Coerced medication in psychiatric inpatient care: literature review

Inpatient antipsychotic medication switching and rehospitalization risk among patients with schizophrenia-spectrum disorders

OBJECTIVE

To describe patterns of antipsychotic switching among patients hospitalized for schizophrenia and to correlate antipsychotic switching with hospital readmission risk.

METHODS

We identified 3295 patients with index hospitalizations for schizophrenia or schizoaffective disorder from New York State Medicaid claims 2017-2018 who had filled at least one prescription for an antipsychotic in both the 44 days (one month +14 day grace period) prior to and after their admission. We identified patients who had kept or switched any of their antipsychotic medication between the pre- and post-periods surrounding their index hospitalization. We compared the kept and switched any groups, adjusting for patient characteristics.

RESULTS

Of patients who had filled antipsychotic prescriptions in both the 44 days prior to and after their hospitalization, 1599 (48.6 %) had switched at least one antipsychotic and 1215 (36.8 %) had switched their primary antipsychotic. Switching any antipsychotic was associated with increased hazards of readmission, HR = 1.21, 95%CI 1.09-1.35, which was slightly concentrated during the first 90 days after hospital discharge.

CONCLUSIONS

Switching antipsychotic medications during hospitalization occurs commonly and is associated with higher rehospitalization risk following hospital discharge.

Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study

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.

Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors

Background

Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent.

Methods

Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication.

Results

Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis.

Conclusion

Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.

Caregivers' perceptions of compulsory treatment of physical illness in involuntarily psychiatric hospitalization

BACKGROUND

Physical morbidity is rife among patients with serious mental illness. When they are involuntarily hospitalized and even treated, they may still refuse treatment for physical illness leading clinicians to wonder about the ethics of coercing such treatments.

RESEARCH AIM

This survey study explored psychiatric caregivers' perceptions on whether compulsory treatment of physical illness is legal and whether it is justifiable in patients with serious mental illness and under what circumstances.

RESEARCH DESIGN

A questionnaire that included two case vignettes of an involuntarily hospitalized psychiatric patient with diabetes refusing treatment with insulin for various reasons. The cases differed in terms of diabetes severity. Participants answered questions regarding the appropriateness of involuntary treatment.

PARTICIPANTS AND RESEARCH CONTEXT

Psychiatric medical doctors and nurses working in a mental health center. (N = 89, 50 female, ages 26-66).

ETHICAL CONSIDERATIONS

The study was approved by the Medical Centre Institutional Review Board (IRB) and the University Ethics Committee. The respondents' anonymity was kept. Participation was voluntary and consent was obtained.

RESULTS

The severity of the patient's medical condition and their reason for refusing treatment were associated with participants' willingness to give insulin despite patient objection [(F(1, 87) = 49.41, p < .01; (F(1, 87) = 33.44, p < .01), respectively]. Participants were more inclined to support compulsory treatment if the patient's refusal was "illness-oriented" (i.e. directly related to psychiatric illness). Participants presented diverse views regarding the perceived legality of compulsory treatment of physical illness in such situations (illegal 63.09%; legal 23.8%; 13% unsure). The majority (53.5%-55.3%) of those who thought it was illegal supported compulsory treatment in high-severity, illness-oriented refusal situations.

CONCLUSIONS

The severity of the medical condition and the reason for treatment refusal influence psychiatric caregivers' willingness to provide compulsory treatment for physical illness in involuntary hospitalized psychiatric patients. Beyond the legal framework, ethical guidelines for these situations are warranted, while decisions should be made on a case-by-case basis.

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review

PURPOSE

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings.

METHODS

A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored.

RESULTS

Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1).

CONCLUSIONS

Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Fear, Neglect, Coercion, and Dehumanization: Is Inpatient Psychiatric Trauma Contributing to a Public Health Crisis?

Inpatient psychiatric hospitalization is often negatively experienced, with previous studies indicating a high frequency of traumatic occurrences. This study aimed to expand upon such research, by obtaining service user perspectives on how inpatient psychiatric hospitalization may constitute an experience of trauma. Relevant posts and comments on the Reddit community r/PsychWardChronicles were collected that described potentially traumatic experiences associated with hospitalization. Reflexive thematic analysis of the data led to the development of 3 themes: neglect and abuse, coercion and obedience, as well as dehumanization and fear. Overall, hospitalization was found to induce significant fear, which eventually acted as a deterrent to seeking future mental healthcare services. Many traumatic occurrences were found to arise from care providers’ behaviors. As hospitalization was experienced to be harmful, many patients reported complying in the hopes of being discharged. Increased fear and traumatic stress due to inpatient stays coupled with the subsequent avoidance of mental health services may contribute to a significant public health problem as many previous patients may then avoid needed mental health support.

