experiences is taken into consideration. The development of the peer support workers position and tasks is demonstrated.

Focus groups and interviews were conducted with several groups of people, amongst them employees of several professions, patients and the peer support worker of the clinic. Interviews and focus groups were recorded and transcribed for thematic analysis.

Reservations of staff comparable to these found in general psychiatry occurred in the forensic mental health professionals. These could be diminished during the first year. Most of the patients were able to accept and trust the peer support worker, in some cases after initial mistrust. The peer support worker felt accepted in the team and was able to develop a routine as well as own tasks.

The experiences from one year testified that implementation of peer support work into a forensic mental health inpatient setting is possible. Further patient outcomes are to be explored but the current results are promising.

No significant relationships.

Compulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use.

To examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis.

New Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status.

In total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups.

CTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.

A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN.

In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics.

IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these.

High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.

The mental health law is not universal. In Portugal the urgent compulsory regimen is based on the principles of the presence of severe mental anomaly and risk to themselves or others.

Characterization of patients admitted in compulsory hospitalization (CH) between 2018 and 2020, in the University Hospital Center of Algarve - Faro Department

Retrospective study from January/2018 to August/2020. Social, demographic, epidemiological and clinical data were evaluated.

Of 1191 patients who were admitted 36% occurred in CH. There was a predominance in male sex (58%), the average age was 43 years old. For 62% it wasn´t the first hospitalization and 58% had a recent prescription. Admission occurred most frequently because of the presence of psychotic symptoms (figure1) and according to the international classification of disease (ICD10) the most frequent diagnosis was unspecified nonorganic psychosis (figure2). At discharge 59% of the patients remained on compulsory treatment (CT), where the most frequent diagnosis was schizophrenia. Although most of these patients were discharged with oral and long-term injectable antipsychotics, there were higher rates of readmissions when compared to non-CT group, were the most frequent diagnosis was mental and behavioural disorders due to psychoactive substance use and most of the patients were discharged only with oral therapy.

Patients in compulsory regimen have a severe mental illness with higher rates of readmission. We highlight the use of long-term injectable antipsychotics in terms of compliance. These findings corroborate the need for specialized and multidisciplinary approach in terms of psychosocial rehabilitation in these patients.

Given the effectiveness and overall safety in several psychiatry conditions, electroconvulsive therapy remains a widely used procedure in current medical practice. Informed consent is still a requirement for the use of ECT both in voluntary and compulsory treatment; however, since severe mental illness can affect decision-making capacity and insight of the need for treatment, this requirement often constitutes an obstacle to its use. In addition, stigma around ECT still contributes to treatment refusal.

To summarize the most recent evidence published about ECT and discuss the ethical and legal implications of its use, enlightened by the empirical description of a clinical vignette.

Review of literature on the ethical and legal issues involving the ECT use in patients on compulsory treatment, considering the efficacy, risks, the mental health legislation in Portugal, and several international directives.

Informed consent is the basic tenet in the contemporary physician-patient relationship. In principle, ECT can only be administered to patients who prior consent to the treatment. In contemporary practice, providing the best medical assistance and respecting the patient’s autonomy are two fundamental principles. However, we often face an ethical dilemma, when severely ill patients, whose insight, the ability for self-determination and decision-making capacity may be impaired, refuse a potential beneficial treatment as ECT.

The use of ECT in severe mental illness is still hampered by legal and ethical constraints. A future revision of the law could protect patients from being excluded from a treatment that may change the course of the disease.

No significant relationships.

Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication.

In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models.

In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; ηp2 = 0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; ηp2 = 0.70; odds ratio: 0.90).

This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.