Skip to main content Accessibility help

Outcomes of a psycho-education and monitoring programme to prevent compulsory admission to psychiatric inpatient care: a randomised controlled trial

  • B. Lay (a1), W. Kawohl (a1) (a2) and W. Rössler (a1) (a3)

There is a need for interventions that effectively reduce compulsory admission to psychiatry. We conducted a randomised controlled trial to investigate whether an innovative intervention programme prevents compulsory re-admission in people with serious mental illness.


The programme addresses primarily patients’ self-management skills. It consists of individualised psychoeducation focusing on behaviours prior to and during illness-related crises, crisis cards and, after discharge from the psychiatric hospital, a 24-month preventive monitoring. A total of 238 inpatients with compulsory admission(s) in the past were randomised to the intervention group or to treatment as usual (TAU).


Fewer participants who completed the 24-month programme were compulsorily readmitted to psychiatry (28%), compared with those receiving TAU (43%). Likewise, the number of compulsory readmissions per patient was significantly lower (0.6 v. 1.0) and involuntary episodes were shorter (15 v. 31 days), compared with TAU. A negative binomial regression model showed a significant intervention effect (RR 0.6; 95% confidence interval 0.3–0.9); further factors linked to the risk of compulsory readmission were the number of compulsory admissions in the patient's history (RR 2.8), the diagnosis of a personality disorder (RR 2.8), or a psychotic disorder (RR 1.9). Dropouts (37% intervention group; 22% TAU) were characterised by a high number of compulsory admissions prior to the trial, younger age and foreign nationality.


This study suggests that this intervention is a feasible and valuable option to prevent compulsory re-hospitalisation in a high-risk group of people with severe mental health problems, social disabilities, and a history of hospitalisations.

