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Moell A, Lyle MS, Rozental A, Långström N. Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis. Lancet Psychiatry 2024:S2215-0366(24)00204-9. [PMID: 39121879 DOI: 10.1016/s2215-0366(24)00204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/30/2024] [Accepted: 06/07/2024] [Indexed: 08/12/2024]
Abstract
Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.
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Affiliation(s)
- Astrid Moell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Maria Smitmanis Lyle
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Alexander Rozental
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Department of Psychology, Uppsala University, Uppsala, Sweden; Department of Health, Education and Technology, Luleå University of Technology, Luleå, Sweden
| | - Niklas Långström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Moell A, Rozental A, Buchmayer S, Kaltiala R, Långström N. Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff. BMC Psychiatry 2024; 24:102. [PMID: 38317134 PMCID: PMC10845720 DOI: 10.1186/s12888-024-05553-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.
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Affiliation(s)
- Astrid Moell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Alexander Rozental
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Susanne Buchmayer
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riittakerttu Kaltiala
- Faculty of Medicine and Health Technology, and Tampere University Hospital, Department of Adolescent Psychiatry, Tampere University, Tampere, Finland
| | - Niklas Långström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Haran M, Killeen D, Healy M, Brophy P, Donohue A, Whyte I, Doody B. Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study. Ir J Med Sci 2023; 192:2929-2936. [PMID: 36813877 PMCID: PMC10692034 DOI: 10.1007/s11845-023-03316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND There has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland. AIMS The purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics. METHODS This is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed. RESULTS Of 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively. CONCLUSIONS Identifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.
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Affiliation(s)
- Maeve Haran
- Department of Psychiatry, School of Medicine, University College Dublin, Dublin, Ireland.
- Children's Health Ireland at Crumlin, Dublin, D12N512, Ireland.
| | - David Killeen
- Dublin North City and County CAMHS - Ballymun CAMHS, Ballymun Civic Centre, Dublin, Ireland
| | - Mike Healy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Peadar Brophy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Aoife Donohue
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Imelda Whyte
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Brendan Doody
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
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Donald BM, Bulik CM, Larsen JT, Carlsen AH, Clausen L, Petersen LV. Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors. Psychol Med 2023; 53:1999-2007. [PMID: 37310331 PMCID: PMC10811565 DOI: 10.1017/s003329172100372x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN. METHODS In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics. RESULTS IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these. CONCLUSIONS High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.
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Affiliation(s)
- Benjamin Mac Donald
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Cynthia M. Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Janne T. Larsen
- The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
| | - Anders H. Carlsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Loa Clausen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Liselotte V. Petersen
- The National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research (CIRRAU), Aarhus University, Aarhus, Denmark
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Mac Donald B, Gustafsson SA, Bulik CM, Clausen L. Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events. J Eat Disord 2023; 11:40. [PMID: 36915181 PMCID: PMC10010243 DOI: 10.1186/s40337-023-00765-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND A small but significant group of patients with anorexia nervosa (AN) undergo multiple involuntary treatment (IT) events. To enhance our understanding of IT and potentially inform treatment, we explored experiences and perspectives on IT of these patients. METHODS We designed a qualitative semi-structured interview study and used reflexive thematic analysis. Participants were at least 18 years of age, had multiple past IT events (≥ 5) related to AN over a period of at least one month of which the last IT event happened within the preceding five years. Participants had no current IT, intellectual disability, acute psychosis, or severe developmental disorder. We adopted an inductive approach and constructed meaning-based themes. RESULTS We interviewed seven participants. The data portrayed a process of living and leaving a life of coercion with a timeline covering three broad themes: living with internal coercion, coercive treatment, and leaving coercion; and five subthemes: helping an internal battle, augmenting suffering, feeling trapped, a lasting imprint, and changing perspectives. We highlighted that patients with AN and multiple IT events usually experienced internal coercion from the AN prior to external coercion from the health care system. IT evoked significant negative affect when experienced, and often left an adverse imprint. Moreover, IT could help an internal battle against AN and perspectives on IT could change over time. CONCLUSIONS Our study suggests that feeling internally coerced by AN itself sets the stage for IT. Clinicians should be conscious of the potential iatrogenic effects of IT, and reserve IT for potentially life-threatening situations.
