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Cited by 9Healthcare Decision-Making and RestraintsSchizophrenia research and treatmentElectroconvulsive Therapy Studies

Patients’ perception of coercion with respect to antipsychotic treatment of psychotic disorders and its predictors

Open access
Hirsch, Sophie, Thilo, Nancy, Steinert, Tilman, Flammer, Erich·2021·Social Psychiatry and Psychiatric Epidemiology
DOI 10.1007/s00127-021-02083-zPMC PMC8316198
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Abstract

Purpose: The present study investigates perceived coercion in psychiatric inpatients under prescribed antipsychotic medication without a court order. The objective of this study was to investigate whether and to what extent involuntary and voluntary inpatients feel coerced to take their medication and which factors affect perceived coercion. Methods: Voluntarily and involuntarily admitted patients (55 and 36, respectively) were interviewed about the extent of perceived coercion. In addition, socio-demographic and clinical data were collected. The Admission Experience Scale (aAES) was used to assess perceived coercion concerning medication. To measure insight into illness, attitude towards medication, and symptom severity, we used a questionnaire on insight into illness (FKE-10), the Drug Attitude Inventory (DAI-10), and the Brief Psychiatric Rating Scale (BPRS-24), respectively. Results: Voluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients. The experience of coercion was not related to socio-demographic or clinical variables nor to the BPRS-24 score, but to insight into illness and attitude towards medication. Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion. Conclusion: Perceived coercion related to medication is dependent on insight into illness and experience of previous coercive interventions rather than on the severity of psychopathological symptoms. These findings are very similar to a previous study in a forensic psychiatric sample. Having experience of at least one coercive measure seems to be a decisive aspect of the extent of the patients’ perceived coercion.

AI snapshot

Written from the paper’s full text.

TL;DR

In 91 general psychiatric inpatients, involuntarily admitted patients felt significantly more coerced to take prescribed antipsychotics than voluntarily admitted patients. Perceived coercion was predicted by insight into illness, attitude toward medication, and experiencing a coercive measure during the index stay, but not by symptom severity or involuntary status in the multivariate model.

Key findings

  • Involuntarily treated participants reported higher perceived coercion on the aAES (mean 11.5, SD 5.2) than voluntarily treated participants (mean 6.5, SD 4.9), with a large effect size (Cohen’s d = −1.0).
  • In linear regression, the model was significant (F(5,67) = 33.4, p < 0.001; adjusted R² = .69). Significant predictors were insight into illness (FKE-10, standardized β = −0.38, p < 0.001), attitude toward medication (DAI-10, β = −0.47, p < 0.001), and experiencing at least one coercive measure during the index hospital stay (β = 0.23, p < 0.01); BPRS-24 symptom severity (β = −0.03, n.s.) and involuntary stay (β = 0.04, n.s.) were not significant.
  • Bivariate correlations with perceived coercion were FKE-10 r = −0.65 (p < 0.01), DAI-10 r = −0.70 (p < 0.01), and BPRS-24 r = 0.24 (p < 0.05).
  • Participants who experienced at least one coercive measure during the index stay had higher aAES scores (mean 10.8, SD 5.6) than those who did not (mean 6.8, SD 5.0, p < 0.05); lifetime experience of coercive measures was not significantly associated (8.9 vs. 7.5).

Methods

  • Analytical observational cross-sectional study of 91 inpatients from two general psychiatric hospitals in Weissenau and Friedrichshafen, recruited September 2017–June 2019; 55 were voluntarily admitted and 36 involuntarily admitted. Inclusion criteria were age 18–65, ICD-10 F20–29 main diagnosis, inpatient treatment, prescribed antipsychotic medication, and written informed consent.
  • Perceived coercion regarding medication was measured with an adapted Admission Experience Scale (aAES); insight into illness with FKE-10; attitude toward medication with DAI-10; and symptom severity with BPRS-24. Socio-demographic, diagnostic, legal-status, and coercive-measure data came from medical records.
  • Analyses used SPSS Version 24, with personal mean imputation for missing values up to 30% per scale, parametric and non-parametric group comparisons, Pearson correlations, and linear regression models with adjusted R².

