FOSTREN Country blog – Sweden

Written by Dr Veikko Pelto-Piri and Dr Anna Björkdahl

(for Swedish version, please click this link)

What is your country’s stand on coercion reduction?

According to the Swedish Law on compulsory psychiatric care (LPT), coercive care may be given if the patient suffers from a serious mental disorder and has an absolute need of full-time psychiatric inpatient care (inpatient psychiatric compulsory care) or if there is a need for specific conditions to give the patient necessary psychiatric care (outpatient psychiatric compulsory care). A prerequisite is that care cannot be given with the patients´ consent, and when assessing the need for care it should be taken into consideration whether the patient may be a danger for others. The purpose of the compulsory care should be to get the patient to voluntarily participate in care. Coercive measures, mainly forced medication, mechanical restraint and seclusion, may be used only if they are reasonable in relation to the purpose of the measure [4]. Care of persons who according to a court decision should be given forensic psychiatric care is regulated in the Law on forensic psychiatric care (LRV) [5].

In 2020 around 12 300 persons were treated according to LPT and around 1 800 according to LRV. The sex distribution was even among LPT patients, while 85 % of LRV patients were men [6]. A small increase of patients treated according to LPT has been registered since 2015, but it is not clear whether there has been an actual increase or an increased tendency to report [7]. In an international comparison, Sweden has a relatively high rate of compulsory admissions per 100 000 inhabitants, 115,5 in 2016 compared to a median of 106,4 for 22 countries [8].

Like in many other countries there has however been many efforts in Sweden aiming to reduce compulsory psychiatric care. The Government and the Swedish Association of Local Authorities and Regions (SALAR) has signed an agreement on mental health and suicide prevention 2021-2022, which includes support to follow-up and systematic quality improvement to reduce the need for compulsory care and coercive measures [9]. A commission appointed by the Government has recently been instructed to present a proposal for a common legislation for persons treated without consent according to the Law on treatment of addicts or LPT [10]. A special investigator has been appointed to analyse the need for changes and clarifications in LPT and LRV in order to strengthen the rights of children and the legal rights and security for persons who are compulsorily treated [11]. The National Board of Health and Welfare has been commissioned by the Government to do a mapping of compulsory psychiatric care of persons above the age of 18 years [12] and to disseminate current knowledge and appropriate knowledge support, methods and way of working to health personnel within child and adolescent inpatient psychiatric care [13]. The Government has also instructed the Health and Social Care Inspectorate to strengthen and develop the supervision and follow-up of the psychiatric compulsory care [14] as this supervision has been criticized by The Parliamentary Ombudsman [15]. SALAR has taken an initiative to reduce the need of coercion, including quality assurance of services applying compulsory care [16].

What kind of research is happening in your country on this topic?

Swedish researchers have for a long time initiated and participated in research on compulsory psychiatric care in international cooperation [17-21]. Research has also been conducted in Sweden on for instance compulsory community care (outpatient commitment) [22-25], informal coercion [26-28] and violence in psychiatric inpatient care [see for example 29-31]. There is also research from the patient perspective regarding coercion, prevention and security in psychiatry [32-35] or how decision-making and law affect coercion in care [36-41]. Ongoing research may be exemplified by research on forensic psychiatric care [42-43] and in an ongoing multi-centre study the Safewards model is implemented and evaluated in a Swedish context [44].

Why are you in the network? What would you like to achieve with it?

Despite efforts to reduce coercive measures in Sweden, these numbers have been relatively high and stable during the 2000s. We think that the psychiatry in Sweden can do more to reduce compulsory care and coercive measures by introducing methods that have been shown to be successful internationally, but also informal coercion can be reduced through better communication with patients. FOSTREN gives us an opportunity to learn from the latest research and practice in Europe that can support a reduction of the use of coercion in Swedish psychiatry, therefore it is important for us to participate in this network.

Is there anything else that you want to share with us?

There is a need to find alternative interventions to coercive measures, however, we are questioning whether it is possible to completely abolish coercive measures, as several well-known international organizations and opinion leaders claim. We believe that medical ethics and legal regulations give healthcare professionals a duty to protect patients and others from injury or death when a patient has a reduced ability to make decisions due to their illness, then coercion can be used if no other methods are available. In such cases, the use of coercion is not a violation of human rights but an ethical and legal obligation for staff. It is also a obligation for staff that treatment is given and coercion applied according to best clinical practice and current research evidence, which gives management an obligation to ensure resources and quality.

