Use of restraint in a general hospital psychiatric unit in Japan

Who is coercively admitted to psychiatric wards? Epidemiological analysis of inpatient records of involuntary psychiatric admissions to a University General Hospital in Greece for the years 2008-2017

BACKGROUND

Involuntary psychiatric admissions are a widely used practice despite ethical concerns about coercion. There are particular concerns that vulnerable groups, such as single, unemployed or racial minorities, may be more subjected to such practices.

AIM

We aimed to investigate the social patterns of involuntary psychiatric admissions from 2008 to 2017 at University General Hospital in Ioannina, Greece.

METHOD

We retrospectively assessed inpatient records from 2008 to 2017 of patients admitted to the Department of Psychiatry of the Ioannina University General Hospital, Northwestern Greece. Alternative patients of alternative years were selected for inclusion; this yielded 332 patients involuntarily admitted, corresponding to 28.5% of total involuntary psychiatric admissions.

RESULTS

Over the 10-year period, the overall numbers of annual involuntary psychiatric admissions remained relatively stable, as did the length of hospital stay (mean = 23.8 days). The most common disorder upon admission was schizophrenia spectrum disorders, accounting for approximately two-thirds of all admissions, followed by mood disorders (about 20%). There was evidence that people who lacked social support or experienced financial hardship were more greatly represented among those admitted: 70.2% of admitted patients were single and 64.8% were unemployed. Most patients had been admitted to the psychiatric ward in the past (64.2%).

CONCLUSION

Our study indicates potentially worrisome evidence that patients who are in vulnerable positions are at elevated likelihood of being involuntarily admitted to psychiatric wards. Future research is needed to evaluate the socio-demographic patterning of involuntary admissions in other European countries.

What is the role of gender in perceived coercion during psychiatric admission?

OBJECTIVES

This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission.

METHODS

We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020.

RESULTS

Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation.

CONCLUSIONS

Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.

Predicting coercion during the course of psychiatric hospitalizations

BACKGROUND

Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail.

METHODS

In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland's largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure.

RESULTS

Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity.

CONCLUSIONS

Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.

Effectiveness of Artificial Intelligence Methods in Personalized Aggression Risk Prediction within Inpatient Psychiatric Treatment Settings—A Systematic Review

Aggression risk assessments are vital to prevent injuries and morbidities amongst patients and staff in psychiatric settings. More recent studies have harnessed artificial intelligence (AI) methods such as machine learning algorithms to determine factors associated with aggression in psychiatric treatment settings. In this review, using Cooper’s five-stage review framework, we aimed to evaluate the: (1) predictive accuracy, and (2) clinical variables associated with AI-based aggression risk prediction amongst psychiatric inpatients. Databases including PubMed, Cochrane, Scopus, PsycINFO, CINAHL were searched for relevant articles until April 2022. The eight included studies were independently evaluated using critical appraisal tools for systematic review developed by Joanna Briggs Institute. Most of the studies (87.5%) examined health records in predicting aggression and reported acceptable to excellent accuracy with specific machine learning algorithms employed (area under curve range 0.75–0.87). No particular machine learning algorithm outperformed the others consistently across studies (area under curve range 0.61–0.87). Relevant factors identified with aggression related to demographic and social profile, past aggression, forensic history, other psychiatric history, psychopathology, challenging behaviors and management domains. The limited extant studies have highlighted a potential role for the use of AI methods to clarify factors associated with aggression in psychiatric inpatient treatment settings.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Identifying Direct Coercion in a High Risk Subgroup of Offender Patients With Schizophrenia via Machine Learning Algorithms

PURPOSE

This study aims to explore risk factors for direct coercive measures (seclusion, restraint, involuntary medication) in a high risk subpopulation of offender patients with schizophrenia spectrum disorders.

METHODS

Five hundred sixty nine potential predictor variables were explored in terms of their predictive power for coercion/no coercion in a set of 131 (36.6%) offender patients who experienced coercion and 227 who did not, using machine learning analysis. The dataset was split (70/30%) applying variable filtering, machine learning model building, and selection embedded in nested resampling approach in one subset. The best model was then selected, and the most important variables extracted on the second data subset.

RESULTS

In the final model the following variables identified coercion with a balanced accuracy of 73.28% and a predictive power (area under the curve, AUC) of 0.8468: threat of violence, (actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments, the positive and negative syndrome scales (PANSS) poor impulse control, uncooperativeness, and hostility and the total PANSS-score at admission, prescription of haloperidol during inpatient treatment, the daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis estimated by a team of licensed forensic psychiatrists.

CONCLUSIONS

Results confirm prior findings, add detail on factors indicative for the use of direct coercion, and provide clarification on inconsistencies. Limitations, clinical relevance, and avenues for future research are discussed.

Predicting mechanical restraint of psychiatric inpatients by applying machine learning on electronic health data

OBJECTIVE

Mechanical restraint (MR) is used to prevent patients from harming themselves or others during inpatient treatment. The objective of this study was to investigate whether incident MR occurring in the first 3 days following admission could be predicted based on analysis of electronic health data available after the first hour of admission.

METHODS

The dataset consisted of clinical notes from electronic health records from the Central Denmark Region and data from the Danish Health Registers from patients admitted to a psychiatric department in the period from 2011 to 2015. Supervised machine learning algorithms were trained on a randomly selected subset of the data and validated using an independent test dataset.

RESULTS

A total of 5050 patients with 8869 admissions were included in the study. One hundred patients were mechanically restrained in the period between one hour and 3 days after the admission. A Random Forest algorithm predicted MR with an area under the curve of 0.87 (95% CI 0.79-0.93). At 94% specificity, the sensitivity was 56%. Among the ten strongest predictors, nine were derived from the clinical notes.

CONCLUSIONS

These findings open for the development of an early warning system that may guide interventions to reduce the use of MR.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Systematic review registry number:

CRD42017054440.

Restraint prevalence and perceived coercion among psychiatric inpatients from South India: A prospective study

BACKGROUND

The Indian Mental Health Care Act 2017 (MHCA -2017) advocates the duty to provide treatment in the least coercive manner. Little data exists on how Indian patients perceive coercion in medical settings.

AIMS

To study the prevalence of restraint in a Indian psychiatric inpatient unit, and to examine the level of perceived coercion correlating to various forms of restraint.

METHODOLOGY

This is a hospital based prospective observational study. Two hundred patients were recruited through computer generated random number sampling. In eligible subjects, demographic and clinical data, restraints used and assessments related to perceived coercion were completed within 3 days of admission. Perceived coercion was reassessed at the time or within 3 days before discharge.

RESULTS

In 66.5% one or more restraint measures were used, physical restraints in 20%, chemical restraints in 58%, seclusion in 18%, and involuntary medication in 32%. ECT is associated with the lowest level of perceived coercion followed by isolation/seclusion, chemical restraint, involuntary medication and physical restraint. Male gender, being married, rural background, low socioeconomic status, having a mood disorder, and alcohol or drug dependence was associated with an increased risk of physical or chemical restraint. Having a mood disorder, being from a rural area and a lower socioeconomic status was associated with being subjected to more than one form of coercion.

CONCLUSION

Restraint measures are more prevalent in psychiatric hospital care in India than in Europe. Physical restraint is particularly associted with higher perceived coercion.

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression

Introduction: Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures. Methods: In a sample of involuntarily hospitalized patients (n = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion (n = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression. Results: In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients without coercion (69% accuracy with 60% sensitivity and 78% specificity, AUC 0.74). In a model with 18 risk-factors, available after discharge, the logistic regression algorithm identified 121 out of 170 with and 176 out of 223 without coercion (75% accuracy, 71% sensitivity, and 79% specificity, AUC 0.82). Discussion: Incorporating both clinical and demographic variables can help to estimate the risk of experiencing coercion for psychiatric patients. This study could show that trained machine learning algorithms are comparable to binary logistic regression and can reach a good or even excellent area under the curve (AUC) in the prediction of the outcome coercion/no coercion when cross validation is used. Due to the better generalizability machine learning is a promising approach for further studies, especially when more variables are analyzed. More detailed knowledge about individual risk factors may help to prevent the occurrence of situations involving coercion.

