Restraint and seclusion: a review of the literature

"Surviving against the odds. The impact of peer support workers on a chronically suicidal adolescent in secure residential youth care: a single case report from the Netherlands"

BACKGROUND

The use of peer support workers to support suicidal adolescents is underdeveloped. This study focuses on the effects of a one-year intervention with peer support workers on a chronically suicidal adolescent residing in a secure residential youth care facility in the Netherlands. Moreover, we explore the mechanisms that underpin the role of peer support workers in detail.

METHOD

This study employed a single case study design. We conducted seven semi-structured interviews with staff, peer support workers, and a chronically suicidal adolescent. The interviews were analysed using a thematic analysis.

RESULTS

The results indicate that the suicidal tendencies of the adolescent decreased significantly one year after the peer support intervention compared to the initial baseline. Working mechanisms that underpinned the peer support intervention emphasized building meaningful and trust-based relationships, providing recognition and hope, and practical support from a recovery-oriented perspective.

CONCLUSION

The results suggest that peer support has a beneficial impact on the adolescent and treatment teams. Peer support workers contribute to a sense of belonging and connection, coping with suicidality, rediscovering life goals, and improving adolescent self-management. Barriers and facilitators to implementing peer support workers are also discussed.

National Seclusion and Restraint Trends within Child Residential Treatment Facilities: 2010-2020 in Review

This study aimed to estimate the percentage of child RTCs utilizing seclusion and restraint (S/R) practices and examine predictors associated with increased likelihood of S/R use between 2010 and 2020. A secondary analysis of the National Mental Health Services Survey was conducted (n-range = 580-781). Facility-level client demographics and facility characteristics were examined using multi-level logistic regression. One-way ANOVA indicated that the percentage of child RTCs using S/R significantly decreased between 2010 and 2020 [F(4, 58074) = 75.62, p <.001]. A post-hoc Bonferroni test found that the percentage of facilities reporting the use of SR in 2010 was significantly higher than in 2014, 2016, 2018, and 2020 (all p <.001). Multi-level logistic regression analysis found that facility-level client demographics (percent male, white, and involuntarily committed) did not significantly predict facility use of SR in 2010, 2014, or 2016. However, facility-level characteristics of SED program (all p <.01), use of psychotropic medication (all p <.001), and facility size as measured by number of mental health beds (all p <.01) consistently predicted usage of SR in 2010 [F(11) = 68.38, p <.001], 2014 [F(12) = 74.25, p <.001], and 2016 [F(12) = 74.48, p <.001]. Facility ownership and accepting Medicare payments did not significantly predict facility usage of SR. Use of SR within child RTCs significantly declined between 2010 and 2020. Larger facilities, facilities with an SED program, and facilities that used psychotropic medications with clients were more likely to use SR practices between 2010 and 2016. More high-quality, publicly available data for monitoring S/R use in mental health services within the United States is needed.

The attitudes of nurses towards seclusion: A New Zealand in-patient mental health setting

Seclusion is a form of restraint practised in mental health services world-wide, and has been criticised as unethical and traumatising to patients. Several countries have committed to reducing or eliminating seclusion. In New Zealand, there has been a focus on reducing seclusion of the indigenous Māori population, who experience particularly high rates. Nurses typically lead decisions to place patients in seclusion and their attitudes towards seclusion likely influence this process. This study aimed to address the primary question: what are the attitudes of registered nurses towards the use of seclusion? A mixed methods pragmatic approach was used involving qualitative interviews of nurses working in a high seclusion mental health ward located in the North Island of New Zealand, and a quantitative analysis of the seclusion data from this ward. This report is adherent with COREQ and STROBE. Thirteen nurses were interviewed and four main themes were identified: seclusion is necessary; seclusion is being used unnecessarily; nurse characteristics influence the use of seclusion; nurses perceived their ward culture to be improving in the use of seclusion. However, analysis of seclusion data indicated that rates had been increasing for this ward prior to this study, and the rates for indigenous Māori patients were especially elevated. This pattern of increasing rates was congruent with the 'supportive' attitudes of nurses towards seclusion. Interestingly, during the time of this study, the seclusion rates began to decline, including for Māori patients. This decline may have been partially due to the increased awareness prompted by the study.

Protocols to reduce seclusion in inpatient mental health units

The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.

Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta-analysis

BACKGROUND

There is a growing consensus to reduce the use of restrictive care practices in mental health settings to minimise the physical and psychological complications for patients. However, data regarding restrictive care practice use and factors contributing to variations in the proportion estimates has not previously been synthesised.

AIMS

This study aimed to synthesise evidence on (1) the pooled proportions of physical restraint, seclusion or chemical restraint in adult mental health inpatients and (2) sources of variability in these proportion estimates.

METHODS

Studies were identified from Scopus, MEDLINE, PsycINFO, Web of Science, Embase and CINAHL databases following the PRISMA 2020 guidelines. We conducted a meta-analysis of studies published in English language from 1 January 2010 to 15 August 2022. Binomial data were pooled using a random effect model, with 95% confidence intervals. Meta-regression was also computed to identify factors that may contribute to variations in the proportion estimates.