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Affiliation(s)
- Benjamin Mac Donald
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens-Boulevard 99, 8200, Aarhus, Denmark. .,Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, Entrance K, 8200, Aarhus, Denmark.
| | - Sanna A Gustafsson
- School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Loa Clausen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens-Boulevard 99, 8200, Aarhus, Denmark.,Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, Entrance K, 8200, Aarhus, Denmark
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What factors contribute to the need for physical restraint in institutionalized residents in Taiwan? PLoS One 2022; 17:e0276058. [PMID: 36395117 PMCID: PMC9671315 DOI: 10.1371/journal.pone.0276058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 09/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background In Taiwan, physical restraint is commonly used in institutions to protect residents from falling or injury. However, physical restraint should be used cautiously to avoid side effects, such as worse cognition, mobility, depression, and even death. Objectives To identify the rate of physical restraint and the associated risk factors in institutionalized residents in Taiwan. Methods A community-based epidemiological survey was conducted from July 2019 to February 2020 across 266 residential institutions. Among the estimated 6,549 residents being surveyed, a total of 5,752 finished the study. The questionnaires were completed by residents, his/her family or social workers. The cognition tests were conducted by specialists and a multilevel analysis approach was used to identify cognition/disability/medical history/special nursing care/BPSD risk factors for physical restraints. Results Of the 5,752 included institutionalized residents, 30.2% (1,737) had been previously restrained. Older age, lower education level, lower cognitive function, higher dependence, residents with cerebrovascular disease, pulmonary disease, dementia, and intractable epilepsy, all contributed to a higher physical restraint rate, while orthopedic disease and spinal cord injury were associated with a lower physical restraint rate. Furthermore, residents with special nursing care had a higher restraint rate. Residents with most of the behavior and psychological symptoms were also associated with an increased restraint rate. Conclusions We studied the rate of physical restraint and associated risk factors in institutionalized residents in Taiwan. The benefits and risks of physical restraint should be evaluated before application, and adjusted according to different clinical situations.
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Perers C, Bäckström B, Johansson BA, Rask O. Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care. Psychiatr Q 2022; 93:107-136. [PMID: 33629229 PMCID: PMC8993718 DOI: 10.1007/s11126-021-09887-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 11/26/2022]
Abstract
Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.
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Affiliation(s)
| | - Beata Bäckström
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
| | - Björn Axel Johansson
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
- Skåne Child & Adolescent Psychiatry, Regional Inpatient Care, Emergency Unit, Malmö, Sweden
| | - Olof Rask
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
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Geng F, Jiang F, Conrad R, Liu T, Liu Y, Liu H, Tang YL. Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors. Child Psychiatry Hum Dev 2021; 52:939-944. [PMID: 33037522 DOI: 10.1007/s10578-020-01074-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
To investigate the rate of restraint and seclusion (R&S) use in child and adolescent psychiatric inpatients in China and to examine factors associated with use of these interventions. As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 youth inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. (1) The overall rate of R&S was 29.1% (N = 57) and the rate of restraint was 28.6% (N = 56), and seclusion was 11.7% (N = 23) respectively. (2) Compared to patients who did not require R&S, those who required R&S were more likely to have been hospitalized on an involuntary basis, more likely to present with either manic symptoms or aggressive behavior as primary reason for admission, had more frequent aggressive behaviors during hospitalization, and had a significantly longer length of stay. (3) A logistic regression showed that aggressive behaviors during hospitalization was significantly associated with the use of R&S (OR = 21.277, p < 0.001), along with three other factors: manic symptoms as a reason for admission, involuntary admission and a lower GAF score at admission (all p < 0.01). The rate of R&S is dramatically higher in child and adolescent psychiatric hospitalizations in China compared to other regions. Targeted training of staff, development of precise operational guidelines for appropriate use of R&S, and strict oversight are urgently needed to minimize the inappropriate use of R&S in child and adolescent patients.