Limitations

  • The paper states that the cross-sectional design cannot establish causality, the sample size is rather small, and the two-hospital southern German setting limits generalizability. It also states that the aAES still requires independent psychometric validation, that BPRS-24 values suggest no seriously ill patients participated, and that voluntary participation may have excluded particularly dissatisfied or highly coerced patients while social-desirability effects may have influenced answers.
  • The paper further notes that the non-significant effects of voluntary versus involuntary hospital stay and symptom severity were very small, so even a much larger sample would probably not protect against a possible type II error for those variables.
  • Evident from the text: Table 1 reports 8 participants (8.8%) with a main diagnosis of F31, although the stated inclusion criteria specified ICD-10 F20–29 diagnoses.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s00127-021-02083-z

Cites

36 of 36 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 12 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Experience of at least one coercive measure in lifetime was not statistically significantly associated with perceived coercion (aAES).

    “Participants who had experienced at least one coercive measure in their lifetime did not express a statistically significant higher perceived coercion (aAES) (mean = 8.9, SD = 5.9) than participants who had not experienced coercive measures (mean = 7.5, SD = 4.7).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Patients who had experienced at least one coercive measure during the index hospital stay expressed significantly higher perceived coercion (aAES) than those who had not.

    “Participants who had experienced at least one coercive measure during the index hospital stay expressed a statistically significant higher perceived coercion (aAES) (mean = 10.8, SD = 5.6) than participants who had never experienced coercive measures (mean = 6.8, SD = 5.0, p < 0.05).”
    • Also stated in: § Results · plain
      “Patients who had experienced at least one coercive measure during the index hospital stay showed a higher level of perceived coercion.”
    Quote in the paperSubstantial claim
  • Findingown data

    The regression model reached overall statistical significance (F(5,67) = 33.4, p < 0.001).

    “The regression model reached overall statistical significance (F(5,67) = 33.4, p < 0.001).”
    Quote in the paperSubstantial claim
  • Findingown data

    Voluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients.

    “Voluntarily treated patients experienced significantly less coercion when taking prescribed medication in inpatient settings than involuntarily treated patients.”
    • Also stated in: § Results · plain
      “Perceived coercion when taking prescribed antipsychotic drugs was significantly higher in involuntarily treated participants with a large effect size (Table 2).”
    • Also stated in: § Discussion · plain
      “In this study, involuntarily admitted patients showed substantially higher expression of perceived coercion with respect to taking their prescribed medication than voluntarily admitted participants.”
    Quote in the paperSubstantial claim
  • Findingown data

    Involuntary hospital stay was not significantly associated with perceived coercion in the multivariate regression.

    “Involuntary stay | 0.04n.s”
    • Also stated in: § Discussion · plain
      “the non-significant effects of voluntary versus involuntary hospital stay and symptom severity are very small in the regression model”
    Quote in the paperNot a substantial claim
  • May combine two claims. 11
  • Classified as probably not a substantial claim. 6

  • May combine two claims.

    Findingown data

    In bivariate correlations, psychopathological symptoms as measured by the BPRS-24 showed a weak statistical correlation with the extent of perceived coercion, but in the multivariate model BPRS-24 yielded no significance.

    “psychopathological symptoms as measured by the BPRS-24 showed a weak statistical correlation with the extent of perceived coercion in bivariate correlations; however, the multivariate model yielded no more significance for this variable.”
    • Also stated in: § Results · plain
      “BPRS-24 | − 0.03n.s”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Involuntarily treated participants differed significantly from voluntarily treated participants in experience of coercive measures, insight into illness (FKE-10, large effect), attitudes towards medication and need for treatment (DAI-10, medium effect), and psychopathological symptoms (BPRS-24, modest effect).

    “Significant differences were found between involuntarily and voluntarily treated participants in terms of experience of coercive measures, insight into illness (FKE-10, large effect), attitudes towards medication, need for treatment (DAI-10, medium effect), and psychopathological symptoms (BPRS-24, modest effect) (Table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Perceived coercion (aAES) was not statistically significantly associated with age, gender, main psychiatric diagnosis, number of previous psychiatric hospital stays, marital status, migration background, language, living condition, or vocational qualification.