RESULTS

A total of 77 studies were included in this meta-analysis. The pooled prevalence of physical restraint, seclusion and chemical restraint was 14.4%, 15.8% and 25.7%, respectively. Data were heterogeneous across studies (I2  > 99%). Reporting practices and geographical locations contributed to the variability in the reported estimates of restrictive care practices, with studies from Asian countries reporting higher proportions.

CONCLUSION

There appear differences between geographical locations in the proportion of restrictive practices in mental health inpatients; however, this is complicated by how these prevalence data have been measured and defined. Consistency in the reporting of restrictive care practices in mental health is required to make valid comparisons between geographical regions, policy settings and practice innovations.

RELEVANCE TO CLINICAL PRACTICE

Efforts are needed to develop training programmes and policy changes to ensure consistency in defining and reporting of restrictive care practices in mental health facilities.

PATIENT/PUBLIC CONTRIBUTION

This is a systematic review that analysed data from previously published studies, and there was no patient/public contribution in this study.

PROTOCOL REGISTRATION

The protocol for this review has been registered to PROSPERO: CRD42022335167.

The impact of adolescent suicide on professionals in secure residential youth care

Professionals in secure residential youth care (SRYC) in the Netherlands are regularly confronted with suicides of adolescents and can be referred to as secondary victims. However, little is known about the impact of suicides on these professionals. This study explores the impact of suicides on professionals working in SRYC. Semi-structured interviews (n = 14) were conducted with professionals from several SRYC institutions. A thematic analysis of the material yielded four main themes: i) impact of suicide on a personal level, ii) impact of suicide on a vocational level, iii) impact of suicide on professional responses, and iv) facilitators and barriers that facilitated or obstructed professional resilience and the prevention of future suicides. The experience of suicide is extremely distressing for professionals. Some interviewees were traumatized by the impact. The findings suggest that most professionals draw on coercive measures for other youngsters sooner and more often after being exposed to suicide. The most commonly reported reason for doing so was the fear of experiencing a fatal incident. Professionals in SRYC require skilled and dedicated support (postvention) following a suicide to minimize its detrimental effects on personal, professional, and team functioning. Further implications for daily practice and policymaking are discussed.

Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project

OBJECTIVES

The goal of the current project was to enhance the feeling of dignity for patients in the seclusion unit in an acute psychiatric ward through environmental design changes and to evaluate the effect of the refurbishment.

BACKGROUND

Treating people with dignity is essential in all health-related work and important for our mental health. Hospital architecture and design signal values that can promote dignity. Patients who must spend time in seclusion are at their most vulnerable mental state and the often worn-down like environment can challenge the feeling of dignity. How environmental design can promote dignity in seclusion units have not been studied.

METHODS

To reach suggestions for design changes enhancing dignity, we used service design that included a broad user group. The effect of design changes was evaluated by a questionnaire answered by the nursing staff during a 4-week period pre- and post refurbishment and included a control group.

RESULTS

The design concepts agreed upon were a welcoming atmosphere, contact with nature, room for privacy, close contact with staff, and a designated smoking area inside the unit. The evaluation found that the environmental design changes significantly supported the patients in their situation and the staff in their work.

CONCLUSION

We conclude that dignity design concepts are highly applicable also in an acute psychiatric setting and improve the situation of secluded mental health patients, which is much needed. Findings align with other environmental changes in psychiatric wards that improve the patients' well-being and reduce aggression.

Second-Generation Antipsychotic Long-Acting Injection Reduced the Time of Restrictive Interventions in Patients With Schizophrenia: Retrospective, A 4-Year Mirror-Image Study

BACKGROUND

Whether second-generation antipsychotic long-acting injection (SGA-LAI) reduces psychotic symptoms at relapse compared with oral antipsychotics remains unclear. The present study investigated the effects of SGA-LAI on the time (in hours) of restrictive interventions in hospitalization by conducting a retrospective observational 4-year mirror-image study at a single medical center in Japan.

METHOD

We performed a retrospective observational mirror-image study conducted between November 2013 and January 2018. Data were initially retrieved from 101 patients. The 38 patients with schizophrenia who met the inclusion criteria were enrolled in the analysis. The primary outcome was the time of restrictive interventions and the secondary outcomes included the number of hospitalizations (total, voluntary, and involuntary) and bed days compared 2 years before and after initiating SGA-LAI. The restrictive interventions were defined as seclusion and physical restraints.

RESULTS

The mean time of restrictive interventions significantly decreased from 43.7 to 3.03 ( P = 0.021). The number of admissions and the total number of bed days in post-SGA-LAI fell from 1.03 to 0.61 ( P = 0.011) and 130 to 39.3 ( P = 0.003), respectively, compared with pre-SGA-LAI. In particular, the number of involuntary admissions was significantly reduced (0.50-0.26, P = 0.039).

CONCLUSIONS

The findings indicate that SGA-LAI reduced the time of restrictive interventions and the number of involuntary admissions. Moreover, SGA-LAI may contribute to mild psychiatric symptoms during relapse.

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression

OBJECTIVE

In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it.

METHOD

We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes.

RESULTS

Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient."

