Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

The therapeutic alliance is critical to the efficacy of psychiatric treatment and can be weakened by involuntary treatment measures. In Western culture, mental illness is still associated with violence and if significant risk of violence is detected, in Spain a civil court can order the application of involuntary treatments such as Involuntary Outpatient Commitment.

To discuss the effectiveness of some psychiatric involuntary treatments used in Spain.

- Literature review about involuntary psychiatric treatments used in Spain - Case report about a patient undergoing Involuntary Outpatient Commitment

We present the case of a 54-year-old man, diagnosed with schizophrenia, admitted to our acute psychiatric yard more than five times due to violent behavior and psychotic symptoms. Five years ago, he was summitted to a period of three years of Involuntary Outpatient Commitment. In Spain this measure can include the administration of involuntary medication, an injectable antipsychotic treatment in this case. At the end of the order, he immediately stops attending consultations and abandoned psychopharmacological treatment.

Involuntary Outpatient Commitment is a controversial measure and it stirs up the concepts of stigma, coercion, care, patient autonomy and, globally, the values of humanization in psychiatry.

No significant relationships.

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.

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

Mental health patients can experience involuntary treatment as disempowering and stigmatising, and contact with recovered peers is cited as important for countering stigma and fostering agency and autonomy integral to recovery.

To advance understanding of the interaction between involuntary treatment and contact with recovered peers, and explore hypothesised relationships to mechanisms of self-evaluation relevant to recovery.

Eighty-nine adults diagnosed with serious mental illness completed items to assess involuntary treatment experience and the extent of prior contact with recovered peers, the Internalised Stigma of Mental Illness Scale, the Self-efficacy for Personal Recovery Scale, the Questionnaire about the Process of Recovery and relevant demographic and clinical scales.

Contact with recovered peers was found to moderate the effects of involuntary treatment on internalised stigma. Sequential conditional process models (i.e. moderated mediation) then demonstrated that conditional internalised stigma (i.e. moderated by contact with recovered peers) mediated the indirect effect of involuntary treatment on recovery-specific self-efficacy, which in turn influenced recovery. Compared with those with low contact with recovered peers, recovery scores were 3.54 points higher for those with high contact.

Although study methods limit causative conclusions, findings are consistent with proposals that contact with recovered peers may be helpful for this patient group, and suggest this may be particularly relevant for those with involuntary treatment experience. Directions for future research, to further clarify measurement and conceptual tensions relating to the study of (dis)empowering experiences in mental health services, are discussed in detail.

Seclusion and mechanical restraint are coercive interventions used at psychiatric hospitals when patients are at imminent risk of harming themselves and/or others. Although these interventions have been used for decades, it remains unclear whether seclusion or mechanical restraint is superior in terms of efficacy and safety. Therefore, we aimed to systematically review studies comparing the intended and unintended effects of seclusion and mechanical restraint.

A systematic search of PubMed and Embase was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Quantitative studies comparing the intended and unintended effects of seclusion and mechanical restraint were included.

The search identified 868 unique records. Fourteen of these (3 reporting on randomized controlled trials and 11 reporting on observational studies) met the predefined inclusion criteria. The study methodology including outcome measures varied significantly across studies. The results of the 11 studies using a subjective outcome measure (patient preference/emotions) were in favour of seclusion, while the 3 studies using an objective outcome measure (duration of coercion/need for transition to other coercive measure) favoured mechanical restraint. There was a high risk of residual confounding by indication and/or bias affecting the reported results.

Based on the available literature, it cannot be determined whether seclusion is superior to mechanical restraint or vice versa. Further studies using stringent methodology are required to answer this question. A cautious conclusion based on this review is that the availability of both methods seems necessary – as both have their pros and cons.

Observational research has found that involuntary treatment provides limited benefits in terms of long-term clinical outcomes. Our aim was to review literature on existing interventions in order to identify helpful approaches to improve outcomes of involuntary treatment.

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement guidelines. Seven databases (AMED, PsycINFO, Embase Classic, Embase 1974–2017, CINAHL, MEDLINE, and BNI) were searched and the results were analysed in a narrative synthesis.

Nineteen papers describing fourteen different interventions were included. Using narrative synthesis the interventions were summarised into three categories: a) structured patient-centred care planning; b) specialist therapeutic interventions; c) systemic changes to hospital practice. The methodologies used and outcomes assessed were heterogeneous. Most studies were of low quality, although five interventions were tested in randomised controlled trials (RCTs). Preliminary evidence supports structured patient-centred care planning interventions have an effect on long-term outcomes (such as readmission), and that specialist therapeutic interventions and systemic changes to hospital practice have an effect on reducing the use of coercive measures on wards.

This review shows that it is possible to conduct rigorous intervention-testing studies in involuntary patients, including RCTs. Yet, the overall evidence is limited. Structured patient-centred care planning interventions show promise for the improvement of long-term outcomes and should be further evaluated.