    “Age, gender, main psychiatric diagnosis, and number of previous psychiatric hospital stays were not statistically significantly associated with perceived coercion (aAES). Furthermore, marital status, migration background, language, living condition, and vocational qualification showed no statistically significant association with perceived coercion (aAES).”
    • Also stated in: § Discussion · plain
      “No association was found between experienced coercion and socio-demographic variables.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In the multivariate linear regression, insight into illness (FKE-10), attitude towards medication (DAI-10), and experience of at least one coercive measure during the index hospital stay were significantly associated with perceived coercion (aAES).

    “Insight into illness, attitude towards medication, and experience of coercive measures were significantly associated with perceived coercion (aAES) and explained a very substantial percentage of variation.”
    • Also stated in: § Discussion · plain
      “Predictors of a higher level of perceived coercion were less insight into illness, negative attitude towards antipsychotic medication, and experience of at least one coercive measure during index hospital stay.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Perceived coercion (aAES) was associated with insight into illness (FKE-10), attitude towards medication (DAI-10), and psychopathological symptoms (BPRS-24) in bivariate analyses.

    “Insight into illness (FKE-10), attitude towards medication (DAI-10), and psychopathological symptoms (BPRS-24) showed an association with the extent of perceived coercion (aAES) (Table 3).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A recent qualitative study found that professionals considered patients' refusal to take medication to be an aspect of their disease, whereas patients and their relatives sorted the refusal into a coherent biographical perspective.

    “They found that the professionals considered the patients’ refusal to take medication to be an aspect of their disease and considered medication as a necessary treatment, whereas patients and their relatives sorted the refusal into a coherent biographical perspective.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] Jaeger S, Hüther F, Steinert T (2019) Refusing medication therapy in involuntary inpatient treatment: a multiperspective qualitative study. Front Psychatry. 10:295. https://doi.org/10.3389/fpsyt.2019.00295 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    In that forensic sample, the extent of feeling coerced to take prescribed medication was affected mainly by the patient's attitude towards medication and the degree of insight into illness but less so, and not significantly, by symptom severity.

    “The extent of feeling coerced to take the prescribed medication was affected mainly by the patient’s attitude towards medication and the degree of insight into illness but less so, and not significantly, by symptom severity.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [26] Horvath J, Steinert T, Jaeger S (2018) Antipsychotic treatment of psychotic disorders in forensic psychiatry: patients’ perception of coercion and its predictors. Int J Law Psychiatry 57:113–121. https://doi.org/10.1016/j.ijlp.2018.02.004 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a previous forensic psychiatric sample, many patients felt compelled to take their antipsychotic medication although only a few were affected by emergency rapid tranquilization or compulsory medical treatment according to a court order.

    “A study in two forensic hospitals in southwest Germany on the perceived coercion regarding prescribed antipsychotic medication showed that although only a few patients were affected by emergency rapid tranquilization or compulsory medical treatment according to a court order, many patients felt compelled to take their antipsychotic medication [26].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [26] Horvath J, Steinert T, Jaeger S (2018) Antipsychotic treatment of psychotic disorders in forensic psychiatry: patients’ perception of coercion and its predictors. Int J Law Psychiatry 57:113–121. https://doi.org/10.1016/j.ijlp.2018.02.004 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    The sample size is rather small, which decreases the statistical power of the analyses.

    “It should also be noted that the sample size is rather small, which decreases the statistical power of the analyses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    For all calculations, sensitivity analyses without imputed data showed the same results.

    “For all calculations, sensitivity analyses without imputed data showed the same results (Supplementary Material).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study is cross-sectional and hardly allows statements about causal relationships.

    “First, it is a cross-sectional study that hardly allows statements about causal relationships.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Post hoc power analysis for multiple regression showed a statistical power of 1.0.