CONCLUSION

Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

Factors associated with the use of mechanical restraint in a mental health hospitalization unit: 8-year retrospective analysis

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Our present understanding of mechanical restraint is heterogenous, largely due to the important differences between countries/regions. In Spain, the use of this restrictive practice is not regulated, nor is its use protocolized. Previous studies that have investigated the impact of organizational factors and changes in these protocols are often short and not conducted within a framework designed to establish a long-term plan for reducing the use of mechanical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We demonstrate that the implementation of administrative and protocol changes in our psychiatric unit significantly reduced the use of mechanical restraint, thus laying the foundations for a regulatory framework. Our analysis shows that the profile of patients who require mechanical restraint is highly variable, but that certain clinical and institutional aspects within the framework of a long-term plan for the reduction in mechanical restraint can be targeted with long-lasting positive effects. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizational changes focussed on training staff, promoting family support and requiring the registration and close monitoring of episodes empower the role of the nursing staff in the prevention, monitoring and regulation of mechanical restraint. ABSTRACT: Introduction Mechanical restraint is a controversial restrictive practice to manage agitation or violent behaviour. Numerous studies have evaluated the factors and organizational changes that influence on mechanical restraint, but only for short time periods. None of those studies have assessed the effects of measures applied within the framework of a long-term plan to reduce the use of mechanical restraint. Given the lack of specific legislation in Spain, more data are required for its proper regulation. Aim/Question To evaluate the risk factors associated and the impact of specific measures designed to minimize the application of mechanical restraint in an acute mental health unit over an 8-year period and previous observation of 5 years. Methods Cross-sectional study based on a retrospective analysis of mechanical restraint records. We compared admissions requiring ≥one episode of restraint versus admissions not requiring this coercive measure. Results Between 2007 and 2014, 412 admissions (12%) required mechanical restraint. The data show that the measures applied in the previous five years had significantly reduced the total hours of restraint per semester. The factors associated with admissions requiring mechanical restraint were involuntary, unscheduled and longer admissions. The best predictor of restraint was involuntary admission (OR = 6.37), followed by the diagnosis of personality disorder (OR = 5.01). Discussion Identification of the factors associated with mechanical restraint would allow for early detection strategies. Our results provide additional evidence on the usefulness of organizational changes to reduce coercive measures, even in a country without specific legislation. Implications for Practice Organizational changes, such as staff training and increased family support during admission of episodes of mechanical restraint, can reduce the use of this measure. These measures also give the nursing staff greater responsibility in terms of their role in registering and monitoring the restrictive practice, thus helping to prevent or minimize the use of mechanical restraint.

Influence of nursing staff characteristics on seclusion in acute mental health care-A prospective two-year follow-up study

INTRODUCTION

Seclusion still occurs on mental health wards, despite absence of therapeutic efficacy and high risks of adverse patient effects. Literature on the effect of nursing teams, and the role of psychological characteristics in particular, on frequency of seclusion is scarce.

AIM

To explore the influence of demographic, professional or psychological, nursing team-level, and shift characteristics on the frequency of use of seclusion.

METHODS

Prospective two-year follow-up study.

RESULTS

We found that the probability of seclusion was lower when nursing teams with at least 75% males were on duty, compared to female only teams, odds ratio (OR = 0.283; 95% CrI 0.046-0.811). We observed a trend indicating that teams scoring higher on the openness personality dimension secluded less, (OR = 0.636; 95% CrI 0.292-1.156).

DISCUSSION

Higher proportions of male nurses in teams on duty were associated with lower likelihood of seclusion. We found an indication that teams with a higher mean openness personality trait tended to seclude less. These findings, if causal, could serve as an incentive to reflect on staff mix if circumstances demand better prevention of seclusion.

Influence of Organizational Climate and Clinician Morale on Seclusion and Physical Restraint Use in Inpatient Psychiatric Units

OBJECTIVES

Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.

METHODS

Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs).

RESULTS

The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement.

CONCLUSIONS

We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.

A Principlist Justification of Physical Restraint in the Emergency Department

The ethics of physical restraint in the Emergency Department (and elsewhere) has always been an emotive and controversial issue. Recently a vanguard of advocacy groups and regulatory agencies have been aiming to reduce and optimize its use, resulting in new guidance around physical restraint. This article considers prevailing opinions surrounding physical restraint in the Emergency Department using a Principlist model of medical ethics (specifically that of Beauchamp and Childress' four pillars). It also examines the ethical underpinning of the new guidance on the usage of restraint. Ultimately, examination from a Principlist perspective suggests the use of physical restraint in the Emergency Department is justified, as long as it is used carefully. Despite this, physical restraint can have severe physical and psychological consequences for patients, and work needs to be continued into its reduction and optimization.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.

Prevalence and risk factors for seclusion and restraint in old-age psychiatry inpatient units

BACKGROUND AND OBJECTIVES

Coercion in psychiatry is legally tolerated as a last resort. The reduction of the use of coercion is a shared goal of hospital administrators, medical and nursing staff and representatives of patients and families but requires the identification of risk factors for coercion. These risk factors in geriatric psychiatric inpatient settings are not well known, especially regarding seclusion. Through examining the prevalence of coercion and patients' characteristics, this study aims to identify risk factors for coercion in elderly people.

METHODS

The use of coercion in the geriatric psychiatry division of Geneva University Hospital in 2017 was retrospectively analyzed. The incidence rate ratios were estimated with multivariable Poisson regressions to assess risk factors for coercion.