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.

Effect of the introduction of immediate judge's decisions in 2018 on the use of coercive measures in psychiatric hospitals in Germany: a population-based study

Background

On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion.

Methods

We analysed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2017 compared to 2019 among a total of 233,0273 admissions.

Findings

The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001).

Interpretation

There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions.

Funding

The registry is funded by the Ministry of Social Welfare and Integration.

Mental health nursing and conscientious objection to forced pharmaceutical intervention

This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider the philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a transformed or alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realize this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments.

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.

Les substances chimiques utilisées à des fins de contrôle : un statut juridique controversé

Au Québec, les mesures de contrôle – isolement, contentions et substances chimiques – font l’objet d’un encadrement législatif depuis 1998. Or, depuis cette date, les substances chimiques sont au coeur d’un débat sur leur statut juridique, entre thérapie et contrôle. En 2015, le ministère de la Santé et des Services Sociaux publie un Cadre de référence révisé sensé établir des normes directrices en matière de substances chimiques utilisées à des fins de contrôle. Un examen de ce cadre laisse pourtant transparaître plusieurs incohérences, entretenant l’indétermination sur leur statut. D’une part, l’exception prévue en matière de consentement ne correspond pas au cadre juridique québécois en matière de soins, laissant penser qu’il s’agit bien d’une mesure de contrôle. D’autre part, les actes réservés sont les mêmes, que les substances chimiques soient utilisées à des fins de contrôle ou à des fins thérapeutiques, laissant penser qu’il s’agit plutôt d’une mesure thérapeutique.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care

OBJECTIVE

Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients.

METHODS

Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables.

RESULTS

Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001).

DISCUSSION

These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Increased use of coercive procedures and prolonged hospitalization in compulsory admitted psychotic patients, who refuse antipsychotic medication

Objective: Current Danish legislation imposes that compulsory admitted psychotic patients have the right to refuse antipsychotic medication, which markedly delays pertinent medical treatment.Material and methods: In a retrospective, observational cohort study, we analyzed data from a 1-year period on 34 consecutively admitted patients with schizophrenia, who had been compulsory admitted due to need of treatment, or because they were judged to constitute an acute danger to themselves or others. We compared the use of other coercive procedures and hospitalization time.Results: Twenty-three patients accepted to commence antipsychotic treatment immediately, and 11 patients submitted an official complaint, which significantly delayed initiation of antipsychotic treatment (1 day ±0.9 versus 14 days ±10.1, p = 0.002). The 11 complaining patients were subjected to 6.8 times more coercive procedures of forced sedative medication compared to the 23 patients without delay (2.7 ± 2.3 episodes versus 0.4 ± 0.7 episodes, p = 0.007). Moreover, the treatment-delay prolonged duration of hospitalization by a factor 2.3 (73.3 ± 28.3 days versus 31.7 ± 22.0 days, p < 0.001).Conclusion: The current legislation intends to preserve patient rights and promote voluntary treatment alliance but may instead lead to prolonged hospitalization and increased use of other coercive measures such as forced sedative medication. Modification of current legislation may therefore be considered.

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

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.

Mental health patients' experiences of softer coercion and its effects on their interactions with practitioners: A qualitative evidence synthesis

AIMS

To synthesize qualitative evidence of mental health patients' treatment-related experiences of softer coercion and its effect on their interactions with practitioners.

BACKGROUND

Coercion is controversial but global in mental health care. It ranges from softer to harder forms, but less attention is given in the literature to softer coercion.

DESIGN

Qualitative thematic synthesis examining patients' experiences of softer coercion.

DATA SOURCES

Electronic databases searched from inception to September 2015 and further updated January 2018.

REVIEW METHODS

Thematic synthesis of 11 UK/Irish articles, quality appraised using the Critical Appraisal Skills Programme tool.

