Restraint and seclusion: a review of the literature

OBJECTIVE

The author reviewed the literature published since 1972 concerning restraint and seclusion.

METHOD

The review began with a computerized literature search. Further sources were located through citations from articles identified in the original search.

RESULTS

The author synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training.

CONCLUSIONS

The literature on restraint and seclusion supports the following. 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation. 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint. 3) Restraint and seclusion have deleterious physical and psychological effects on patients and staff, and the psychiatric consumer/survivor movement has emphasized these effects. 4) Demographic and clinical factors have limited influence on rates of restraint and seclusion. 5) Local nonclinical factors, such as cultural biases, staff role perceptions, and the attitude of the hospital administration, have a greater influence on rates of restraint and seclusion. 6) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects. 7) Studies comparing well-defined training programs have potential usefulness.

Lead, mercury, and cadmium exposure and attention deficit hyperactivity disorder in children

BACKGROUND

There is limited research examining the relationship between lead (Pb) exposure and medically diagnosed attention deficit hyperactivity disorder (ADHD) in children. The role of mercury (Hg) and cadmium (Cd) exposures in ADHD development is even less clear.

OBJECTIVES

To examine the relationship between Pb, Hg, and Cd and ADHD in children living inside and outside a Lead Investigation Area (LIA) of a former lead refinery in Omaha, NE.

METHODS

We carried out a case-control study with 71 currently medically diagnosed ADHD cases and 58 controls from a psychiatric clinic and a pediatric clinic inside and outside of the LIA. The participants were matched on age group (5-8, 9-12 years), sex, race (African American or Caucasians and others), and location (inside or outside LIA). We measured whole blood Pb, total Hg, and Cd using inductively coupled plasma mass spectrometry.

RESULTS

Inside the LIA, the 27 cases had blood Pb geometric mean (GM) 1.89 µg/dL and the 41 controls had 1.51 µg/dL. Outside the LIA, the 44 cases had blood Pb GM 1.02 µg/dL while the 17 controls had 0.97 µg/dL. After adjustment for matching variables and maternal smoking, socioeconomic status, and environmental tobacco exposure, each natural log unit blood Pb had an odds ratio of 2.52 with 95% confidence interval of 1.07-5.92. Stratification by the LIA indicated similar point estimate but wider CIs. No associations were observed for Hg or Cd.

CONCLUSIONS

Postnatal Pb exposure may be associated with higher risk of clinical ADHD, but not the postnatal exposure to Hg or Cd.

Gender incongruence/gender dysphoria and its classification history

In this article we discuss the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization. A diagnosis of 'transsexualism' appeared first in DSM-III in 1980. This version also included a childhood diagnosis: gender identity disorder of childhood. As research about gender incongruence/gender dysphoria increased, the terminology, placement and criteria were reviewed in successive versions of the DSM. Changes in various aspects of the diagnosis, however, were not only based on research. Social and political factors contributed to the conceptualization of gender incongruence/gender dysphoria as well.

Psychiatric residents' sexual contact with educators and patients: results of a national survey

In a national survey of PGY-4 psychiatric residents, 4.9% of the 548 respondents indicated that they had been sexually involved with psychiatric educators and 0.9% reported that they had been sexually involved with patients. Most residents reported no or minimal instruction in their residency programs about educator-resident and resident-patient sexual contact. The authors compare these results with those from previous surveys of psychologists. They discuss the need for expanding training curricula to include specific education on sexual exploitation.

Medical, judicial, and statutory regulation of ECT in the United States

The standards for ECT recommended by an APA task force report and those embodied in federal court orders and state statutes and regulations are compared. The authors conclude that there is serious boundary and role confusion owing to progressive intrusion of state authority into areas traditionally held to lie in the domain of medical judgment and clinical care. In spite of comprehensive safeguards promulgated by the psychiatric community, overregulation by legislatures and courts is commonplace, interposing law between physicians and patients and resulting in delays or denials of service while failing to resolve critical legal issues involving competence and consent.

Competence to consent to voluntary psychiatric hospitalization: a test of a standard proposed by APA. American Psychiatric Association

OBJECTIVE

In the wake of the U.S. Supreme Court's 1990 decision in Zinermon v. Burch, renewed attention has been given to capacities patients must have to be considered competent to consent to voluntary hospitalization. An American Psychiatric Association (APA) task force suggested that strong policy interests support the establishment of a low threshold for competence in this situation. The study examined whether, as previous research suggested, patients would have difficulty meeting even this lenient standard.

METHODS

One hundred voluntarily hospitalized psychiatric patients were read two brief paragraphs, one explaining the purposes of psychiatric hospitalization and and the other explaining policies for discharge. The paragraphs' readability measured about eighth-grade level. After each paragraph, participants were read two sets of questions, one testing recall of the presented information and the other testing recognition of the information in a true-false format. The scores of patients grouped by selected demographic and clinical variables were compared.

RESULTS AND CONCLUSIONS

The vast majority of patients were able to comprehend the information that the APA task force suggested was relevant to their decision. However, a subgroup of patients who were initially admitted involuntarily had significantly poorer performance and may constitute a group who need special educational efforts focused on the consequences of voluntary admission.

Mental health professionals and assisted death: perceived ethical obligations and proposed guidelines for practice

I have three purposes in this article: (a) to briefly review the legal obligations a mental health professional has when working with a client who is talking about taking some action that could lead to his or her death, (b) to clarify the positions of the 4 major national mental health organizations regarding the acceptable roles of their members with clients who are discussing the possibility of receiving assisted death, and (c) to propose a set of guidelines for practice for mental health professionals working with clients who are considering assisted death that comport with the various laws and codes of ethics.