RESULTS

Eighty-one of 494 patients (16.4%) experienced at least one coercive measure during their stay (mainly seclusion). The risk factors for coercion were younger age, male gender, being divorced or married, cognitive disorders, high item 1 of the Health of the Nation Outcome Scales (HoNOS) score (overactive, aggressive, disruptive or agitated behavior) at admission, previous psychiatric hospitalizations and involuntary referrals from the emergency department. Other disorders and global HoNOS scores were not associated with the use of coercion.

CONCLUSION

Higher risks of coercion were outlined in men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. They differed from those observed in younger adults in terms of age, civil status, disorders, global HoNOS scores and referrals. Therefore, geriatric psychiatric populations should be specifically investigated for the development of interventions aiming coercion reduction.

Coercive Measures in Psychiatry: A Review of Ethical Arguments

Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues. Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords "coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy." We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories. Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development. Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.

Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program

Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.

The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry

Many determinants leading to the use of different coercive measures in psychiatry have been widely studied and it seems that staff attitudes play a crucial role when it comes to the decision-making process about using coercion. However, research results about staff attitudes and their role in the use of coercive measures are inconsistent. This might be due to a focus on self-report studies asking for explicit answers, which involves the risk of bias. This study aimed to expand research on this topic by examining the impact of explicit and implicit staff attitudes on the use of coercive measures in clinical practice. In addition, the influence of gender, profession (nurses, psychiatrists), and years of professional experience as well as their influence on staff attitudes were examined. An adaption of the implicit association measure, the Go/No-Go Association Task (GNAT), with the target category coercion and distracter stimuli describing work load, as well as the explicit questionnaire Staff Attitudes to Coercion Scale (SACS) was completed by staff (N = 149) on 13 acute psychiatric units in 6 hospitals. Data on coercive measures as well as the total number of treated cases for each unit was collected. Results showed that there was no association between staff's implicit and explicit attitudes toward coercion, and neither measure was correlated with the local frequency of coercive measures. ANOVAs showed a significant difference of the GNAT result for the factor gender (F = 9.32, p = 0.003), demonstrating a higher tendency to justify coercion among female staff members (M = -0.23, SD = ±0.35) compared to their male colleagues (M = -0.41, SD = ±0.31). For the SACS, a significant difference was found for the factor profession (F = 7.58, p = 0.007), with nurses (M = 2.79, SD = ±1.40) showing a more positive attitude to the use of coercion than psychiatrists (M = 2.15, SD = ±1.11). No significant associations were found regarding the extent of professional experience. Results indicate a complex interaction between implicit and explicit decision-making processes dependent on specific contexts. We propose future research to include primers for more context-related outcomes. Furthermore, differences in gender suggest a need to direct attention toward occupational safety and possible feelings of anxiety in the workplace, especially for female staff members.

La face cachée de la coercition : une herméneutique de l’ambivalence

La coercition est un sujet épineux en santé mentale. Peu de philosophes s’y sont intéressés. En principe, dans un contexte où l’on valorise l’autonomie et la liberté, la coercition ne devrait pas exister. Pourtant, la coercition est bien présente et probablement pour les meilleures raisons. La coercition soulève plusieurs questions éthiques. Souvent le problème se pose relativement au bien et au mal à l’intérieur d’une logique binaire et du tiers exclu. De notre côté, il s’agit de montrer qu’il est avantageux de nous sortir du conflit en posant le problème autrement. Nous nous demanderons jusqu’où nous devons insister dans nos interventions et comment faire évoluer une situation. Nous verrons que ces deux questions se répondent l’une et l’autre. C’est en interrogeant nos présupposés concernant la santé, l’autonomie, la sécurité et la coercition que nous réussirons à modifier notre compréhension de la situation et, par le fait même, à tracer une limite qui prendrait en compte plusieurs perspectives. Au lieu de nous questionner sur la manière de respecter l’autonomie, la santé, la sécurité, il convient plutôt de nous demander comment accompagner le patient dans des situations difficiles. En guise de conclusion, il est souhaitable d’accepter l’ambivalence entourant la coercition et de demeurer prudent en maintenant le doute et le questionnement. En ce sens, l’éthique participe à la définition de la psychiatrie et à son devenir en mettant en valeur l’importance de l’accueil, de l’écoute et du dialogue avec ce qui donne sens à une vie.

Seclusion: A Patient Perspective

The appropriate treatment of mentally unwell, aggressive patients has challenged psychiatry for centuries. Seclusion is practiced worldwide, but concerns remain regarding its appropriateness and lack of alternatives. Patients generally report seclusion as a negative experience, though there is a paucity of literature exploring this in detail. This investigation was a service evaluation appraising inpatients' perspective of processes occurring before (information, communication), during (review, care), and after (debrief, reflection) seclusion in a psychiatric intensive care unit (PICU). In this phenomenological study, qualitative data were gathered using a questionnaire in a structured interview. All patients had been nursed in seclusion during admission to a male PICU at South London and the Maudsley NHS Foundation Trust. Ten patients were interviewed over 4 months. The central theme was perceived lack of communication in the patient-professional relationship, which manifested itself as (i) violence against patients, (ii) lack of psychological support, and (iii) the need for alternatives. Such feedback from patients queries whether national guidelines are appropriate and/or being adhered to. Healthcare practitioners have a responsibility to challenge accepted practice to continually improve the standard of patient-centred care. Utilising patient perspectives can be a powerful driver of change towards more humane treatment of vulnerable patients.

The Role of the Psychiatrist in Seclusion and Restraint

Psychiatrists have been involved in seclusion and restraint (S-R) management and mitigating its abuses for 200 years. The emphasis on finding alternatives to S-R has produced much of the recent success in decreasing its use. Nonetheless, patients continue to suffer from abuse and to die in S-R events, so a need for more assessments and interventions seems like a productive avenue to pursue. One approach is to involve psychiatrists more intensively in all S-R activities as is part of the widely used, rationale-based practice, Six Core Strategies to Prevent Conflict, Trauma, and Violence. These opportunities are reviewed.

The role of physical exercise and rehabilitation in delirium

PURPOSE

This article aims to analyze the intersections between delirium, physical exercise and rehabilitation, to better understand their interrelation and to visualize future lines of research.

METHODS

In this narrative review, after an overview of brain neurophysiology and function, as common substrates to understand the relationship between delirium and physical function, we explore the scientific evidence in: (1) physical dysfunction as a risk factor for delirium; (2) physical dysfunction as a symptom of delirium and (3) functional consequences related to delirium. Later, we analyze the physical therapy as one of the main strategies in multicomponent interventions to prevent delirium, by examining intervention studies including rehabilitation, which have shown to be effective in managing delirium. Finally, we analyze how frailty, delirium and physical exercise interact with each other.

RESULTS

This review confirms the close relationship between delirium and physical dysfunction; therefore, it is not surprising that physical exercise is widely used in delirium preventive strategies. Although delirium is catalogued as a neurocognitive disorder, scientific evidence shows that it is also a motor disorder, which is to be expected, since a vast body of literature already supports an interaction between motor and cognitive function.

CONCLUSION

The motor component of delirium should be taken into account when designing interventions or strategies to address delirium. These interventions may have a special importance in frail older adults.

Ethical challenges of seclusion in psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental health professionals

BACKGROUND

Seclusion is an invasive clinical intervention used in inpatient psychiatric wards as a continuation of milieu therapy with vast behavioural implications that raise many ethical challenges. Seclusion is in Norway defined as an intervention used to contain the patient, accompanied by staff, in a single room, a separate unit, or an area inside the ward. Isolation is defined as the short-term confinement of a patient behind a locked or closed door with no staff present. Few studies examine how staff experiences the ethical challenges they encounter during seclusion. By making these challenges explicit and reflecting upon them, we may be able to provide better care to patients. The aim of this study is to examine how clinical staff in psychiatric inpatient wards describes and assess the ethical challenges of seclusion.

METHODS

This study was based on 149 detailed written descriptions of episodes of seclusion from 57 psychiatric wards. A descriptive and exploratory approach was used. Data were analysed using qualitative content analysis.

RESULTS

The main finding is that the relationship between treatment and control during seclusion presents several ethical challenges. This is reflected in the balance between the staff's sincere desire to provide good treatment and the patients' behaviour that makes control necessary. Particularly, the findings show how taking control of the patient can be ethically challenging and burdensome and that working under such conditions may result in psychosocial strain on the staff. The findings are discussed according to four core ethical principles: autonomy, beneficence, non-maleficence, and justice.

CONCLUSION

Ethical challenges seem to be at the core of the seclusion practice. Systematic ethical reflections are one way to process the ethical challenges that staff encounters. More knowledge is needed concerning the ethical dimensions of seclusion and alternatives to seclusion, including what ethical consequences the psychosocial stress of working with seclusion have for staff.

Seclusion versus mechanical restraint in psychiatry - a systematic review

OBJECTIVE

Seclusion and mechanical restraint are coercive interventions used at psychiatric hospitals when patients are at imminent risk of harming themselves and/or others. Although these interventions have been used for decades, it remains unclear whether seclusion or mechanical restraint is superior in terms of efficacy and safety. Therefore, we aimed to systematically review studies comparing the intended and unintended effects of seclusion and mechanical restraint.

METHODS

A systematic search of PubMed and Embase was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Quantitative studies comparing the intended and unintended effects of seclusion and mechanical restraint were included.

RESULTS

The search identified 868 unique records. Fourteen of these (3 reporting on randomized controlled trials and 11 reporting on observational studies) met the predefined inclusion criteria. The study methodology including outcome measures varied significantly across studies. The results of the 11 studies using a subjective outcome measure (patient preference/emotions) were in favour of seclusion, while the 3 studies using an objective outcome measure (duration of coercion/need for transition to other coercive measure) favoured mechanical restraint. There was a high risk of residual confounding by indication and/or bias affecting the reported results.

CONCLUSION

Based on the available literature, it cannot be determined whether seclusion is superior to mechanical restraint or vice versa. Further studies using stringent methodology are required to answer this question. A cautious conclusion based on this review is that the availability of both methods seems necessary - as both have their pros and cons.

Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit

INTRODUCTION

The use of restrictive interventions is one of the most controversial practices in medicine. They are utilized in an inpatient setting to manage agitated or aggressive behaviour or to ensure that an individual receives the necessary treatments. However, restrictive interventions remove autonomy and adverse events can be associated with their practice. Youth-specific inpatient units (IPUs) are now being established and it is imperative that the use of restrictive interventions is reduced. In order to inform and facilitate prevention and reduction strategies, this study aimed to determine the prevalence and determinants of restrictive interventions (restraint, seclusion and medication without consent) in a youth specialist mental health IPU.

METHODS

This study was set at a 16-bed youth specialist acute IPU of Orygen Youth Health, a specialist youth mental health service that provides inpatient care for those aged 18 to 25 years within a catchment area of west and north-western regions of Melbourne, Australia. A retrospective file audit was conducted of all the admissions to the unit from 01 January 2015 to 30 June 2015.

RESULTS

Over the 6-month study period, 159 young people were admitted and this accounted for 188 admissions. Over half (54.3%) of admissions were involuntary and restrictive intervention were used in 17.6% of admissions. Specifically, 15.7% (N = 25) of young people experienced restraint, 10.1% (N = 16) were secluded, and 8.1% (N = 12) experienced medication without consent. Absent insight and involuntary status on admission were associated with restrictive interventions.

CONCLUSION

As youth mental health services develop, interventions aimed at reducing restrictive interventions are needed.

Factors associated with the use and longer duration of seclusion and restraint in psychiatric inpatient settings: a retrospective chart review

Objectives: To examine factors that may affect the use and duration of seclusion and restraint (SR) in psychiatric inpatient settings. Methods: First, multivariable logistic regression analysis was used to examine factors associated with the use of SR in an unmatched case-control study, comparing SR cases and controls. Second, for patients that underwent SR, multivariable linear regression analysis was used to determine factors contributing to the duration of SR. Results: Out of 213 patients, 58 underwent SR. An F00 diagnosis, a history of epilepsy, antipsychotics usage and antidepressants usage were significantly associated with the use of SR (odds ratio = 7.98; 95% CI = 1.11-57.50, odds ratio = 4.89; 95% CI = 1.12-21.36, odds ratio = 4.59; 95% CI = 1.54-13.68 and odds ratio = 0.29; 95% CI = 0.10-0.86, respectively). An F00 and F32 diagnosis significantly extended the duration of SR (coefficient = 13.10; 95% CI = 2.11-24.11 and coefficient = 20.52; 95% CI = 9.68-31.37, respectively). Conclusions: A variety of factors are associated with the use and longer duration of SR. Given the potentially harmful effects of these practices, further studies with larger samples and a wider range of quantitative outcome measures are warranted. Key points An F00 diagnosis, a history of epilepsy and antipsychotics usage may increase the use of SR. Antidepressants may decrease the use of SR. An F00 and F32 diagnosis may extend the duration of SR.

Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon)

Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation - stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure - if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon's psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.

Alternatives to use of restraint: A path toward humanistic care

Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.

Clinical and demographic characteristics of secluded and mechanically restrained mentally ill patients: a retrospective study

Background

Restraint or seclusion measures in acute psychiatric care are used as a last resort when all other methods for removal of physical threat have failed. The purpose of this study is to find a correlation between coercive measures, demographic characteristics within this patient group, and factors associated with shortened periods of restriction.

Methods

This is a one-year retrospective study conducted in a male acute closed ward of a psychiatric hospital in Israel. The data from January 1, 2014 to December 31, 2014 were retrieved from the records of patients who underwent restraint and/or seclusion interventions during this period. The analyzed data included age, psychiatric diagnosis, marital status, education, race, ethnicity, length of hospital stay, legal status during admission, type of coercive measure (mechanical restraint, seclusion), number and duration of coercive episodes, reasons for coercion, time of event, number of previous hospitalizations, aggression in past and present treatment, and treatment during events.

Results

During this time period, there were 563 admissions in the study ward. Over this period, 176 subjects (31.3%) underwent 488 restraints and/or seclusions. 98% were aggressive in the past. (Although some results reached statistical significance, we prefer to emphasize here only the most important results, while the others will be presented in the text.) Patients with personality disorders were physically limited for the longest time, while schizophrenia patients were restricted for the shortest time compared with other diagnoses (p = 0.007). A negative correlation was found between the length of coercion and the number of academic female nurses on duty (p = 0.005), as well as the administration of sedative medications during the restricting procedure.

Conclusions

We believe that the presence of registered, academic female nurses on duty and medication administration during coercive measures can reduce the length of restriction.

Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective:

To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient’s appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.

Conclusion:

The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.

Systematic review registry number:

CRD42017054440.

[Coercive interventions: historical summary and review of subjective experience]

Psychiatric treatment has always been associated with violence and coercion. Involuntary admission and coercive measures are still frequently occurring components in everyday clinical practice.Up to 15% of psychiatric inpatients experience coercive treatment at least once during hospital stay. Particularly patients suffering from schizophrenia, organic mental disorders and mania have a high risk for such incidents.There is an ongoing intense debate on the need and justification of coercive measures, although most clinicians and scientists currently agree that there is no alternative. Several investigations have shown that seclusion and mechanical restraint go along with physical and psychological problems affecting both, patients and staff. However, it was possible to identify aspects that could be improved: Maintaining an objective and professional communication during coercive treatment seems just as important as making comprehensible decisions. Alternative treatment options should be focus of further investigations.

Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon

Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians' opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians' preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies.