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Affiliation(s)
- Feng Geng
- Affiliated Psychological Hospital of Anhui Medical University, No. 316 Huangshan Road, Hefei, 230022, China.,Hefei Fourth People's Hospital, No. 316 Huangshan Road, Hefei, 230022, China.,Anhui Mental Health Center, No. 316 Huangshan Road, Hefei, 230022, China.,Department of Psychiatry, Chaohu Hospital of Anhui Medical University, No. 64 Chaohu North Road, Chaohu District, Hefei, 238000, China
| | - Feng Jiang
- Institute of Health Yangtze River Delta, Shanghai Jiaotong University, No. 1954 Huashan Road, Xuhui District, Shanghai, 200030, China
| | - Rachel Conrad
- Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School Center for Bioethics, 641 Huntington Ave, Boston, MA, 02115, USA
| | - Tingfang Liu
- Institute for Hospital Management of Tsinghua University, Haidian District, Beijing, 100730, China
| | - Yuanli Liu
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 3 Dong Dan San Tiao, Dongcheng District, Beijing, 100730, China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, No. 64 Chaohu North Road, Chaohu District, Hefei, 238000, China.
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA. .,Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033, USA.
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Nielson S, Bray L, Carter B, Kiernan J. Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. J Child Health Care 2021; 25:342-367. [PMID: 32633554 PMCID: PMC8422777 DOI: 10.1177/1367493520937152] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.
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Affiliation(s)
- Simon Nielson
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Lucy Bray
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, UK
| | - Joann Kiernan
- Faculty of Health and Social Care, Edge Hill University, UK
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Blikshavn T, Halvorsen I, Rø Ø. Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up. J Eat Disord 2020; 8:20. [PMID: 32514349 PMCID: PMC7262758 DOI: 10.1186/s40337-020-00297-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/23/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome. METHOD Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up. RESULTS A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up. CONCLUSIONS Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.
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Affiliation(s)
- Thomas Blikshavn
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Department of Child and Adolescent Mental Health, Akershus University Hospital, Lørenskog, Norway
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Goz K, Rudhran V, Blackburn J, Schäfer MR, O'Donoghue B. Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit. Early Interv Psychiatry 2019; 13:1105-1110. [PMID: 30328276 DOI: 10.1111/eip.12739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/12/2018] [Accepted: 09/09/2018] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Kubra Goz
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Brian O'Donoghue
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Orygen Youth Health, Melbourne, Victoria, Australia
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Bregar B, Skela-Savič B, Kores Plesničar B. Cross-sectional study on nurses' attitudes regarding coercive measures: the importance of socio-demographic characteristics, job satisfaction, and strategies for coping with stress. BMC Psychiatry 2018; 18:171. [PMID: 29866142 PMCID: PMC5987471 DOI: 10.1186/s12888-018-1756-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 05/22/2018] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Coercive measures are containment methods used in psychiatry to curb patients' disruptive and aggressive behaviours towards themselves, others or objects. The prevalence of the practice of coercive measures in psychiatry is directly related to the attitudes of the staff. When discussing these attitudes, nurses are often particularly singled out. The purpose of the study is to research the impact of individual factors on nurses' attitudes in the decision-making process for the use of coercive measures. METHODS A cross-sectional study among all psychiatric nursing staff in Slovenia (n = 367, 79%) was conducted over the years 2013/2014. Standardized questionnaires were used, including a survey of nurses' attitudes to the use of seclusion, the Job Descriptive Index, and the Folkman-Lazarus test. RESULTS Nurses' attitudes towards special coercive measures are predominantly negative ([Formula: see text] = 11.312, SD = 2.641). The factors that explain a positive attitude are as follows: female gender (β = - 0.236, p < 0.001), fewer years of service (β = - 0.149, p = 0.023), emotion-focused strategies of coping with stress (β = 0.139, p = 0.020), and less-threatening patient behaviour (β = 0.157, p = 0.012). CONCLUSIONS The effects of some known factors did not prove important in the model. Newly recognized factors are "less-threatening patient behaviour" and "emotion-focused strategies of coping with stress". Therefore, attitudes towards special coercive measures in psychiatry must be regarded as contextualized, interactive, and multidimensional phenomena that cannot be explained merely through a defined set of factors.
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Affiliation(s)
- Branko Bregar
- University Psychiatric Hospital Ljubljana, Studenec 48, 1260, Ljubljana Polje, Slovenia.