RESULTS

Three analytic themes were developed: Losing a sense of self, Less than therapeutic relationship, and Journey through treatment.

CONCLUSION

Softer coercion is experienced across mental health care in a context of broader coercion.

How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study

BACKGROUND

The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication.

METHODS

The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document.

RESULTS

Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times.

CONCLUSION

The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

A case report of guardian-consent forced paliperidone palmitate for behavioral disturbance due to traumatic brain injury

Psychosis after traumatic brain injury (TBI) occurs in up to 10% of cases. Although guideline consensus is lacking regarding drugs of choice for this condition, current literature points to the use of atypical antipsychotics. This case describes a 58-year-old male with major neurocognitive disorder due to TBI with behavioral disturbance that was successfully treated with paliperidone palmitate. In addition to the off-label use of paliperidone, this case also explores the use of forced medication as the initial injection was given per guardian consent. After completion of a literature review, this appears to be the first case report describing the use of a long-acting antipsychotic for the treatment of TBI-related psychosis. This case suggests that paliperidone palmitate may be efficacious for psychosis following TBI; however, further study is warranted.

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.

Antipsychotic treatment of psychotic disorders in forensic psychiatry: Patients' perception of coercion and its predictors

BACKGROUND

Despite the major encroachment of coercive measures on the fundamental rights of affected forensic psychiatric patients, there is relatively few research done in this field. Considering the relevance of this subject for psychiatric care and the recent changes of the legal basis of coercive treatment in Germany, more studies are needed. The present study examines forensic psychiatric inpatients' perception of coercion regarding the prescribed antipsychotic medication and factors associated with the perception of coercion.

MATERIAL AND METHODS

Patients with schizophrenia, schizotypal and delusional disorders in two forensic psychiatric institutions in Southern Germany were interviewed about their experience of coercion related to antipsychotic medication. Due to a lack of appropriate psychometric scales, the perception of coercion regarding antipsychotic medication was assessed using an adapted version of the MacArthur Admission Experience Survey (aAES). The influence of sociodemographic and illness-related factors, of the attitude towards medication, insight into illness and symptom severity on the extent to which patients felt coerced to take the prescribed medication was analyzed. Two Visual Analog Scales, the Drug Attitude Inventory DAI-10, the Positive and Negative Syndrome Scale PANSS, the Fragebogen zur Krankheitseinsicht (Questionnaire about insight into illness) FKE-10 and the Coercion Experience Scale CES were used as psychometric scales.

RESULTS

50% of all patients eligible for the study gave their written consent. 70% of all participants had experienced coercive measures between admission and time of data assessment. The DAI-10 and the aAES correlated moderately, a high level of insight into illness being correlated to less perceived coercion. The FKE-10 and the aAES correlated moderately as well, a high level of insight into illness being correlated to less perceived coercion. The severity of symptoms (PANSS score) and the level of perceived coercion (aAES score) correlated weakly, participants with more severe symptoms perceived more coercion than those with less marked symptoms. A linear regression model showed that to what extent patients felt coerced to take the prescribed antipsychotic medication was mainly influenced by their attitude towards medication and the degree of insight into illness, to a lesser extent by symptom severity (R² = 0.565, p < 0.001). Sociodemographic factors were not related to the extent to which patients felt coerced to take the antipsychotic medication.

CONCLUSIONS

Predictors of the experience of coercion related to the prescribed antipsychotic medication of forensic psychiatric inpatients with schizophrenia and related disorders are not so much sociodemographic or illness-related factors as education or past medical history, but rather potentially influenceable variables such as insight into illness or attitude towards medication.

Patients' attitudes towards and acceptance of coercion in psychiatry

Coercive interventions for psychiatric patients are controversial. Research on different preventive measures has increased over the last years. The present study examined patients' attitudes towards and understanding of previously experienced coercive measures as well as their preferences related to coercive measures and possible alternatives. In total, 213 patients who had experienced coercion and 51 patient controls (patients staying voluntarily on a closed ward with no coercive treatment) from three acute wards were examined via expert interviews and questionnaires in the framework of a naturalistic trial. Assessments included a new self-developed questionnaire as well as instruments measuring psychopathology. Patients who had experienced coercion differed from controls in both symptoms and insight into their illness. As expected, "noninvasive measures" (e.g., the use of a "soft room," observation in seclusion) were better accepted by patients than "invasive measures" (e.g., mechanical restraint, forced medication). Forced medication and mechanical restraint were less well accepted than involuntary hospitalization, seclusion, or video surveillance. The retrospective understanding of coercive measures increased over the course of treatment. In addition, patients rated a number of options for reducing coercion on the wards, particularly music or exercises. A large subgroup indicated they would like to discuss future admissions with the staff.