Listening to the Patient Perspective: Psychiatric Inpatients' Attitudes Towards Physical Restraint

When other options fail, physical restraint is used in inpatient psychiatric units as a means to control violent behavior of agitated inpatients and to prevent them from harm. The professional and social discourse regarding the use of restrictive measures and the absence of the inpatients' attitudes towards these measures is notable. Our research therefore tries to fill this gap by interviewing inpatients about these issues. To assess the subjective experience and attitudes of inpatients who have undergone physical restraint. Forty inpatients diagnosed with psychiatric disorders were interviewed by way of a structured questionnaire. Descriptive statistics were conducted via use of SPSS statistical software. 1.Inpatients reported that physical restraint evoked an experience of loneliness (77.5%) and loss of autonomy (82.5%). 2.Staff visits during times of physical restraint were reported as beneficial according to 73.6% of the inpatients interviewed. 3.Two thirds of the inpatients viewed the use of physical restraints as justified when an inpatient was dangerous. 4.Two thirds of the inpatients regarded physical restraint as the most aversive experience of their hospitalization. Our pilot study explored the subjective experience and attitudes of psychiatric inpatients towards the use of physical restraint. Inpatients viewed physical restraint as a practice that was sometimes justified but at the same time evoked negative subjective feelings. We conclude that listening to inpatients' perspectives can help caregivers to evaluate these measures.

Factors associated with the use of seclusion in an inpatient psychiatric unit in Lilongwe, Malawi

Background

Data on the use of seclusion for psychiatric inpatients in sub-Saharan Africa are extremely limited. Though seclusion is sometimes necessary for patients that pose a threat to themselves or others, adverse physical and psychological sequelae from the experience are increasingly being recognized, leading to efforts to reduce its use. The purpose of this study was to calculate the frequency of seclusion in patients hospitalized in an inpatient psychiatric unit in Lilongwe, Malawi, and to identify factors associated with its use.

Methods

Records of 419 psychiatric inpatients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi, from January 1, 2011 to December 31, 2011, were reviewed. Multivariate logistic regression analysis was employed to identify factors associated with the use of seclusion.

Results

Seclusion was used for 30.3% (127/419) of patients during the study period. Male patients had increased odds of being secluded (aOR: 2.22, p=0.02). Assaulting other patients on the unit (aOR 7.92, p<0.01) and presenting to the unit in mechanical restraints (aOR 2.33, p<0.01) were also associated with seclusion. There was no association between seclusion and age; diagnosis of alcohol use disorder, marijuana use disorder, or schizophrenia; involuntary admission; presence of extra pyramidal side effects; presence of hallucinations; suicidality; or commission of violent acts prior to admission.

Conclusions

Documentation about the rationale for the use of seclusion on the unit was minimal. Improved record keeping requirements will be essential to future efforts to study seclusion and reduce its use. Development of strategies to address patient violence on the unit could decrease the use of seclusion for aggressive patients. Patients arriving to the unit in restraints would benefit from increased efforts by staff to apply behavioural interventions or administer medications, in order to deescalate these individuals and limit the use of seclusion in their treatment.

Violence, research, and non-identity in the psychiatric clinic

Violence in psychiatric clinics has been a consistent problem since the birth of modern psychiatry. In this paper, I examine current efforts to understand and reduce both violence and coercive responses to violence in psychiatry, arguing that these efforts are destined to fall short. By and large, scholarship on psychiatric violence reduction has focused on identifying discrete factors that are statistically associated with violence, such as patient demographics and clinical qualities, in an effort to quantify risk and predict violent acts before they happen. Using the work of Horkheimer and Adorno, I characterize the theoretical orientation of such efforts as identity thinking. I then argue that these approaches lead to epistemic imperceptiveness and a subtle form of conceptual restraint on patients. I suggest a reorientation in psychiatric research, away from identity thinking and toward a more productive and just approach to the problem of violence in psychiatric clinics.

Factors to consider in evaluating the appropriateness of restraints during forensic evaluations

Forensic examiners frequently conduct evaluations with individuals who may be regarded as dangerous. To manage this situation, forensic examiners may prefer examinees to wear restraints. Available literature indicates that the use of restraints may be both physically and psychologically detrimental and thus possibly both reduces the yield and limits the utility of psychological test data. Although there is a lack of research addressing this concern, one must use the available information to inform the decision on utilization of restraints during forensic evaluations. In addition, professional ethics, test standards and norms, the reported adverse effects of restraints on both psychiatric patients and inmates, and the concept of forced medication are reviewed to help assess the appropriateness of restraints during forensic evaluations. This analysis provides forensic examiners with insight and recommendations to determine if the use of restraints is best practice during forensic evaluations, particularly within the United States.

Restraint, Restrictive Intervention, and Seclusion of People With Intellectual and Developmental Disabilities

Restraint, restrictive interventions, and seclusion are hotly contested practices with inconclusive evidence of their effectiveness. Because the use of restraint and seclusion on people with intellectual and developmental disabilities (IDD) is controversial and its effectiveness doubtable, this study was conducted to explore if and how they were permitted in Medicaid HCBS 1915(c) waivers, the largest providers of long-term services and supports (LTSS) for people with IDD. To do so, 111 fiscal year 2015 IDD waivers from across the nation were examined to determine if and how states permitted restraint, restrictive interventions, and seclusion. Findings revealed an overwhelming majority of waivers permitted the use of restraint (78.4%) and restrictive interventions (75.7%). A smaller proportion (24.3%) allowed the use of seclusion.