    “Post hoc power analysis for multiple regression showed a statistical power of 1.0.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The adapted Admission Experience Scale (aAES) still requires independent psychometric validation.

    “However, the aAES still requires independent psychometric validation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The inclusion criteria excluded people with very severe or acute symptoms, so the findings may only be valid for people with mild-to-moderate symptom severity.

    “These inclusion criteria excluded people with very severe or acute symptoms, as in most other studies, and hence, it is possible that our findings are only valid for people with mild-to-moderate symptom severity.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Regression diagnostics showed no substantial violation of the underlying statistical assumptions.

    “Regression diagnostics showed no substantial violation of the underlying statistical assumptions.”
    Quote in the paperSubstantial claim
15 of 15

  • The paper relies on this without support.

    The adapted Admission Experience Scale (aAES) validly measures perceived coercion with respect to prescribed antipsychotic medication despite lacking independent psychometric validation.

    “To assess the extent of perceived coercion with respect to prescribed antipsychotic medication, we used an adapted version of the MacArthur Admission Experience Survey [26, 27].”
    “However, the aAES still requires independent psychometric validation.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Another study found no significant difference in perceived coercion between individuals who had experienced at least one coercive measure and those who had not.

    “and another found no significant difference in perceived coercion between individuals who had experienced at least one coercive measure and those who had not [139].”

    From Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review (2025) · cites this paper as [139]

    The Results report no statistically significant difference when comparing participants who had experienced a coercive measure at any point in their lifetime with those who had not. The claim omits that timeframe: the same Results section reports significantly higher perceived coercion among participants who experienced a measure during the index hospital stay. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • No association was found between migration background and perceived coercion.

    “Moreover, no association was found between migration background and perceived coercion [139,160].”

    From Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review (2025) · cites this paper as [139]

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(5, 67) = 33.4reported p < .001 · recomputed p < .001

    “F(5,67) = 33.4, p < .001”

1 of 1

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Eight participants have a diagnosis outside the inclusion range

    Major

    The inclusion criteria require a main diagnosis in ICD-10 category F20-29, but Table 1 lists eight participants whose main diagnosis is F31.

  • Abstract denies an association reported for BPRS-24

    Minor

    The abstract says perceived coercion was not related to the BPRS-24 score, while Table 3 reports a positive correlation marked statistically significant at p < 0.05. The paper later describes this as a significant bivariate correlation that was not significant in the multivariate model.

2 of 2

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Authors
Hirsch, S., Thilo, N., Steinert, T., & Flammer, E.
Affiliations
Universität Ulm (DE)
Corresponding author
Flammer, Erich
ORCID
Venue
Social Psychiatry and Psychiatric Epidemiology
Publisher
Springer Science and Business Media LLC
Published
2021-04-27
Volume
56
Issue
8
Pages
1381-1388
ISSN
  • 0933-7954 (ISSN-L)
  • 1433-9285
DOI
10.1007/s00127-021-02083-z
PMC
PMC8316198
OpenAlex
W3159585603
Semantic Scholar
934c64206a5e4d44101ca6dd340fc2ef190299b0
Cited by
9
References
36
Citations by year
2026: 1 · 2025: 2 · 2024: 3 · 2023: 1 · 2022: 2
FWCI
1.02
Type
journal article
Language
en
Open access
Licence
Locations
  • Social Psychiatry and Psychiatric Epidemiology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Informationszentrum Lebenswissenschaften (ZB MED) (submittedVersion, cc-by)
  • OPen Access Repositorium der Universität Ulm (OPARU) (Ulm University) (submittedVersion, cc-by)
  • Universität Ulm, Kommunikations- und Informationszentrum (kiz) (cc-by)
Funders
German Ministry of Health (ZMVI-2515FSB406)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
Keywords
perceived coercion, antipsychotic drugs, involuntary admission, voluntary admission, psychosis, psychiatric inpatients, insight into illness, coercive measures, symptom severity
MeSH terms
Mental Disorders, Coercion, Hospitals, Psychiatric, Humans, Patient Admission, Perception, Psychotic Disorders, Antipsychotic Agents

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