Psychiatric Care Pathways and the Use of Coercion: From Pre-Hospital to Inpatient Settings

The use of coercive measures in psychiatry raises ethical and clinical concerns, particularly given their potential psychological harm and long-term consequences. While most studies focus on inpatient settings, little is known about coercion applied earlier in the care pathway.This retrospective observational study included all patients (N = 695) admitted through the psychiatric emergency department (ED) to the adult psychiatry division of Geneva University Hospitals in 2019. Data were extracted from electronic medical records and included sociodemographic variables, clinical characteristics, and the use of coercion (seclusion, restraint, or forced medication) in three settings: ambulance, ED, and inpatient wards. Bivariate analyses and logistic regressions were conducted to identify predictors of inpatient coercion.Overall, 33.7% of patients experienced coercion in at least one setting: 22.4% during hospitalization, 20.7% in the ED, and 4% during ambulance intervention. Logistic regression identified several factors independently associated with inpatient coercion: coercion in the ED (p < .001), involuntary admission (p= .009), ambulance intervention (p = .035), younger age (p = .039), higher aggression score at admission (HoNOS item 1; p < .001), and a diagnosis of psychotic or bipolar disorder (p = .001).This study highlights that coercion often begins before psychiatric hospitalization and that early coercive experiences significantly predict subsequent inpatient coercion. A comprehensive evaluation of the entire psychiatric care trajectory is essential to better understand and reduce coercion. Targeted preventive strategies-such as pre-hospital crisis interventions, ED de-escalation protocols, and early pharmacological treatments-may help promote more ethical and patient-centered care.