References

  1. Parliamentary Assembly. Ending coercion in mental health: the need for a human rights-based approach. European union, Resolution 2291 (2019)
  2. United Nations. Convention on the Rights of Persons with Disabilities. New York: UN, Department of Economic & Social Affairs; 2006. https://www.un.org/esa/socdev/enable/rights/convtexte.htm. Accessed 18 November 2020.
  3. The European Mental Health Action Plan 2013–2020. Copenhagen Ø, Denmark: WHO Regional Office; 2015.
  4. Sveriges riksdag. Lag (1991:1128) om psykiatrisk tvångsvård. 1991. https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-19911128-om-psykiatrisk-tvangsvard_sfs-1991-1128
  5. Sveriges riksdag. Lag (1991:1129) om rättspsykiatrisk vård. 1991. https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-19911129-om-rattspsykiatrisk-vard_sfs-1991-1129
  6. Socialstyrelsen. Statistik om psykiatrisk tvångsvård och rättspsykiatrisk vård – Socialstyrelsen. https://www.socialstyrelsen.se/statistik-och-data/statistik/statistikamnen/psykiatrisk-tvangsvard/
  7. Socialstyrelsen. Tvångsvård enligt LPT. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/statistik/2021-4-7335.pdf
  8. Luke Sheridan Rains, Tatiana Zenina, Marisa Casanova Dias, Rebecca Jones, Stephen Jeffreys, Stella Branthonne-Foster, Brynmor Lloyd-Evans, Sonia Johnson. Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study. The Lancet Psychiatry, 2019, 6(5).
  9. Sveriges kommuner och regioner. Överenskommelse insatser psykisk hälsa 2021. https://skr.se/download/18.4d3d64e3177db55b1663b1c6/1615532219113/Overenskommelse_insatser_psykisk_halsa_2021.pdf
  10. Regeringskansliet. Tilläggsdirektiv till Samsjuklighetsutredningen (S 2020:08). https://www.regeringen.se/4aab0e/contentassets/54121979287046e99aec293489054c1e/tillaggsdirektiv-till-samsjuklighetsutredningen-dir.-202196.pdf
  11. Regeringskansliet. Översyn av vissa frågor gällande den psykiatriska tvångsvården och den rättspsykiatriska vården, Dir. 2021:36. https://www.regeringen.se/49b730/contentassets/95d63dd37f0343aca4443d79ba2b6724/dir2021_36.pdf
  12. Regeringskansliet. Regeringen stärker den psykiatriska tvångsvården och den rättspsykiatriska vården. https://www.regeringen.se/pressmeddelanden/2021/03/regeringen-starker-den-psykiatriska-tvangsvarden-och-den-rattspsykiatriska-varden/
  13. Regeringskansliet. Uppdrag rörande den barn- och ungdomspsykiatriska heldygnsvården inklusive den psykiatriska tvångsvården.https://www.regeringen.se/regeringsuppdrag/2019/04/uppdrag-rorande-den-barn–och-ungdomspsykiatriska-heldygnsvarden-inklusive-den-psykiatriska-tvangsvarden/
  14. Regeringskansliet. Uppdrag att förstärka och utveckla tillsynen och uppföljningen av den psykiatriska tvångsvården och den rättspsykiatriska vården. https://www.regeringen.se/regeringsuppdrag/2021/06/uppdrag-att-forstarka-och-utveckla-tillsynen-och-uppfoljningen-av-den-psykiatriska-tvangsvarden-och-den-rattspsykiatriska-varden/
  15. Justitieombudsmannen. Inspektionen för vård och omsorg (IVO) kritiseras för brister i myndighetens tillsyn över den psykiatriska tvångsvården, 2021-04-28, Dnr O 60-2019. https://www.jo.se/PageFiles/32642/O%2060-2019.pdf
  16. Sveriges kommuner och landsting. Psykiatrisk tvångsvård | Uppdrag Psykisk Hälsa. https://www.uppdragpsykiskhalsa.se/psykiatrisk-tvangsvard/
  17. Kjellin L, Høyer G, Engberg M, Kaltiala-Heino R, Sigurjónsdóttir M. Differences in perceived coercion at admission to psychiatric hospitals in the Nordic countries. Social Psychiatry and Psychiatric Epidemiology, 2006;41:241-247.
  18. Kallert TW, Katsakou C, Adamowski T, Dembinskas A, Fiorillo A, Kjellin L, Mastrogianni A, Nawka P, Onchev G, Raboch J, Schützwohl M, Solomon Z, Torres-Gonzales F, Bremner S, Priebe S. Coerced Hospital Admission and Symptom Change – A Prospective Observational Multi-Centre Study. PLoS ONE 6(11): e28191, 2011.
  19. Luciano M, De Rosa C, Sampogna G, Del Vecchio V, Giallonardo V, Fabrazzo M, Catapano F, Onchev G, Raboch J, Mastrogianni A, Solomon Z, Dembinskas A, Nawka P, Kiejna A, Torres-Gonzales F, Kjellin L, Kallert T, Fiorillo A. How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study. European Psychiatry 2018, 54, 35-40.
  20. Cowman S, Björkdahl A, Clarke E, Gethin G, Maguire J. A descriptive survey study of violence management and priorities among psychiatric staff in mental health services, across seventeen european countries. BMC Health Serv Res 2017, 17(1):59.
  21. Valenti E, Banks C, Calcedo-Barba A, Bensimon CM, Hoffmann KM, Pelto-Piri V, Jurin T, Mendoza OM, Mundt AP, Rugkåsa J et al. Informal coercion in psychiatry: a focus group study of attitudes and experiences of mental health professionals in ten countries. Soc Psychiatry Psychiatr Epidemiol 2015, 50(8):1297-1308.
  22. Zetterberg, L., Markström, U., Sjöström, S. Translating Coercion Policy into Inter-Organisational Collaboration–the Implementation of Compulsory Community Care for People with Mental Illness. Journal of Social Policy, 2016, 45(4), 655-671.
  23. Zetterberg L, Sjöström S, Markström U. The compliant court–procedural fairness and social control in compulsory community care. Int J Law Psychiatry 2014, 37(6):543-550.
  24. Kjellin L, Pelto-Piri V: Community treatment orders in a Swedish county–applied as intended? BMC Res Notes 2014, 7:879.
  25. Jansson S, Fridlund B. Perceptions Among Psychiatric Staff of Creating a Therapeutic Alliance With Patients on Community Treatment Orders. Issues Ment Health Nurs 2016, 37(10):701-707.
  26. Andersson U, Fathollahi J, Gustin LW. Nurses’ experiences of informal coercion on adult psychiatric wards. Nursing Ethics. 2020, 27(3):741-753.
  27. Pelto-Piri V, Kjellin L, Hylén U, Valenti E, Priebe S. Different forms of informal coercion in psychiatry: a qualitative study. BMC Res Notes 2019, 12(1):787.
  28. Gerle E, Fischer A, Lundh L-G. “Voluntarily Admitted Against My Will”: Patient Perspectives on Effects of, and Alternatives to, Coercion in Psychiatric Care for Self-Injury. Journal of Patient Experience. December 2019:265-270.
  29. Björkdahl A, Hansebo G, Palmstierna T. The influence of staff training on the violence prevention and management climate in psychiatric inpatient units. Journal of Psychiatric and Mental Health Nursing 2013, 20(5):396-404.
  30. Pelto-Piri V, Warg LE, Kjellin L: Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions. BMC Health Serv Res 2020, 20(1):362.
  31. Hedlund Lindberg M, Samuelsson M, Perseius KI, Björkdahl A. The experiences of patients in using sensory rooms in psychiatric inpatient care. Int J Ment Health Nurs. 2019 Aug;28(4):930-939.
  32. Ejneborn Looi GM, Engström Å, Sävenstedt S. A self-destructive care: self-reports of people who experienced coercive measures and their suggestions for alternatives. Issues Ment Health Nurs 2015, 36(2):96-103.
  33. Olsson H, Schön UK. Reducing violence in forensic care – how does it resemble the domains of a recovery-oriented care? J Ment Health 2016, 25(6):506-511.
  34. Pelto-Piri V, Kjellin L. Social inclusion and violence prevention in psychiatric inpatient care. A qualitative interview study with service users, staff members and ward managers. BMC Health Serv Res 2021, 21(1):1255.
  35. Pelto-Piri V, Wallsten T, Hylen U, Nikban I, Kjellin L. Feeling safe or unsafe in psychiatric inpatient care, a hospital-based qualitative interview study with inpatients in Sweden. Int J Ment Health Syst 2019, 13:23.
  36. Skott M, Durbeej N, Smitmanis-Lyle M, Hellner C, Allenius E, Salomonsson S, Lundgren T, Jayaram-Lindström N, Rozental A. Patient-controlled admissions to inpatient care: A twelve-month naturalistic study of patients with schizophrenia spectrum diagnoses and the effects on admissions to and days in inpatient care. BMC Health Serv Res. 2021 Jun 24;21(1):598. 
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  38. Edin Renberg F, Sandlund M. Microdecisions instead of coercion: patient participation and self-perceived discrimination in a psychiatric ward. Nord J Psychiatry 2019, 73(8):532-538.
  39. Pelto-Piri V, Kjellin L, Lindvall C, Engström I. Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden. BMC Health Serv Res 2016, 16:66.
  40. Schön UK, Grim K, Wallin L, Rosenberg D, Svedberg P. Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study. Int J Qual Stud Health Well-being 2018, 13(1):1421352.
  41. Wasserman D, Apter G, Baeken C, Bailey S, Balazs J, Bec C, Bienkowski P, Bobes J, Ortiz MFB, Brunn H et al. Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries. Eur Psychiatry 2020, 63(1):e82.
  42. Degl’ Innocenti A, Alexiou E, Andiné P, Striskaite J, Nilsson T. A register-based comparison study of Swedish patients in forensic psychiatric care 2010 and 2018. Int J Law Psychiatry 2021, 77:101715.
  43. Levin SK, Nilsen P, Bendtsen P, Bülow P. Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records. Int J Law Psychiatry 2019, 64:71-82.
  44. Safewards Sverige. Project information. https://www.researchgate.net/project/Safewards-Sweden