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.

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.

Improving medication adherence for severely mentally ill adults by decreasing coercion and increasing cooperation

Severe mental illnesses, mainly schizophrenia and bipolar disorders, often go untreated until the afflicted persons become dangerous to themselves or others. In such states, they must be hospitalized and medicated, often involuntarily due to the stigma and low insight into need for treatment that can be considered characteristic of severe illnesses. Hospitalization and medications can help the mentally ill stabilize. But these options also can have a demoralizing effect on future engagement with providers. Accordingly, the process of involuntary hospitalization and medication treatment must be maximally dignified and respectful of patient autonomy, within the limits of manifest illnesses. Literature that was reviewed and synthesized suggests best practice strategies for helping involuntary mentally ill patients grow into voluntary consumers of medication. In turn, risk of relapse is lowered and quality of life is enhanced. Best practice strategies included decreasing usage of coercive tactics, helping patients cope with medication side effects, and emphasizing the necessity of family involvement. The authors conclude with a review of the limitations of arguing for involuntary hospitalization and treatment as restoring patient autonomy, along with implications for future practice focusing on increasing the medication adherence of severely mentally ill populations.

The give and take of freedom: The role of involuntary hospitalization and treatment in recovery from mental illness

The authors reviewed and synthesized scholarly literature on the topic of involuntary confinement and treatment for severely mentally ill adults. Objectively, all facets of the issue are reported, including recurrent positive outcomes, negative outcomes, and patient experiences in common. Patient experiences are organized into related subthemes of autonomy, patient satisfaction, relationships with staff, perceived coercion, traumatization, and humiliation. The literature suggests that short-term involuntary hospitalization is sometimes necessary in order to prevent the mentally ill from psychiatrically decompensating or harming themselves or others. Understandably, hospitalization is often experienced by the mentally ill as a demoralizing violation of their rights and tends to lead them to disengage further from the professional help they need in order to recover. In turn, disengagement leads to further decompensation and resulting risk for rehospitalization. In order to intervene in this cycle and instill severely mentally ill patients with hope in the recovery process, the use of coercive tactics must be decreased in favor of cooperative engagement measures to the greatest extent possible. Patients must be empowered to make choices within the limits of their illnesses through positive interactions with staff, particularly in potentially negative, autonomy-compromising situations. Cooperative measures may help to minimize the potentially traumatic and humiliating effects of being involuntarily hospitalized and medicated. In turn, trusting patient-provider relationships may develop. Thereafter, the severely mentally ill may become more likely to seek professional help on their own volition in the future.

Care planning for aggression management in a specialist secure mental health service: An audit of user involvement

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation.

Nurses' attitudes towards professional containment methods used in psychiatric wards and perceptions of aggression in Turkey

AIMS AND OBJECTIVE

The aim of this study was to determine nurses' attitudes towards professional containment methods and to explore the relationship between those attitudes and nurses' perception of aggression.

BACKGROUND

Different containment methods are used in psychiatric wards when patients behave aggressively towards others or exhibit self-harm. It is known that in addition to patient-specific and environmental influences, many factors related to the staff influence the choice of containment method. One of these factors is the perception of aggression.

DESIGN

A cross-sectional descriptive design was used and the sample consisted of 144 nurses who are employed in a psychiatric hospital in Istanbul and who volunteered to participate in the study.

METHOD

Data were collected using a questionnaire addressing the socio-demographic and professional features of nurses and using the attitudes to professional containment methods and Perception of Aggression Scale.

RESULTS

While pro re nata medication was used commonly, time-out was infrequently used in the wards. Intermittent observation, pro re nata medication and containment in the psychiatric intensive care unit were the most approved methods. The use of net beds was the least approved method. Nurses who perceive aggression as dysfunctional/undesirable are more likely to approve compulsory intramuscular medication and mechanical restraint.

