European evaluation of coercion in psychiatry and harmonisation of best clinical practise (EUNOMIA)

Based on the clinical recommendations for the use of the 5 coercive treatment measures mostly established in group discussions of local expert groups - the co-ordinating centre used a qualitative methodology, in which 2 feedback loops with all centres were implemented, to produce a common clinical recommendation for the use of the 5 coercive treatment measures: involuntary admission, detention after voluntary admission, mechanical restraint, seclusion, and forced medication. These recommendations follow a structure addressing a range of important issues, the selection of which was oriented at the research question to produce recommendations aiming to improve the procedural quality of the measures (for the best of the patient). As an example, the recommendations for involuntary hospital admission cover the following issues: pre-conditions for this measure subdivided into lawfulness, and clinical situations; professionals/persons addressed by this recommendation subdivided into police, emergency service physicians, physicians in the psychiatric facility, nurses/paramedic staff, judges, and others; practical issues concerning the contact with the patients; ethical issues; practical issues referred to procedural aspects like information, and decision taking; practical issues referred to other persons; issues of special importance, and not to be categorized otherwise; issues significantly different across the centres; and general proposals for improving the present situation.

The design includes detailed definitions of the following issues: research questions, patient-centred inclusion and exclusion criteria, power calculation of sample sizes, definition of the recruitment and follow-up time-points, definition of the study groups: legally involuntarily admitted patients, and legally voluntarily admitted patients who feel coerced to admission, time-points of assessment and assessment instruments, assessment of the patientęs key relatives.

At the official end of the project a huge amount of publications and presentations at scientific conferences, for other professional organisations and health-political bodies, for media and newspapers has emanated from the project; for details please see the continuously updated list of references at www.eunomiastudy.net, available via the project co-ordinator.

By use of a standardized methodology special legal expert groups collected and cross-nationally compared all relevant country-specific legal issues of coercive mental health care (except criminal law issues relevant for forensic psychiatric settings and health care) in 12 European countries. All reports deal with: principal legal terms, applicable laws and general norms, jurisprudence (e.g. sentences by judicial bodies), protocols and internal norms related to coercive measures or compulsory medical treatment, reports (by national or international organisations) on the topic, and the safeguard system.

The full set of translated mental health services research instruments (available in 12 European languages) comprises: - Brief Psychiatric Rating Scale (BPRS): this is an instrument for the differentiated assessment of (the severity of) psychopathological symptoms; - The Manchester Short Assessment of Quality of Life (MANSA): this is an instrument for differentiated assessment of (area-specific) subjective quality of life; - Clients Scale for Assessment of Treatment (CAT):this instrument assesses the patient;s satisfaction with the treatment (also available in a format assessing relatives view) - Perceived coercion items from MacArthur Admission Experience Survey assessing perceived coercion concerning hospital admission - Cantril Ladder of perceived coercion assessing perceived coercion (versions assessing the views of patients, staff, and relatives available) - Global Assessment of Functioning scale (GAF) assessing (symptom severity and) level of social functioning - Modified Overt Aggression Scale (MOAS) assessing patient s aggression 8.2-item-rating assessing patient's compliance with treatment - Self-defined items for outcome assessment, e.g. use of psychiatric services and contact with the police and criminal justice services after discharge - Self-defined standardized documentation of the details of each coercive measure applied in the first 4 weeks after index admission

The project's multimodal website (www.eunomiastudy.net) not only presents details of the research design, but also characteristics of the research sites and the involved staff members. It can also be used as an interactive working tool, including a domain available only for team members, from which e.g. important documents can be downloaded, in which important literature for and from the project is stored, and in which the project's research logbook is included.

Under the general theme of Coercive Treatment in Psychiatry: A Comprehensive Review, this conference will for the first time host scientific studies (and other empirical contributions) from all over the world exploring all clinical, legal, and ethical aspects of this issue relevant for the provision of mental health care. The scientific program will include plenary lectures, symposia, workshops, courses, and poster presentations. Details of this event can be seen at the website: www.wpa2007dresden.org

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