| | | | - Blanka Kores Plesničar
- grid.440807.fUniversity Psychiatric Hospital Ljubljana, Studenec 48, 1260 Ljubljana Polje, Slovenia
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Nyttingnes O, Ruud T, Norvoll R, Rugkåsa J, Hanssen-Bauer K. A cross-sectional study of experienced coercion in adolescent mental health inpatients. BMC Health Serv Res 2018; 18:389. [PMID: 29848338 PMCID: PMC5977498 DOI: 10.1186/s12913-018-3208-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 05/15/2018] [Indexed: 11/24/2022] Open
Abstract
Background Involuntary care and coercive measures are frequently present in mental healthcare for adolescents. The purpose of this study was to examine to what extent adolescents perceive or experience coercion during inpatient mental health care, and to examine predictors of experienced coercion. Methods A cross-sectional sample of 96 adolescent inpatients from 10 Norwegian acute and combined (acute and sub-acute) psychiatric wards reported their experienced coercion on Coercion Ladder and the Experienced Coercion Scale in questionnaires. Staff reported use of formal coercion, diagnoses, and psychosocial functioning. We used two tailed t-tests and mixed effects models to analyze the impact from demographics, alliance with parents, use of formal coercion, diagnostic condition, and global psychosocial functioning. Results High experienced coercion was reported by a third of all patients. In a mixed effects model, being under formal coercion (involuntary admission and / or coercive measures); a worse relationship between patient and parent; and lower psychosocial functioning, significantly predicted higher experienced coercion. Twenty-eight percent of the total sample of patients reported a lack of confidence and trust both in parents and staff. Conclusions Roughly one third of patients in the sample reported high experienced coercion. Being under formal coercion was the strongest predictor. The average scores of experienced coercion in subgroups are comparable with adult scores in similar care situations. There was one exception: Adolescents with psychosis reported low experienced coercion and almost all of them were under voluntary care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3208-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olav Nyttingnes
- R&D department, Division of Mental Health Services, Akershus University Hospital, PB 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Torleif Ruud
- R&D department, Division of Mental Health Services, Akershus University Hospital, PB 1000, 1478, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Reidun Norvoll
- Work Research Institute, Oslo Metropolitan University, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Oslo, Norway.,Centre for Care Research, University College of Southeast Norway, Notodden, Norway
| | - Ketil Hanssen-Bauer
- R&D department, Division of Mental Health Services, Akershus University Hospital, PB 1000, 1478, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Furre A, Falk RS, Sandvik L, Friis S, Knutzen M, Hanssen-Bauer K. Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study. Child Adolesc Psychiatry Ment Health 2017; 11:3. [PMID: 28096898 PMCID: PMC5234258 DOI: 10.1186/s13034-016-0136-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of restraints in adolescent psychiatric settings requires particular professional, ethical, and legal considerations. The purpose of this study was to investigate whether the number of restraint episodes per patient was related to any of several characteristics of the adolescents. METHODS In this nationwide study, we included all adolescents restrained during the period 2008-2010 (N = 267) in Norwegian adolescent acute psychiatric inpatient units. They constitute 6.5% of the adolescents hospitalized in these units in the same period of time. We collected data on the number of restraint episodes they experienced during the study period; Poisson regression was then used to analyze the impact of gender, social, mental health, and treatment characteristics on the frequency of restraint. We developed a risk index for the likelihood of experiencing multiple restraint episodes. RESULTS We found a skewed distribution of restraint episodes in which a small group (18%) of restrained adolescents experienced a majority (77%) of the restraint episodes. A large percentage of the restrained adolescents (36%) experienced only one restraint episode. Risk factors for multiple restraint episodes were female gender, lower psychosocial functioning (Children's Global Assessment Scale below 35), more and longer admissions, and concomitant use of pharmacological restraint. Except for gender, we used these variables to develop a risk index that was moderately associated with multiple restraint episodes. CONCLUSIONS As a small group of patients accounted for a large percentage of the restraint episodes, future research should further investigate the reasons for and consequences of multiple restraint episodes in patients at acute adolescent psychiatric units, and evaluate preventive approaches targeted to reduce their risk for experiencing restraint.
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Affiliation(s)
- Astrid Furre
- Division of Mental Health and Addiction, Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway ,Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Ragnhild Sørum Falk
- Oslo Centre for Epidemiology and Biostatistics, Oslo University Hospital, Oslo, Norway
| | - Leiv Sandvik
- Oslo Centre for Epidemiology and Biostatistics, Oslo University Hospital, Oslo, Norway
| | - Svein Friis
- Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Maria Knutzen
- Division of Mental Health and Addiction, Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Ketil Hanssen-Bauer
- Division of Mental Health Services, Akershus University Hospital, Lorenskog, Norway ,Division of Health Service Research and Psychiatry, University of Oslo, Oslo, Norway
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