A Brief Case Management Intervention to Promote Personal Recovery and Prevent Psychiatric Involuntary Readmissions: a Randomised Controlled Trial

Background: The use of coercion in psychiatry has been increasing for many years, both in Switzerland and abroad. While it is justified by the need to protect the health and safety of the concerned patients, coercion also represents an infringement of their fundamental rights. It can have negative effects on their health and care, for example, by causing post-traumatic stress disorder or leading to a breakdown in care. Having been involuntarily hospitalised in psychiatry is one of the main predictors of compulsory readmission. While numerous interventions have been proposed to limit the use of coercion, very few have been rigorously studied, and even fewer have been shown to be effective. Personal recovery involves leading a satisfying, contributory life, full of hope and meaning, despite the existence of a mental disorder and the resulting limitations. According to the WHO, services should be recovery-oriented to respect and promote human rights. To date, very little work has been done on the links between personal recovery and coercion. A brief case management intervention designed to promote the personal recovery of involuntarily hospitalised psychiatric patients has been developed in partnership with service-users. Its acceptability, feasibility and patients' satisfaction with the intervention were demonstrated in a six-month pilot phase.

Aims: The primary aim of the study is to test, by means of a randomised controlled trial, the effectiveness of the intervention in reducing involuntary readmissions incidence in a population of adult patients involuntarily hospitalised in psychiatry. The secondary aim is to assess the impact of the intervention on patients' personal recovery, perceived coercion, satisfaction with treatment, and on their exposure to other forms of formal and informal coercion.

Methods: 262 patients involuntarily hospitalised in psychiatry will be randomly assigned to either the intervention or control group. Patients in the intervention group will receive, in addition to standard care, a 5-session case management intervention starting within the first two weeks of hospitalisation and lasting a maximum of two months after discharge. During the sessions, patients will discuss their experience of coercion and its impact on their personal recovery. The intervention is designed to enable them to identify and mobilise their resources, improve their self-esteem, restore their confidence in the future and strengthen ties and collaborations with their entourage. They will also be invited to draw up a personal recovery plan. The number of involuntary readmissions at 18 months after inclusion will be measured in both groups as the primary outcome. The shorter-term impact of the intervention on the number of involuntary readmissions will also be assessed at the 6-month follow-up. Changes in personal recovery and other relevant variables, such as self-esteem, self-stigma, post-traumatic stress symptoms, satisfaction with care and exposure to other forms of formal or informal coercion, will also be measured at the 6- and 18-month follow-ups as secondary outcomes. Results will be evaluated on an Intent To Treat basis. Generalized linear models (GLMs) with a Poisson or negative binomial regression, based on overdispersion diagnostics, will be used to determine group differences. Other estimands such as treatment effect for patients who would not experience the intercurrent event will be considered as sensitivity analysis.

Expected results and impact: Promoting personal recovery of involuntarily admitted patients by helping them to develop and implement strategies that improve their mental well-being should mitigate the adverse consequences of coercion and reduce the risk of exposure to new coercive measures. This study will also provide a deeper understanding of the links between personal recovery and coercion.