Corresponding author
*Address for correspondence: PD Dr. B. Lay, Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Lenggstr. 31, PO Box 1931, CH-8032 Zurich, Switzerland. (Email:
Hide All
Bäuml, J, Pitschel-Walz, G, Volz, A, Engel, RR, Kessling, W (2007). Psychoeducation in schizophrenia: 7-year follow-up concerning rehospitalization and days in hospital in the Munich psychosis information project study. Journal of Clinical Psychiatry 68, 854861.
Bonsack, C, Borgeat, F (2005). Perceived coercion and need for hospitalization related to psychiatric admission. International Journal of Law and Psychiatry 28, 342347.
Campbell, LA, Kisely, SR (2009). Advance treatment directives for people with severe mental illness. Cochrane Database of Systematic Reviews, Issue 1, Art. No.: Cd005963.
Chisholm, D, Knapp, MR, Knudsen, HC, Amaddeo, F, Gaite, L, van Wijngaarden, B (2000). Client socio-demographic and service receipt inventory – European version: development of an instrument for international research. EPSILON study 5. British Journal of Psychiatry 177 (Suppl.), s28s33.
Cotton, MA, Johnson, S, Bindman, J, Sandor, A, White, IR, Thornicroft, G, Nolan, F, Pilling, S, Hoult, J, McKenzie, N, Bebbington, P (2007). An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams. BMC Psychiatry 7, 52.
de Jong, MH, Kamperman, AM, Oorschot, M, Priebe, S, Bramer, W, van de Sande, R, Van Gool, AR, Mulder, CL (2016). Interventions to reduce compulsory psychiatric admissions: a systematic review and meta-analysis. JAMA Psychiatry 73, 657664.
de Stefano, A, Ducci, G (2008). Involuntary admission and compulsory treatment in Europe: an overview. International Journal of Mental Health 37, 1021.
Drack-Schönenberger, T, Bleiker, M, Lengler, S, Blank, C, Rössler, W, Lay, B (2016). Krisenkarten zur Prävention von Zwangseinweisungen [crisis cards for the prevention of compulsory hospitalization]. Psychiatrische Praxis 43, 253259.
Gassmann, J (2011). Wirksamkeit des Rechtsschutzes bei psychiatrischen Zwangseinweisungen in der Schweiz ( Accessed 20 September 2016.
Health and Social Care Information Centre (2015). Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment ( Accessed 20 September 2016.
Henderson, C, Flood, C, Leese, M, Thornicroft, G, Sutherby, K, Szmukler, G (2004). Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 329, 136.
Henderson, C, Flood, C, Leese, M, Thornicroft, G, Sutherby, K, Szmukler, G (2009). Views of service users and providers on joint crisis plans: single blind randomized controlled trial. Social Psychiatry and Psychiatric Epidemiology 44, 369376.
Jäger, M, Rössler, W (2010). Enhancement of outpatient treatment adherence: patients’ perceptions of coercion, fairness and effectiveness. Psychiatry Research 180, 4853.
Juckel, G, Haußleiter, I (2015). Die stationäre Unterbringung nach dem Psychisch-Kranken-Gesetz (PsychKG NRW) – was sind die stärksten Prädiktoren? [involuntary admissions in accordance to the mental health Act (PsychKG) – what are the strongest predictors?]. Psychiatrische Praxis 42, 133139.
Kallert, TW, Katsakou, C, Adamowski, T, Dembinskas, A, Fiorillo, A, Kjellin, L, Mastrogianni, A, Nawka, P, Onchev, G, Raboch, J, Schutzwohl, M, Solomon, Z, Torres-Gonzalez, F, Bremner, S, Priebe, S (2011). Coerced hospital admission and symptom change – a prospective observational multi-centre study. PLoS ONE 6, e28191.
Kaltiala-Heino, R, Korkeila, J, Tuohimaki, C, Tuori, T, Lehtinen, V (2000). Coercion and restrictions in psychiatric inpatient treatment. European Psychiatry 15, 213219.
Katsakou, C, Bowers, L, Amos, T, Morriss, R, Rose, D, Wykes, T, Priebe, S (2010). Coercion and treatment satisfaction among involuntary patients. Psychiatric Services 61, 286292.
Katsakou, C, Priebe, S (2006). Outcomes of involuntary hospital admission – a review. Acta Psychiatrica Scandinavica 114, 232241.
Keown, P, Weich, S, Bhui, KS, Scott, J (2011). Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988–2008: ecological study. BMJ 343, d3736.
Khazaal, Y, Manghi, R, Delahaye, M, Machado, A, Penzenstadler, L, Molodynski, A (2014). Psychiatric advance directives, a possible way to overcome coercion and promote empowerment. Frontiers in Public Health 2, 37.
Krischke, N (2006). Sozialpsychiatrische Gesundheitspsychologie: Qualitätssicherung in der Zwangseinweisungspraxis. Psychiatrie-Verlag: Bonn.
Lay, B, Nordt, C, Rössler, W (2011). Variation in use of coercive measures in psychiatric hospitals. European Psychiatry 26, 244251.
Lay, B, Salize, HJ, Dressing, H, Rusch, N, Schönenberger, T, Buhlmann, M, Bleiker, M, Lengler, S, Korinth, L, Rössler, W (2012). Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring. BMC Psychiatry 12, 136.
Mulder, CL, Broer, J, Uitenbroek, D, van Marle, P, van Hemert, AM, Wierdsma, AI (2006). Accelerated increase in the number of involuntary admissions following the implementation of the Dutch Act on compulsory admission to psychiatric hospitals (BOPZ). Nederlands Tijdschrift voor Geneeskunde 150, 319322.
Onyett, S, Linde, K, Glover, G, Floyd, S, Bradley, S, Middleton, H (2008). Implementation of crisis resolution/home treatment teams in England: national survey 2005–2006. Psychiatrist 32, 374377.
Papageorgiou, A, King, M, Janmohamed, A, Davidson, O, Dawson, J (2002). Advance directives for patients compulsorily admitted to hospital with serious mental illness. British Journal of Psychiatry 181, 513519.
Priebe, S, Badesconyi, A, Fioritti, A, Hansson, L, Kilian, R, Torres-Gonzales, F, Turner, T, Wiersma, D (2005). Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ 330, 123126.
Priebe, S, Katsakou, C, Yeeles, K, Amos, T, Morriss, R, Wang, D, Wykes, T (2011). Predictors of clinical and social outcomes following involuntary hospital admission: a prospective observational study. European Archives of Psychiatry and Clinical Neuroscience 261, 377386.
Ruchlewska, A, Mulder, CL, Van der Waal, R, Kamperman, A, Van der Gaag, M (2014). Crisis plans facilitated by patient advocates are better than those drawn up by clinicians: results from an RCT. Administration and Policy in Mental Health 41, 220227.
Salize, HJ, Dressing, H (2004). Epidemiology of involuntary placement of mentally ill people across the European Union. British Journal of Psychiatry 184, 163168.
Sutherby, K, Szmukler, GI, Halpern, A, Alexander, M, Thornicroft, G, Johnson, C, Wright, S (1999). A study of ‘crisis cards’ in a community psychiatric service. Acta Psychiatrica Scandinavica 100, 5661.
Swanson, JW, Swartz, MS, Elbogen, EB, Van Dorn, RA, Ferron, J, Wagner, HR, McCauley, BJ, Kim, M (2006). Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry 163, 19431951.
Swartz, MS, Swanson, JW, Hiday, VA, Wagner, HR, Burns, BJ, Borum, R (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52, 325329.
Ten Have, TR, Normand, S-LT, Marcus, SM, Brown, CH, Lavori, P, Duan, N (2008). Intent-to-treat vs. non-intent-to-treat analyses under treatment non-adherence in mental health randomized trials. Psychiatric Annals 38, 772783.
Thornicroft, G, Farrelly, S, Szmukler, G, Birchwood, M, Waheed, W, Flach, C, Barrett, B, Byford, S, Henderson, C, Sutherby, K, Lester, H, Rose, D, Dunn, G, Leese, M, Marshall, M (2013). Clinical outcomes of joint crisis plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet 381, 16341641.
van der Post, LFM, Beekman, ATF, Peen, J, Zoeteman, J, Twisk, JWR, Dekker, JJM (2016). Patterns of care consumption after compulsory admission: a five-year follow-up to the Amsterdam study of acute psychiatry VIII. International Journal of Mental Health 45, 105117.
Wampold, BE (2015). How important are the common factors in psychotherapy? An update. World Psychiatry 14, 270277.
Wheeler, C, Lloyd-Evans, B, Churchard, A, Fitzgerald, C, Fullarton, K, Mosse, L, Paterson, B, Zugaro, CG, Johnson, S (2015). Implementation of the crisis resolution team model in adult mental health settings: a systematic review. BMC Psychiatry 15, 74.
World Health Organization (1996). Mental Health Care Law: Ten Basic Principles ( Accessed 20 September 2016.
Xia, J, Merinder, LB, Belgamwar, MR (2013). Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews, Issue 6, Art. No.: Cd002831.
ZInEP (2009) Zürcher Impulsprogramm zur nachhaltigen Entwicklung der Psychiatrie [Zurich Program for Sustainable Development of Mental Health Services] ( Accessed 20 September 2015.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Lay supplementary material
Lay supplementary material 1

 Word (39 KB)
39 KB
Supplementary materials

Lay supplementary material
Lay supplementary material 2

 PDF (389 KB)
389 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed