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 . 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) .
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 . 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 . 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 .
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 . 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 . 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 . 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  and to disseminate current knowledge and appropriate knowledge support, methods and way of working to health personnel within child and adolescent inpatient psychiatric care . 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  as this supervision has been criticized by The Parliamentary Ombudsman . SALAR has taken an initiative to reduce the need of coercion, including quality assurance of services applying compulsory care .
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 .
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.
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