Paternalism versus autonomy – are we barking up the wrong tree?

SummaryWe explore whether we can reduce paternalism by increasing patient autonomy. We argue that autonomy should not have any automatic priority over other ethical values. Thus, balancing autonomyv.other ethical pillars and finding the optimal balance between the patient's wishes and those of other relevant stakeholders such as the patient's family has to be dynamic over time.</jats:p

Occurrence of post traumatic stress symptoms and their relationship to professional quality of life (ProQoL) in nursing staff at a forensic psychiatric security unit: a cross-sectional study

Background: Violence is frequent towards nurses in forensic mental health hospitals. Implications of this high risk environment have not been systematically explored. This paper explores occurrence of symptoms on post traumatic stress and their relationship to professional quality of life. Methods: Self report questionnaires assessing symptoms of post traumatic stress and professional quality of life were distributed among psychiatric nurses in a high security forensic psychiatric unit with high frequency of violent behaviour. Relationships between post traumatic stress symptoms, forensic nursing experience, type of ward and compassion satisfaction, burnout and compassion fatigue were explored. Results: The prevalence of post traumatic stress symptoms was low. Low scores were found on compassion satisfaction. Length of psychiatric nursing experience and low scores on compassion satisfaction were correlated to increased post traumatic stress symptoms. Conclusion: Although high violence frequency, low rate of post traumatic stress symptoms and low compassion satisfaction scores was found. High staff/patient ratio and emotional distance between staff and patients are discussed as protective factors

The Predictive Properties of Violence Risk Instruments May Increase by Adding Items Assessing Sleep

Background: The psychometric instruments developed for short-term prediction of violence in psychiatric inpatients do not include variables assessing sleep. Disturbances in sleep may precede aggression in this setting. We investigated whether adding information on sleep improved the predictive properties of the Brøset Violence Checklist (BVC).Methods: The study population consists of all patients admitted to a psychiatric intensive care unit (PICU) over a 6-month period who were hospitalized for at least one night (n = 50). Sleep observed by staff (521 nights), behavior assessed with the BVC (433 days), and aggressive incidents recorded by the Staff Observation Scale-Revised (n = 14) were included in the analysis.Results: The ability of the BVC to predict aggressive incidents improved from AUCROC 0.757 to AUCROC 0.873 when a combined sleep variable including both sleep duration and night-to-night variations of sleep duration was added to the BVC recordings. The combined sleep variable did not significantly predict aggressive incidents (AUCROC 0.653, p = 0.051).Conclusions: A sleep disturbance variable improves the predictive properties of the BVC in PICUs. Further studies of sleep duration, night-to-night variations in duration of sleep, and aggression are needed

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics

<p>Abstract</p> <p>Background</p> <p>The aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance.</p> <p>Methods</p> <p>In 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed.</p> <p>Results</p> <p>The global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents.</p> <p>Conclusions</p> <p>In a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients.</p> <p>Trial registrations</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT00184119">NCT00184119</a>/<a href="http://www.clinicaltrials.gov/ct2/show/NCT00184132">NCT00184132</a></p

Unidimensionality of the Strengths and Vulnerabilities Scales in the Short-Term Assessment of Risk and Treatability (START)

The Short-Term Assessment of Risk and Treatability (START) is a 20-item structured professional judgment instrument for assessing dynamic risk in mental health services. Much of the START research literature examines the relationship between Strengths and Vulnerabilities sub-scale total scores and various adverse outcomes including violence. This assumes that the two sub-scales have the psychometric property of unidimensionality i.e. all the items cluster together as a measure of a single construct. Such assumed unidimensionality is a necessary condition for any analyses based on scale “total score” and the widespread use of scores summated in this way in research studies may obscure more specific clusters of items within each sub-scale. This multinational study examined START assessments (n = 685) conducted in four forensic services in Scandinavia and the UK using principal component analysis. It was found that all but three Strengths items (Substance Use, Social Support and Material Resources) and all but four Vulnerabilities items (Substance Use, Social Support, Material Resources and Self care) loaded >0.5 on the expected component. This indicates a unidimensional structure underlying the START and provides empirical support from a large multinational sample for the widespread use of summated Strengths and Vulnerabilities scores in forensic psychiatric risk research

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: protocol for a controversies in psychiatry research project

Objectives: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry‐ based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. Methods: By using the natural variation in health providers' preference for compulsory care as a source of quasi‐randomisation we will estimate causal effects of compulsory care on short‐ and long‐term trajectories. Conclusions: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group

Reducing recidivism in crime by psychiatric and substance use treatment

This exam project from the institution of psychology at Karolinska Institutet explores the relationship between outpatient treatment for psychiatric and substance use on recidivism in criminality. The results indicate that compliance to outpatient treatment for these disorders reduce recidivism in new crimes and thereby corroborates similar studies in the field