CONCLUSION

These results showed that nurses' perception of aggression is an important factor influencing the choice of a professional containment method.

RELEVANCE TO CLINICAL PRACTICE

This study might lead to closer critiquing of psychiatric ward nurses' attitudes towards professional containment methods, leading to a decrease in the usage of these methods.

A self-destructive care: self-reports of people who experienced coercive measures and their suggestions for alternatives

Coercive measures are commonly used as a method of intervention, despite insufficient evidence for their effectiveness and benefits. The aim of this study was to describe how people who self-harm perceive alternatives to coercive measures in relation to actual experiences of psychiatric care. A total of 19 self-reports have been analysed with qualitative content analysis, resulting in three categories: a wish for understanding instead of neglect; a wish for mutual relation instead of distrust; a wish for professionalism instead of a counterproductive care. In conclusion, if the caregivers can understand and collaborate with the patient, there is seldom any need for coercive measures.

Clinical and organizational factors related to the reduction of mechanical restraint application in an acute ward: an 8-year retrospective analysis

Background:

The purpose of this study was to describe the frequency of mechanical restraint use in an acute psychiatric ward and to analyze which variables may have significantly influenced the use of this procedure. Methods: This retrospective study was conducted in the Servizio Psichiatrico di Diagnosi e Cura (SPDC) of Modena Centro. The following variables of our sample, represented by all restrained patients admitted from 1-1-2005 to 31-12-2012, were analyzed: age, gender, nationality, psychiatric diagnoses, organic comorbidity, state and duration of admission, motivation and duration of restraints, nursing shift and hospitalization day of restraint, number of patients admitted at the time of restraint and institutional changes during the observation period. The above variables were statistically compared with those of all other non-restrained patients admitted to our ward in the same period. Results: Mechanical restraints were primarily used as a safety procedure to manage aggressive behavior of male patients, during the first days of hospitalization and night shifts. Neurocognitive disorders, organic comorbidity, compulsory state and long duration of admission were statistically significantly related to the increase of restraint use (p<.001, multivariate logistic regression). Institutional changes, especially more restricted guidelines concerning restraint application, were statistically significantly related to restraint use reduction (p<.001, chi2 test, multivariate logistic regression). Conclusion: The data obtained highlight that mechanical restraint use was influenced not only by clinical factors, but mainly by staff and policy factors, which have permitted a gradual but significant reduction in the use of this procedure through a multidimensional approach.

Solving the staff's problem or meeting the patients' needs: staff members' reasoning about choice of action in challenging situations in psychiatric inpatient care

Coercion in challenging situations is often seen as a necessary component of psychiatric care. This study aims to describe staff members' reasoning about their choice of action in challenging situations in inpatient psychiatric care. Focus group interviews with 26 staff members were analyzed using qualitative content analysis. The results provide an overview of the integrated structure of participants' reasoning and suggest that staff members' reasoning about choice of action can be described as a matter of either solving the staff's problems or meeting the patients' needs. These results can be of use in further research, educational interventions, and staff development activities.

Patients subject to high levels of coercion: staff's understanding

Measures to keep staff and patients safe (containment) frequently involve coercion. A small proportion of patients is subject to a large proportion of containment use. To reduce the use of containment, we need a better understanding of the circumstances in which it is used and the understandings of patients and staff. Two sweeps were made of all the wards, spread over four hospital sites, in one large London mental health organization to identify patients who had been subject to high levels of containment in the previous two weeks. Data were then extracted from their case notes about their past history, current problem behaviours, and how they were understood by the patients involved and the staff. Nurses and consultant psychiatrists were interviewed to supplement the information from the case records. Twenty-six heterogeneous patients were identified, with many ages, genders, diagnoses, and psychiatric specialities represented. The main problem behaviours giving rise to containment use were violence and self-harm. The roots of the problem behaviours were to be found in severe psychiatric symptoms, cognitive difficulties, personality traits, and the implementation of the internal structure of the ward by staff. Staff's range and depth of understandings was limited and did not include functional analysis, defence mechanisms, specific cognitive assessment, and other potential frameworks. There is a need for more in-depth assessment and understanding of patients' problems, which may lead to additional ways to reduce containment use.

Involuntary treatment of schizophrenia patients 2004-2010 in Denmark

OBJECTIVE

Treatment of schizophrenia is frequently complicated by patients' ambivalence and lack of insight into the disease, occasionally warranting involuntary treatment. This study aims to describe involuntary treatment in Danish schizophrenia patients.

METHOD

Patients diagnosed with a lifetime ICD-10 F20 schizophrenia diagnosis and alive in the period 2004-2010 were identified in the Danish Psychiatric Central Research Register, and data were linked to The Registry of Coercive Measures in Psychiatric Treatment.

RESULTS

Within the study period, a total of 18,599 admitted patients were identified, 3078 of which underwent involuntary treatment. The incidence rate for any involuntary treatment was 2.1 per in-patient year and 1.7 and 0.3 per in-patient year for rapid tranquilization and involuntary treatments, respectively. Somatic diseases comprised 34.5% of all involuntary treatments. Psychotropics comprised 56.9% with antipsychotics as the most common drug class (99.5%). Olanzapine was the most commonly used antipsychotic drug (33.2%). Treatment with depot injection and clozapine comprised only 13% and 4.8% of the antipsychotics used, respectively. Electroconvulsive therapy comprised 4.8% of all involuntary treatment.

CONCLUSION

Involuntary treatment involved a wide range of somatic treatment. Antipsychotic medicine was the most common psychotropic used. Involuntary treatment with depot antipsychotics and clozapine were rare.

Variables associated with the use of coercive measures on psychiatric patients in Spanish penitentiary centers

We have studied the use of coercive medical measures (forced medication, isolation, and mechanical restraint) in mentally ill inmates within two secure psychiatric hospitals (SPH) and three regular prisons (RP) in Spain. Variables related to adopted coercive measures were analyzed, such as type of measure, causes of indication, opinion of patient inmate, opinion of medical staff, and more frequent morbidity. A total of 209 patients (108 from SPH and 101 from RP) were studied. Isolation (41.35%) was the most frequent coercive measure, followed by mechanical restraint (33.17%) and forced medication (25.48%). The type of center has some influence; specifically in RP there is less risk of isolation and restraint than in SPH. Not having had any previous imprisonment reduces isolation and restraint risk while increases the risk of forced medication, as well as previous admissions to psychiatric inpatient units does. Finally, the fact of having lived with a partner before imprisonment reduces the risk of forced medication and communication with the family decreases the risk of isolation. Patients subjected to a coercive measure exhibited a pronounced psychopathology and most of them had been subjected to such measures on previous occasions. The mere fact of external assessment of compliance with human rights slows down the incidence of coercive measures.

Why are people with mental illness excluded from the rational suicide debate?

The topic of rational suicide is often approached with some trepidation by mental health professionals. Suicide prevention strategies are more likely to be seen as the domain of psychiatry and a wealth of psychiatric literature is devoted to identifying and managing suicide risk. Whether or not suicide can be deemed permissible is ostensibly linked to discussions of autonomy and mental capacity, and UK legislation directs that a patient's wishes must be respected with regard to treatment refusal where decisional capacity is intact. In the context of the care and treatment of those with physical disorders, extreme and untreatable physical suffering is likely to be accepted as rational grounds for suicide, where the person possesses cognitive coherence and an ability to realistically appreciate the consequences of his or her actions. In the case of those with serious mental disorder, the grounds for accepting that suicide is rational are however less clear-cut. Serious mental illness is typically conceived of as a coercive pressure which prevents rational deliberation and as such, the suicides of those with serious mental illness are considered to be substantially non-voluntary acts arising from constitutive irrationality. Therefore, where an appropriate clinician judges that a person with serious mental disorder is non-autonomous, suicide prevention is likely to be thought legally and morally justified. There are arguably, two questionable assumptions in the position that psychiatry adopts: Firstly, that psychogenic pain is in some way less real than physical pain and secondly, that mental illness invariably means that a desire to die is irrational and inauthentic. If it can be shown that some people with serious mental illness can be rational with regard to suicide and that psychological pain is of equal significance as physical suffering, then it may be possible to conclude that some persons with serious mental illness should not by definition be excluded from the class of those for whom rational suicide may be a coherent choice.

Understanding psychiatric institutionalization: a conceptual review

BACKGROUND

Since Goffman's seminal work on psychiatric institutions, deinstitutionalization has become a leading term in the psychiatric debate. It described the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. Yet, there is a lack of clarity on what exactly the concept of institutionalization means in present-day psychiatry. This review aims to identify the meaning of psychiatric institutionalization since the early 1960s to present-day.

METHOD

A conceptual review of institutionalization in psychiatry was conducted. Thematic analysis was used to synthesize the findings.

RESULTS

Four main themes were identified in conceptualizing institutionalization: bricks and mortar of care institutions; policy and legal frameworks regulating care; clinical responsibility and paternalism in clinician-patient relationships; and patients' adaptive behavior to institutionalized care.

CONCLUSIONS

The concept of institutionalization in psychiatry reflects four distinct themes. All themes have some relevance for the contemporary debate on how psychiatric care should develop and on the role of institutional care in psychiatry.

The influence of staff training on the violence prevention and management climate in psychiatric inpatient units

Violence prevention and management is an important part of inpatient psychiatric nursing and specific staff training is regarded essential. The training should be based on primary, secondary and tertiary prevention. In Stockholm, Sweden, the Bergen model is a staff-training programme that combines this preventive approach with the theoretical nursing framework of the City model that includes three staff factors: positive appreciation of patients, emotional regulation and effective structure. We evaluated this combination of the Bergen and City models on the violence prevention and management climate in psychiatric inpatient wards. A 13-item questionnaire was developed and distributed to patients and staff in 41 wards before the staff was trained and subsequently to 19 of these wards after training. Data analyses included factor analysis, Fisher's exact test and Mann-Whitney U-test. The result showed that the staff on trained wards had a more positive perception of four of the items and the patients of one item. These items reflected causes of patient aggression, ward rules, the staff's emotional regulation and early interventions. The findings suggest that a focus on three levels of prevention within a theoretical nursing framework may promote a more positive violence prevention and management climate on wards.

[Compulsory treatment under legal uncertainty: part 2: consequences of legal uncertainty in clinical practice - suggestions for improvement]

The current legal uncertainty on compulsory treatment of mentally ill patient incapable of giving consent favors the practice of defensive treatment, such as the increased use of isolation and fixation instead of medication. Such a stance runs the risk of acute or chronic health damage for patients. The dissent between legal practitioners and psychiatrists on compulsory treatment is obviously based on a different understanding of autonomy and its prerequisites. We advocate an individual centered, preferably open form of treatment by medicinal and milieu therapeutic approaches in association with intensified relationships with the aim to restore or improve the ability for self-determination. We also call upon the legislative authorities to establish legal certainty. It is decisive that the characteristics of mental diseases and the possibilities of modern treatment are taken into consideration in order to suitably respect patient autonomy without neglecting the necessary help.

Event sequencing of forced intramuscular medication in England

In most inpatient psychiatric care systems it is permissible in certain situations for staff to forcibly inject patients with psychotropic medication. The aim of this study is to describe what precedes and follows a coerced intramuscular injection within a nursing shift. Data were collected on the sequence of conflict (aggression, absconding, etc.) and containment (seclusion, restraint, etc.) for the first 2 weeks of 522 acute admissions on 84 wards in 31 UK hospitals. Injections were given to 9% of patients. Aggression, regular medication refusal and pro re nata (PRN) medication refusal preceded injections. The giving of coerced medication concluded most crises. Coerced medication effectively resolves crises in the short term. Staff should offer oral PRN as an alternative, unless this is unsafe. Where only verbal violence has occurred staff should try to resolve the crisis without enforcing medication. More research on the best way to respond to inpatients' medication refusal is required.

Physical restraints in an Italian psychiatric ward: clinical reasons and staff organization problems

PURPOSE

To analyze physical restraint use in an Italian acute psychiatric ward, where mechanical restraint by belt is highly discouraged but allowed.

DESIGN AND METHODS

Data were retrospectively collected from medical and nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint rate and relationships between restraints and selected variables were statistically analyzed.

FINDINGS

Restraints were statistically significantly more frequent in compulsory or voluntary admissions of patients with an altered state of consciousness, at night, to control aggressive behavior, and in patients with "Schizophrenia and other Psychotic Disorders" during the first 72 hr of hospitalization.

PRACTICAL IMPLICATIONS

Analysis of clinical and organizational factors conditioning restraints may limit its use.

