In ongoing studies of the quality of the mental health services in two Swedish counties, two thirds of the committed versus about one third of the voluntarily admitted patients reported coercive measures during the index period of care. Committed patients reported an equal degree of coercive treatment and restraint, whereas restraint dominated among the voluntarily admitted. The majority of the patients described the coercive measures as implemented by fait accompli; force was reported in 23% of the examples given by the committed patients but never by the voluntarily admitted. The committed patients justified 19% and the voluntarily admitted 38% of the coercive measures reported; the committed patients justified coercive treatment and restraint to about the same extent; the voluntarily admitted patients justified 65% of the examples of restraint but only 20% of the examples of coercive treatment. There was a 70% concordance between the reports of the committed patients and psychiatric personnel as to the occurrence of coercion, but the head nurses tended to state that treatment had been implemented by persuasion in cases where the patients stated that implementation was by coercion.
In a study of involuntary psychiatric care in two Swedish counties psychiatric examinations and interviews were carried out with 100 committed and 99 voluntarily admitted patients, and 155 relatives of these patients were interviewed. Questionnaires were sent to psychiatric staff, health and welfare personnel of primary care and a representative sample of the general public. As a frame of reference, a two-dimensional model for description and analysis of ethical conflicts was developed. The fwst dimension specifies the relevant principles of medical ethics and the second specifies the persons involved. The results indicate ethical "benefits" (fulfilment of ethical principles) and ethical "costs" (violation of ethical principles) for both committed and voluntarily admitted patients, as well as for other groups involved. The study shows the need and feasibility of comprehensive studies of coercion, and the need to develop concepts and methods in such studies as well as for quasiexperimental investigations of involuntary psychiatric care.
Background and Aims. Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. Framework. Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of 'asylum treatment' and 'community care'. Hospitals and community mental health centers are viewed as treatments with indications and 'dosages', such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science.There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. Methods. Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. Results. Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. 'partial hospitalization'), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. 'integrated treatment' for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities-each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness.
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