Psychopathological Assessment of Risk of Restraint in Acute Psychiatric Patients

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

Contenção física no hospital psiquiátrico: estudo transversal das práticas e fatores de risco

RESUMO Objetivos Descrever a utilização da contenção física em um hospital psiquiátrico público e analisar os fatores de risco associados com seu uso, no contexto da implantação de um protocolo clínico. Métodos Em um hospital psiquiátrico público de Belo Horizonte-MG, os formulários de registro e monitoramento de contenção física (2011-2012) foram analisados e comparados com os registros das demais internações englobadas no mesmo período. Neste estudo transversal, além das análises descritivas das características clínicas e demográficas dos pacientes contidos, das técnicas utilizadas e das complicações reportadas, os fatores de risco associados com o uso da contenção foram analisados por meio de regressão logística múltipla. Resultados A contenção foi utilizada em 13,4% das internações, sendo mais comum em pacientes jovens, do sexo masculino, portadores de psicoses não orgânicas, apresentando agitação/agressividade. A técnica foi geralmente de quatro pontos, durando entre 61-240 minutos. Os únicos fatores de risco significativos para o uso da contenção incluíram a idade (OR = 0,98; p = 0,008) e o tempo de permanência (OR = 1,01; p < 0,001). Conclusões A contenção física foi utilizada usualmente na abordagem aguda do paciente agitado/agressivo inabordável verbalmente, no contexto de um transtorno psicótico. O registro dos dados vitais e dos efeitos adversos foram os itens menos aderentes aos protocolos vigentes.

One-year incidence and prevalence of seclusion: Dutch findings in an international perspective

BACKGROUND

The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law.

OBJECTIVE

The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data.

METHODS

2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed.

RESULTS

12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia.

CONCLUSIONS

Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.

Effects of a Regulatory Protocol for Mechanical Restraint and Coercion in a Spanish Psychiatric Ward

PURPOSE

There is still limited information on what type of measures are most efficient to reduce coercion. The aim of this study was to determine if the introduction of a new regulatory protocol in a specific psychiatric ward in Andalusia (Spain) contributed to reducing the use of mechanical restraint.

DESIGN AND METHODS

The study included a comparison of two time periods: 2005 (one year before the implementation of the new regulatory protocol) and 2012, in all hospitalized patients (N=1,094). The study also analyzes with logistic regression the variables related to a shorter duration of mechanical restraint.

FINDINGS

Mechanical restraint rate per year was reduced, not significantly, from 18.2% to 15.1%. The average duration of each mechanical restraint episode was significantly reduced from 27.91 to 15.33 hr. The following variables have been associated with a shorter period of coercion: being female and the year of restraint (2012).

PRACTICE IMPLICATIONS

Specific plans are required, including different interventions, in order to achieve marked reduction in the use of coercive measures.

Psychiatric Patients Experiences with Mechanical Restraints: An Interview Study

Objective. To examine psychiatric patients' experience of mechanical restraints and to describe the care the patients received. Background. All around the world, threats and violence perpetrated by patients in psychiatric emergency inpatient units are quite common and are a prevalent factor concerning the application of mechanical restraints, although psychiatric patients' experiences of mechanical restraints are still moderately unknown. Method. A qualitative design with an inductive approach were used, based on interviews with patients who once been in restraints. Results. This study resulted in an overbridging theme: Physical Presence, Instruction and Composed Behaviour Can Reduce Discontent and Trauma, including five categories. These findings implicated the following: information must be given in a calm and sensitive way, staff must be physically present during the whole procedure, and debriefing after the incident must be conducted. Conclusions. When mechanical restraints were unavoidable, the presence of committed staff during mechanical restraint was important, demonstrating the significance of training acute psychiatric nurses correctly so that their presence is meaningful. Nurses in acute psychiatric settings should be required to be genuinely committed, aware of their actions, and fully present in coercive situations where patients are vulnerable.

