Psychiatrists’ motives for compulsory care of patients with borderline personality disorder – a questionnaire study

Introduction Borderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality. Aim To investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care. Materials and Methods A questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with room for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis. Results The psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent. Conclusion The large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time.

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

Background Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. Aims We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. Method This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. Results Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. Conclusions A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

The right to smoke and the right to smoke-free surroundings: international comparison of smoke-free psychiatric clinic implementation experiences

Background In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15–20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics. Aims To investigate the attitudes and experiences regarding smoke-free policies among managers and staff involved in the implementation processes of smoke-free psychiatric clinics at hospitals in Malmö (Sweden) and Barcelona (Spain). Method We used a qualitative methodology, with 15 semi-structured interviews. The interviews were conducted with each participant individually, and were subsequently transcribed. The data were analysed with systematic text condensation. Results There were notable differences in how the smoke-free policies were carried out and experienced, and attitudes regarding the policy changes differed in the two settings. Key differences were the views on the right to smoke in compulsory care and to stay in smoke-free surroundings supported by smoking cessation intervention; the prioritisation of staff facilitation of smoking breaks; and views on smoking and smoke-free psychiatry. In contrast, participants agreed on the importance of staff education and management support. A smoking ban by law and belonging to a network of smoke-free hospitals were also relevant. Conclusions Staff education, and support from staff and management for the patients’ right to stay in smoke-free surroundings, facilitated successful implementation of smoke-free policies in the psychiatric clinics, whereas supporting the right to smoke was a barrier.

Mat, makt och motstånd: Om konflikter inom tvångsvård

This article discusses how food constitutes a source of conflict at locked compulsory care institutions for youth and adults. The conflicts that arise are often about where, when and what one is allowed to eat, and can have serious consequences such as isolation of the inmate. Both the inmates and the staff describe these conflicts as being about »small things«. But while the staff maintains this level of interpretation, stories from the inmates reveal that in the context of the total institution, these »small things« can be very significant. The rules regarding food are both a reminder of the loss of the outside world and evidence of the loss of control and power that comes with confinement. The results show that younger inmates are more thoroughly controlled than their older counterparts in several respects.

Dutch Mental Health Patients’ and Significant Others’ Perspectives on Compulsory Treatment at Home: One Size Does Not Fit All

On January 1, 2020, the Compulsory Mental Health Care Act took effect in the Netherlands. It contains provisions for compulsory community treatment (CCT) and compulsory treatment at home (CTH). In this study, we collected the opinions of patients and their significant others on CTH and on their preferences regarding compulsory care in their homes. Patients and their significant others were involved in the experience-based co-design of a purpose-built online questionnaire. This questionnaire was completed by 624 patients and 531 significant others. Sixty-one percent of the patients and 62% of the significant others did not want compulsory treatment to take place at home but in hospital or elsewhere. Patients’ and significant others’ opinion showed few differences, except with regard to the involvement of the significant others in CTH. As the respective views of patients and significant others were mixed, we recommend that crisis plans and compulsory treatment plans should be individually tailored to the needs and wishes of patients and their significant others regarding CTH.

The pragmatic application of attachment theory in medical decision making regarding emotionally unstable personality disorder presentations to healthcare settings

A hypothesis is formulated whereby individuals with adverse childhood experiences can come to have a disrupted attachment system and this can impact the manner in which individuals engage in healthcare. Maslow's hierarchy of needs suggests a motivation for safety and it is proposed that the healthcare system can come to represent the secure base. Behaviours that lead an individual into the healthcare setting can thus be positively reinforced by satisfying such a dynamic need. Prescribing behaviours are examined relating to this notion. The spectrum of intention-to-die type presentations in an acute healthcare setting are considered. The contribution of the concept of risk and uncertainty to decision makers is examined as a possible component to the propagation of unhelpful care pathways, where risk averse decision making leads to interventions of limited clinical utility for an individual. An introduction to the notion of a "corrupted capacity assessment" is made, which refers to the process of a doctor concluding that an individual lacks capacity without considering that this may be the outcome desired by a patient with capacity. Pragmatic strategies are suggested as a way to minimise iatrogenic harms and maximise therapeutic potential at clinical encounters where risk is a facet. Longitudinal assessments with an acknowledgement of the harms in preceding compulsory care pathways are promoted as well as an articulation of the clinician's anxiety for the purposes of reflection, in order to arrive at a clinical decision that is solely in the patient's best interest. It is suggested that ambivalence over the patient's perception of value to life is explicitly validated at such junctures. Personal responsibility and capacity for individuals presenting should be therapeutic goals if an individual has come to, or is doubting, their own autonomy and wishing to invest such factors in compulsory care pathways.

Are the problems and motives clear enough? A study on the placement of unaccompanied asylum-seeking minors at compulsory care institutions in Sweden

The Swedish National Board of Institutional Care (SNBIC) is an independent governmental agency that provides compulsory care for minors with psychosocial problems, criminal behavior, and substance abuse. During recent years, a noticeable number of the youth placed at compulsory care institutions have been asylum-seeking minors who have arrived in Sweden without parents or guardians. This steady increase in placements has raised questions and concerns among the involved actors regarding the motives and needs underlying these placements. This qualitative study investigates the main motives that lead unaccompanied asylum-seeking minors to be placed at SNBIC residential homes and the problems that are to be solved during their placement, according to social workers and SNBIC staff. The study is based on 28 in-depth interviews with social workers and SNBIC staff. Findings indicate clear disagreement between social workers and SNBIC staff with regard to the motives for placing unaccompanied minors at SNBIC homes. Although the social workers and SNBIC staff explain that most of the unaccompanied youth placed at SNBIC homes have some form of criminal behavior or substance abuse, SNBIC staff believe, in some cases, the problem is not sufficiently serious to warrant compulsory care. As these disagreements and misunderstandings between the actors have an impact on their collaboration and, consequently, the situation of the unaccompanied minors, all attempts to reach a consensus on the leading causes for placement and the problems that need to be solved with SNBIC placement would increase security for both the young people and the relevant staff.

Against Ulysses contracts for patients with borderline personality disorder

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients.

Associations between a risky psychosocial childhood and recurrent addiction compulsory care as adult

Background: Treatment for substance use disorder (SUD), results, in general, in improvements in terms of both drug use and social functioning. However, there are clients who are in need of repeated treatment. The aim of this retrospective study was to identify, for adults in compulsory care for severe SUD, the association between reporting having experienced a risky psychosocial childhood and repeated entries into the Swedish compulsory care system for SUD. Method: Hierarchical logistic regression and mediation analysis methods were used to analyse data from the Swedish National Board of Institutional Care (SiS) database. The sample included 2719 adults assessed at their compulsory care intake. The study examined the association between history of institutional care, family with SUD or psychiatric problem and repeated compulsory care entries as an adult controlling for main drug, age and gender. Results: In the regression model the factor with the strongest association with repeated compulsory care intakes for SUD, was as a child having been in mandated institutional care ( OR = 2.0 (1.60–2.51)). The proportion of the total effect that is mediated through LVU (law (1990:52) the care of young persons (special provisions) act) was 33% for SUD problems in family during childhood, 44% for psychiatric problems in family during childhood, and 38% for having been in foster care. Conclusion: Having been in mandated institutional care as a youth was strongly associated with repeated compulsory care for SUD as an adult. This is concerning since receipt of services as a child is supposed to mediate against the consequences of risky childhood conditions. These adults, as a group, are in need of a well-coordinated and integrated system of extensive aftercare services to reduce the likelihood of re-entry into compulsory care for an SUD.