Psychiatrist-patient sexual contact: results of a national survey, II: Psychiatrists' attitudes

In a national random-sample survey of 1,423 practicing psychiatrists, the overwhelming majority of the respondents (98%) said that therapist-patient sexual contact is always inappropriate and usually harmful to the patient. However, 29.6% said that such contact after termination of therapy might sometimes be acceptable. Psychiatrists who acknowledged having had sexual contact with one or more patients (N = 84) differed markedly from their peers in their attitudes. The majority (74%) of these offenders believed that sexual contact could be appropriate after termination; many apparently rationalized their behavior in this manner. The authors discuss the need for systematic professional education on the subject.

ADHD in the DSM-5-TR: What has changed and what has not

In this article, we critically review the changes made to the DSM-5 Text Revision published in 2022 regarding the diagnostic entity of Attention Deficit/Hyperactivity Disorder (ADHD). We structure our critique around three points. The first discusses the acknowledgment of ADHD as a neurodevelopmental disorder. The second examines the definition of ADHD provided in the updated edition of the manual. The third scrutinizes the changes in the diagnostic criteria for ADHD and assesses whether these changes make the diagnosis more accurate. We conclude that DSM's latest edition does not escape the logical and scientific pitfalls of its predecessor. DSM-5-TR keeps the faith in the neo-Kraepelinian paradigm by explicitly and implicitly cultivating the essentialist medical scientific metaphor of disorder, creating the illusion that it represents scientific progress that validates ADHD as a neurodevelopmental disorder.

Internet Gaming Disorder in adolescence: investigating profiles and associated risk factors

Background

Electronic gaming is a popular free-time activity and its deleterious effects have been considered by the American Psychiatric Association and World Health Organization. More recently ‘Gaming Disorder’ (GD) has been added to the 11^th revision of the International Classification of Diseases, while ‘Internet Gaming Disorder’ (IGD) remains as a tentative disorder in the 5^th revision of the Diagnostic and Statistical Manual of Mental Disorders. This study aimed to explore the characteristics of young gamers at risk for developing IGD.

Methods

To achieve this, a quantitative and nationally representative study was conducted in primary schools in Slovenia with eighth grade as the primary sampling unit (N = 1071, Mean_age = 13.44 years, SD_age = 0.59). Psychometric testing assessing IGD was conducted to identify participants’ IGD risk levels and to compare ‘high risk gamers’, ‘low risk gamers’, and ‘non-gamers’ in relation to free-time activities, self-control, and parent-child relationship. A one-way ANOVA analysis was conducted with Games-Howell post-hoc test to compare the three groups of participants. Statistically significant IGD factors were then included in a multinomial logistic regression analysis to identify the most relevant predictors of IGD.

Results

About 4.7% (n = 48) [95% CI: 3.4–6.0%] of Slovenian adolescents were found to be ‘high risk gamers’ when considering risk of IGD. These were mostly males (n = 42, 87.5%), and their preferred leisure activities involved more screen time activities (e.g., watching TV, playing video games, using social media). Moreover, ‘high risk gamers’ showed significantly lower levels of self-control compared to ‘low risk gamers’, and poorer understanding with their parents. Perceived satisfaction with life and mental health did not differ significantly between the three groups. The multinomial logistic regression identified four key predictors of IGD: male gender, gaming as a frequent free-time activity, attending music school or a choir and self-control.

Conclusion

Public health measures should target adolescents at increased risk of developing IGD in early age because they are particularly drawn to excessive gaming behaviors and present greater IGD vulnerability.

Need-for-treatment criteria for involuntary civil commitment: impact in practice

There has been considerable discussion in the literature on the differences between criteria for involuntary commitment that are based on dangerousness and criteria based on need for treatment. A number of states have adopted clinical criteria, and other state legislatures are actively considering them. Some libertarians argue that dangerousness is constitutionally required if a person is to undergo the loss of liberty involved in commitment. Citing widely publicized data from the state of Washington, they predict that a return to clinical criteria would result in a deluge of inappropriate commitments. Some clinicians counter that use of clinical criteria would result in selection of a much more appropriate clinical population and point to research indicating that strict observation of the need-for-treatment provisions of the APA model commitment statute would actually decrease the number of commitments. The author examines state hospital admission and census data from eight states that added need-for-treatment criteria to their commitment codes between 1975 and 1990 and argues that the data indicate that there is little reason to believe that such changes would result in the deluge of admissions predicted by the critics.

Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care

Although the medical profession's codes of ethics have rightly been criticized for having claimed authority to decide questions of medical ethics for society, codes continue to provide crucial guidance to the individual clinician in matters of ethics. Examination of the code of the American Psychiatric Association (APA) shows that while it emphasizes the psychiatrist's fiduciary responsibility to individual patients, it ignores the crucial dimension of stewardship responsibilities to society. As a result, the ethical pronouncements of the APA have thus far been of little use to clinicians with regard to the major issues posed by managed care. In contrast, the code of the National Association of Social Workers considers the ethics of social institutions as well as those of individual practitioners, and advises clinicians on how to manage the inevitable and legitimate tensions between fiduciary and stewardship commitments. Until the APA extends the scope of its ethical vision, it will not be able to help clinicians struggle constructively with the question of how it is possible to "care about patients" and "care about money."

An empirical comparison of the stone and dangerousness criteria for civil commitment

Massachusetts civil commitment criteria were compared in an emergency setting with a set of criteria developed by Dr. Alan Stone. Contrary to expectations, the Stone criteria proved to be more restrictive in a sample of 503 patients. Few patients would be newly committable under the Stone criteria; of the 35 patients committable under the Stone standard, 32 also met the current Massachusetts criteria for commitment. The clinical and policy implications of the adoption of the Stone criteria are discussed.