Frequency of physical restraint and its associations with demographic and clinical characteristics in a Chinese psychiatric institution

PURPOSE

Physical restraint (PR) is a highly controversal topic in psychiatry. Little is known about PR among psychiatric inpatients in China. This study examined the frequency of PR and its relationships with demographic and clinical characteristics among a large psychiatric institution in the Hunan Province, China.

DESIGN AND METHODS

The study included a consecutively assessed sample of 160 psychiatric inpatients. Sociodemographic and clinical data including use of PR were collected from the medical records using a form designed for this study and confirmed via interview.

FINDINGS

The frequency of PR was 51.3% in the whole sample; 63.2% among female and 39.2% among male patients. In multiple logistic regression analysis PR was independently associated with male gender (p = 0.001, odds ratio [OR] = 0.2, 95% confidence interval [CI] 0.1-0.6), less outpatient treatment prior to admission (p = 0.03, OR = 0.3, 95% CI 0.1-0.9), more frequent use of mood stabilizers (p = 0.002, OR = 5.6, 95% CI 1.9-16.7), more aggressive behavior prior to admission (p = 0.002, OR = 1.1, 95% CI 1.04-1.2), and younger age (p = 0.04, OR = 0.97, 95% CI 0.93-0.99).

PRACTICE IMPLICATIONS

PR is very common in clinical practice in China. Its demographic and clinical correlates are similar to findings in Western settings.

Characteristics of international assaultive psychiatric patients: review of published findings, 2000-2012

In international reviews of psychiatric inpatient violence, one study of all types of patient violence found hostility, involuntary admission, and longer hospital stays associated with violence. A second study of comparison-group papers of patient assaults found younger males with schizophrenia, past violence, and substance abuse assaultive. The present review of raw assault data studies assessed characteristics of assaultive patients worldwide. It was hypothesized that patients with schizophrenia would present greatest assault risk. There were three analyses: International/no American studies (reviewed earlier), European studies, and merged International/American studies. Results revealed that male and female patients with schizophrenia, affective disorders, personality disorders, and other diagnoses presented greatest worldwide risk. Results partially support earlier findings. Given that individual institutional studies in this review reported significant assailant characteristics, a second finding is the absence of most of these institutional characteristics in this international review. Possible explanations for findings and a detailed methodological review are presented.

Acute psychiatric treatment and the use of physical restraint in first-generation immigrants in Italy: a prospective concurrent study

BACKGROUND

and

AIMS

Immigrants in Europe appear at higher risk of psychiatric coercive interventions. No studies have investigated this issue in Italy. The aim of this study is to investigate whether the use of physical restraint, compulsory admission and other treatment characteristics differ in immigrated and Italian-born patients admitted to a psychiatric intensive care unit.

METHODS

One hundred first-generation immigrant patients were compared to 100 age-, gender- and diagnosis-matched Italian-born patients. Subjects were diagnosed according to DSM-IV-TR and rated on the Clinical Global Impression - Severity Scale and the Global Assessment of Functioning. Clinical data and treatment characteristics were collected.

RESULTS

Immigrant patients were more likely to be physically restrained as compared to Italian-born patients (11% vs 3%; χ (2) = 4.92; p = 0.027; RR = 3.67; 95% CI = 1.05-12.7). No differences in the proportion of involuntary treatment were found. Immigrant patients did not receive higher doses of antipsychotics or benzodiazepines, but they had a longer stay in the hospital.

CONCLUSIONS

The higher rate of physical restraint among migrants may reflect cultural, ethnic and language differences leading to communication problems between immigrant patients and mental health professionals. Since coercive interventions can be harmful, specific strategies to prevent this phenomenon in immigrants are needed.