The Impact of 'Being There': Psychiatric Staff Attitudes on the Use of Restraint

The practice of mechanically restraining psychiatric patients is constantly under debate, and staff attitudes are considered a central factor influencing restraining practices. The aim of this study was to explore associations between psychiatric staff members' presence and participation in incidences of restraint and attitudes towards mechanical restraints.

METHODS

Staff members (psychiatrists, nurses, paramedical staff; N = 143 working in a government psychiatric hospital in Israel) completed a questionnaire including personal information, participation in incidents of restraint and attitudes towards mechanical restraints. Items were categorized into the following categories: security and care; humiliation and offending; control; order; education and punishment.

RESULTS

Compared to those who were not present during restraint, staff members who were present agreed significantly less with statements indicating that restraints are humiliating and offending and agreed more with statements indicating that restraints are used primarily for security and care (p < .05). Among those present in incidences of restraint, staff members who physically participated in restraint agreed significantly more with statements indicating that restraints are a means for security, care and order, and less with statements indicating restraints are humiliating and offending, compared to those present but not physically participating in restraint (p < .05).

CONCLUSIONS

These findings highlight the importance of proximity of staff members to incidences of restraints. This may have implications in understanding the professional and social discourse concerning mechanical restraints.

Use of mechanical and pharmacological restraint over an eight-year period and its relation to clinical factors

BACKGROUND

Use of restraint and finding the balance between security and ethics is a continuous dilemma in clinical psychiatry. In daily clinic and in planning health-care service, knowledge on the characteristics of restraint situations is necessary to optimize its use and avoid abuse.

METHODS

We describe characteristics in the use of pharmacological and mechanical restraint in psychiatric acute wards in a hospital in Middle Norway over an eight-year period. Data on all cases of mechanical and pharmacological restraint from 2004 to 2011 were retrospectively collected from hand-written protocols. Complementary information on the patients was obtained from the hospital patient administrative system.

RESULTS

Restraint in acute wards was used on 13 persons per 100,000 inhabitants annually. The percentage of admitted patients exposed to restraint was 1.7%, with a mean of 4.5 cases per exposed patient. Frequency per 100 admitted patients varied from 3.7 (in 2007) to 10 (in 2009). The majority of restraint cases concerned male patients under 50 years and with substance-abuse, psychotic, or affective disorders. Significantly more coercive means were used during daytime compared to night and morning. There was a significant increase in pharmacological coercion during spring and mechanical coercion during summer.

CONCLUSIONS

Restraint was used on 1.7% of admitted patients, representing 13 per 100,000 inhabitants per year. Use of restraint was higher during certain periods of the day and was associated with the patient's diagnosis, age, gender, and legal status of hospitalization. There was a marked variation over the years.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Psychopathological Assessment of Risk of Restraint in Acute Psychiatric Patients

The study aims to identify independent predictors of physical restraint in acute psychiatric patients and to determine the predictive power of a risk assessment model centered on psychopathological dimensions. We included 1552 patients admitted to a psychiatric intensive care unit over a 5-year period. Patients were rated on the Brief Psychiatric Rating Scale (BPRS-E) at admission. Principal axis factoring (PAF) with varimax rotation was performed on BPRS-E items to identify psychopathological factors. Multiple logistic regression analysis was performed. PAF pointed six factors: positive symptoms, negative symptoms, resistance, activation, negative affect, and disorganization. Male sex, younger age, proposal for compulsory admission, severity of symptoms, resistance, activation, and disorganization were identified as independent predictors. Negative symptoms and negative affect were instead protective factors. The BPRS-E factors, when added to other sociodemographic and clinical variables, significantly increased the predictive power of the model. Our findings suggest that a systematic evaluation of the psychopathological dimensions can be usefully included in the early risk assessment of restraint.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

Reduction of Physical Restraints in Residential Treatment Facilities

Children and adolescents with severe emotional and behavioral problems in residential settings can become so aggressive that physical restraints are utilized to keep them and others safe. Recently, the use of physical restraints in residential treatment facilities for school-aged children has come under increased scrutiny, and there have been legislative mandates that the use of physical restraints be reduced. This article describes a quasi-experimental field study conducted to examine the effectiveness of a 2-phase (organizational and milieu) physical restraint reduction intervention in a multisite residential treatment center. Results provide support for the effectiveness of organizational-level and milieu interventions for restraint reduction. Overall, restraint rates were reduced by 59% using these interventions.

Influence of staff's emotional reactions on the escalation of patient aggression in mental health care

Patient aggression is universally recognized as an important challenge in mental health care (MHC). Based upon a pragmatic exploration of the professional literature, we seek here to determine how negative emotional reactions of staff-including those conveyed in terms of fear, anger, and insult-may serve to exacerbate this serious impediment to safe and effective MHC. This is done using biological and evolutionary paradigms. Studies of patient aggression have tended to focus more on patient characteristics and behavior than on those of their caregivers. The authors suggest that patient aggression may be viewed as a response to "normal" interaction processes. The results of this investigation imply that the emotional reactions of staff may escalate the aggressive interaction by increasing the patient's perception of threat, and also, increase the probability of new incidents by creating a patient-staff relationship characterized by unsafety and mistrust. Mindfulness-based interventions are suggested as useful strategies to expand the staff's emotional awareness and increase emotional control.

Restraint and the Question of Validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.