Predictors of compulsory admission in schizophrenia-spectrum patients: excitement, insight, emotion perception

PURPOSE

We explored socio-demographic and clinical variables associated with compulsory admissions (CA) compared with voluntary admissions in schizophrenia-spectrum patients; moreover, we investigated the ability of excitement, emotion perception, and lack of insight to predict CA.

METHODS

119 consecutive schizophrenia-spectrum patients admitted to the Servizio Psichiatrico di Diagnosi e Cura (SPDC = PES = psychiatric emergency service) of the Department of Neuroscience and Mental Health-San Giovanni Battista Hospital of Turin in the period between December 2007 and December 2009 were enrolled in the study. A backward stepwise logistic regression was used to test factors contributing to CA.

RESULTS

CA rate in our sample was 28.5%. Previous CAs, drop-out, severity of illness, positive symptoms, excitement, emotion perception, and insight were significantly different in CA patients compared to voluntary ones. After backward selection of variables, three variables predicted CA in our sample: excitement, impaired emotion perception and lesser insight. Finally, the effect of excitement on CA status seemed partially mediated by emotion perception, the prediction model accounting for 53.8% of the variance of CA status. Conversely, insight seemed not to be a mediator of excitement on CA.

IMPLICATIONS

Understanding CA patterns in special populations represents a first step towards improving clinical decision-making and developing appropriate interventions and service-provision.

Spider in a Jar: Women Who Have Recovered From Psychosis and Their Experience of the Mental Health Care System

A growing body of literature has documented considerable dissatisfaction with the mental health care system among people who use mental health services. This article adds to this literature by reporting on the results of qualitative interviews done with 18 women who had recovered from some form of transformative psychotic experience and were willing to share their experiences with the mental health care system. The participants unanimously felt that their experiences with the mental health system were very negative and detrimental to their overall healing and recovery process. Four main themes emerged from the qualitative analysis of the interview transcripts: (1) “the label factory,” which described the capricious and destructive nature of the psychiatric diagnoses they received; (2) “invalidated and unheard,” which described how little the women’s voices seemed to matter to the mental health care professionals caring for them; (3) “violence and violations,” which described the loss of free will and dignity the women experienced during inpatient psychiatric hospitalizations; and (4) “smashing the jar,” which described the hopes and dreams these women had for changing the way people receive mental health care. The implications of these findings for mental health practice are discussed.

Reflecting on forced medication

There are multiple concerns regarding the practice of forced medication of clients with mental illness. Clients often report that side effects outweigh the benefits of psychotropic medication, while mental health clinicians often think the client may become dangerous without medication. Who should have the right to decide whether a client takes medication? Nursing plays an integral role in the decision making by considering alternative therapies and current research, addressing the diversity among our clients, and ensuring comprehensive assessments. This article presents circumstances that may lead to forced medication and explores beliefs of clients, mental health clinicians, and mental health advocacy groups.Building upon Johns' (2008) model for structured reflections of clinical experiences, this article reflects upon the experience of forced medication in psychiatric nursing practice. First, the process and consequences of forced medication are explored. Next, the factors influencing the thoughts and responses of psychiatric clinicians, clients, and advocacy groups is discussed. Finally, possible alternative actions are presented.

Compulsory treatment in psychiatry

PURPOSE OF REVIEW

Compulsory treatment is a common, yet controversial, practice in psychiatry. This paper reviews recent studies on the use of compulsory measures in hospital, the community and special populations.

RECENT FINDINGS

Researchers continue to examine the rates and patterns of involuntary hospitalization. However, they have extended their investigations to care in the community, acknowledging it as the primary locus of treatment for most patients. Research shows that the implementation of community mental health legislation presents complex clinical and practical issues that require further investigation. Recognition that compulsory treatment is an objective event which is subjectively experienced by patients, families and clinicians has led to research investigating stakeholder views. The therapeutic relationship has been found to be an important modifier of the experience of compulsory treatment. Recent studies have also focused on specific coercive practices, such as forced medication and seclusion, and the use of these in patient subgroups, including those with eating disorders and adolescents. The debate about whether compulsory treatment is ethical continues in the literature.

SUMMARY

Compulsory treatment in psychiatry remains an ethically and clinically contentious issue. As ethical concerns are generally countered by the argument that compulsory measures can lead to beneficial clinical outcomes, further empirical investigation in this area is required.