TREC-SAVE: a randomised trial comparing mechanical restraints with use of seclusion for aggressive or violent seriously mentally ill people: study protocol for a randomised controlled trial

BACKGROUND

Thousands of people whose aggression is thought due to serious mental illness are secluded or restrained every day. Without fair testing these techniques will continue to be used outside of a rigorous evidence base. With such coercive treatment this leaves all concerned vulnerable to abuse and criticism. This paper presents the protocol for a randomised trial comparing seclusion with restraints for people with serious mental illnesses.

METHODS/DESIGN

Setting-General psychiatric wards of a large psychiatric hospital in Rio de Janeiro, Brazil. Participants-Anyone aggressive or violent suspected or known to have serious mental illness for whom restriction is felt to be indicated by nursing and medical staff, but also for whom they are unsure whether seclusion or restraint would be indicated. Interventions-The standard care of either strong cotton banding to edge of bed with medications as indicated and close observation or the other standard care of use of a minimally furnished seclusion room but with open but barred windows onto the nursing station. Outcomes-time to restrictions lifted, early change of treatment, additional episodes, adverse effects/events, satisfaction with care during episode. Duration-2 weeks. Identifier: ISRCTN 49454276 http://www.controlled-trials.com/ISRCTN49454276.

Use of coercive physical measures in a psychiatric ward of a general hospital in Greece

BACKGROUND

Coercive physical measures are commonly used in psychiatric units throughout the world for the management of severe behaviourally disturbed patients.

AIM

The aim of this study was to assess the rates of coercive physical measures (seclusion and restraint) used in psychiatric inpatients in the psychiatric unit of a general hospital in Greece.

METHODS

A retrospective chart review of all admissions to the psychiatric unit of the University General Hospital of loannina during a six-month period was conducted. Differences between patients who were subjected to coercion and patients who did not receive any coercive treatment were statistically analyzed and compared.

RESULTS

Of the total of 282 admissions during the study period, 31 (11.0%) cases had been subjected to some form of coercive physical measures: 9.55% and 1.76% were affected by seclusion and mechanical restraint, respectively (one patient had been subjected to both). The mean duration of any one seclusion and mechanical restraint was 64.9 hours and the mean number of seclusion and restraint per affected case was 3.58. Statistical analysis between the group subjected to coercive measures and the group who was not did not reveal any association with demographic data or diagnosis. Coercive measures were found to be associated only with the type of admission at intake.

CONCLUSIONS

Involuntary admissions were associated with statistically significant higher levels of restraint and seclusion in this patient sample. Strategies that will enhance patients' follow-up are expected to prevent involuntary admissions and reduce the use of coercive measures.

The early experience of Old Age Psychiatrists in the application of the Mental Capacity Act 2005: a pilot study

BACKGROUND

The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales.

METHODS

A pilot questionnaire study examined the experience of consultants in Old Age Psychiatry in the early implementation of the MCA pertaining to local policy and training in the application of the MCA, the assessment of decision-making capacity, the determination of best interests, and the use of the least restrictive option and restraint.

RESULTS

Fifty-two (27%) of the 196 consultants in Old Age Psychiatry returned useable questionnaires. Seventy-five percent of them reported that local training on the application of the MCA was available, but less than 50% reported that training was mandatory. The vast majority of assessments of decision-making capacity were conducted by consultants in Old Age Psychiatry. Almost all of them reported using the four-fold specific test of decision-making capacity (DMC) described in the MCA. Restraint was reported to be rarely used.

CONCLUSIONS

Consultants in Old Age Psychiatry generally reported using the criteria for the assessment of DMC, the determination of best interests and restraint described in the MCA. The findings highlight concern about the workload of clinicians in implementing the MCA and this requires careful monitoring. Consideration should be given to statutory provision of training in the application of the MCA by all healthcare and social care providers for all their healthcare and social care staff.