Use of restraint and seclusion in psychiatric settings in New York State

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.

Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics

BACKGROUND

Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors.

METHODS

Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated.

RESULTS

Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9).

CONCLUSIONS

The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.

Alternatives to use of restraint: A path toward humanistic care

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

How patients' characteristics influence the use of coercive measures

BACKGROUND

Coercive measures are applied in psychiatry as a last resort to control self- and hetero-aggressive behaviors in situations where all other possible strategies have failed. For ethical and clinical reasons, the number of instances of coercion should be reduced as far as possible.

AIM

The aim of the study was to identify sociodemographic and clinical characteristics of patients that were associated with coercion during hospital treatment.

MATERIALS AND METHODS

The study has a descriptive, longitudinal design, based on a 1 year prospective observation of patients admitted to a psychiatric hospital consisting of six inpatient psychiatric wards with a total of 236 beds.

RESULTS

In the 12-month period covered by the study, 1476 people (778 men and 698 women) were treated in the hospital; 226 of them (15%) were subjected to coercion on a total of 405 occasions. The most frequently implemented form of direct coercion was mechanical restraint. The following factors involved in the use of direct coercion were identified: Male gender, young age, mental disorders resulting from the abuse of psychoactive drugs, involuntary admission to the hospital and the use of direct coercion in the past.

CONCLUSION

Assessments of patients' sociodemographic and clinical characteristics can help clinicians recognize patients who are particularly at risk of being subjected to coercive measures.

Deprivation of Liberty in Psychiatric Treatment: a Finnish perspective

This article is concerned with the deprivation of patients’ liberty while undergoing psychiatric treatment, with special reference to the situation in Finland. It is based on a review of Finnish law, health care statistics, and empirical and theoretical studies. Relevant research findings from other countries are also discussed. In Finland, it is required that patients are cared for by mutual understanding with themselves; coercive measures may be applied only if they are necessary for the treatment of the illness, or for safeguarding patients’ safety or the safety of others. Involuntary psychiatric hospitalization is closely regulated by the Mental Health Act. However, the rules concerning the deprivation of liberty during inpatient treatment (by seclusion, restraint and restricted leave) are formulated in very general terms. Therefore, Finnish psychiatric hospitals have their own policies concerning when and how seclusion may be used. The practice of seclusion and the use of restraint therefore vary among the psychiatric hospitals in Finland.

Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups

BACKGROUND

Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person's behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint.

METHODS

The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes.

RESULTS

Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and 'othering', and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma.

CONCLUSIONS

Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.

An interpretative phenomenological analysis (IPA) of coercion towards community dwelling older adults with dementia: findings from Mysore studies of natal effects on ageing and health (MYNAH)

PURPOSE

Limited availability of specialist services places a considerable burden on caregivers of Persons with Dementia (PwD) in Low- and Middle-Income Countries (LMICs). There are limited qualitative data on coercive behavior towards PwD in an LMIC setting.

AIM

The aim of this study was to find relevant themes of the lived experience of relatives as caregivers for PwD in view of their use of coercive measures in community setting in South India.

METHOD

Primary caregivers (n = 13) of PwDs from the Mysore study of Natal effects on Ageing and Health (MYNAH) in South India were interviewed to explore the nature and impact of coercion towards community dwelling older adults with dementia. The narrative data were coded using an Interpretative Phenomenological Analysis (IPA) approach for thematic analysis and theory formation.

RESULTS

Caregivers reported feeling physical and emotional burn-out, a lack of respite care, an absence of shared caregiving arrangements, limited knowledge of dementia, and a complete lack of community support services. They reported restrictions on their lives through not being able take employment, a poor social life, reduced income and job opportunities, and restricted movement that impacted on their physical and emotional well-being. Inappropriate use of sedatives, seclusion and environmental restraint, and restricted dietary intake, access to finances and participation in social events, was commonly reported methods of coercion used by caregivers towards PwD. Reasons given by caregivers for employing these coercive measures included safeguarding of the PwD and for the management of behavioral problems and physical health.

CONCLUSION

There is an urgent need for training health and social care professionals to better understand the use of coercive measures and their impact on persons with dementia in India. It is feasible to conduct qualitative research using IPA in South India.

Exploring patterns of seclusion use in Australian mental health services

Seclusion has remained a common practice in mental health services. In Australia, recent mental health policy has reflected a desire to reduce (and, if possible, eliminate) the use of seclusion. The collection and analysis of data on the use of seclusion have been identified as an important component of the success of reduction initiatives. A cross-sectional design was used in the collection of inpatient unit data on seclusions that occurred in 11 mental health services in Australia over a 6-month period. During this time, there were 4,337 episodes of care. One or more seclusions occurred in 6.8% of episodes of care, with consumers being secluded, on average, 2.32 times and with 44% of them having been secluded more than once. The average length of the seclusions was 2 hours 52 minutes, with 51.4% of seclusions being less than 2 hours. These rates were lower than those reported in previous research studies. The practice of seclusion occurred more commonly on the first 2 days following admission, on weekdays than weekends, and between the hours of 9:00 a.m. and midnight. An understanding of seclusion data can provide fundamental information from which strategies to reduce seclusion can be developed.

Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2-year retrospective audit

Seclusion with or without restraint is a measure used to manage patients with challenging behaviours. Although controversial, the intervention remains poorly documented, especially in Canadian psychiatric hospitals. The purpose of this study is to assess the prevalence of the measure and identify any correlated demographic characteristics and psychiatric disorders. Episodes of seclusion with or without restraint were extracted from a computerized, hospital-based system introduced specifically to track such interventions. Of 2721 patients hospitalized during that time, 23.2% (n = 632) were secluded with or without restraint, and 17.5% (n = 476) were secluded with restraint. Younger age, schizophrenia or other psychosis, bipolar and personality disorder, and longer stay in hospital are predictors of an episode of seclusion with or without restraint. Younger age, bipolar and personality disorders and a longer stay in hospital are predictors of an episode of seclusion with restraint. For patients who spent longer in seclusion and under restraint, there is a positive association with longer stay in hospital. In this inpatient psychiatric facility, seclusion with or without restraint thus appears to be common. More research is warranted to better identify the principal factors associated with seclusion and restraint and help reduce resort to these measures.

Nursing practices recorded in reports of episodes of seclusion

The purpose of this study is to describe the nursing practices recorded in reports of patient episodes of seclusion, with or without restraints, in a specialized psychiatric facility in Quebec. The reports for all adult patients secluded (n = 4863) in a psychiatric unit between April 1, 2007 and March 31, 2009, were examined. Descriptive analyses were performed. The main reasons for seclusion were agitation, disorganization, and aggressive behaviour. The alternative methods that were attempted included stimulus reduction, extra medication, and working with the patient to find a solution. Few families were notified about their relation's seclusion. More hours of seclusion were reported in the evening and at night. Our results are comparable to those obtained by other investigators. Some of the variables have not been the subject of much research: for example, health conditions during seclusion with or without restraint and partnerships with family members. Our findings also suggest that, in their analyses, studies should differentiate between cognitive-impairment and adult-psychiatry units as well as long-term seclusion and short-term seclusion. The information reported by the nurse makes no distinction between short-stay and long-stay adult psychiatric units. Only one psychiatric facility was investigated in this study, precluding generalization.

A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked.

From numbers to understanding: the impact of demographic factors on seclusion rates

The reduction and, where possible, elimination of seclusion has been recognized as a national safety priority for mental health services in Australia, with significant attention devoted to strategies to achieve this goal. The aim of this study was to compare specific demographic characteristics between consumers who have been secluded to those who have not. Patient data (n = 3244) collected by 11 mental health services across Australia for six months over a 12 month period were analysed using demographic statistics. A comparison was undertaken between those who were secluded one or more times (n = 271) and those who were not secluded (n = 2973). Differences were measured with the use of independent samples t-tests and chi-square statistics. Age, gender, diagnosis, indigenous status and Health of the National Outcomes Scores (HoNOS) were found to be significant factors in relation to seclusion. Men, younger people, and indigenous people were found to be more likely to be secluded. In addition, consumers who scored higher on the behaviour,impairment and social subscales of HoNOS were more likely to be secluded. Comparative analysis of demographic characteristics of secluded and non-secluded patients can provide vital information for consideration when planning and evaluating seclusion reduction strategies.

The use of seclusion in the Netherlands compared to countries in and outside Europe

The use of seclusion in psychiatric practice is a contentious issue in the Netherlands as well as other countries in and outside Europe. The aim of this study is to describe Dutch seclusion data and compare these with data on other countries, derived from the literature. An extensive search revealed only 11 articles containing seclusion rates of regions or whole countries either in Europe, Australia or the United States. Dutch seclusion rates were calculated from a governmental database and from a database covering twelve General Psychiatric Hospitals in the Netherlands. According to the hospitals database, on average one in four hospitalized patients experienced a seclusion episode. The mean duration according to the governmental database is a staggering 16 days. Both numbers seem much higher than comparable numbers in other countries. However, different definitions, inconsistent methods of registration, different methods of data collection and an inconsistent expression of the seclusion use in rates limit comparisons of the rates found in the reviewed studies with the data gathered in the current study. Suggestions are made to improve data collection, to enable better comparisons.

Decreasing the use of restraint and seclusion among psychiatric inpatients

OBJECTIVE

We describe a hospital-wide effort to decrease restraint and seclusion of psychiatric inpatients. Our hypotheses were that interventions could reduce the number of patients as well as patient hours in restraint and seclusion, without an increase in adverse outcomes (fights/assaults, staff injuries, and elopements).

METHOD

This study was performed at an urban academic psychiatric hospital (New York State Psychiatric Institute) with 3 inpatient units totaling 58 beds. Interventions included 1) decreasing initial time in restraint or seclusion from 4 to 2 hours before a new order was required; 2) education of staff concerning identification of patients at risk of restraint or seclusion and early interventions to avoid crises; and 3) use of a coping questionnaire to assess patient preferences for dealing with agitation. Data were assessed 20 months before and 67 months following the implementation of these interventions.

RESULTS

The mean number of patients restrained went from 0.35 +/- 0.6 to 0.32 +/- 0.5 patients/month; mean hours of restraint decreased from 1.7 +/- 5.2 to 1.0 +/- 2.4 hours/month. The mean number of patients secluded decreased significantly from 3.1 +/- 1.4 to 1.0 +/- 1.1 patients/month. The mean hours of seclusion decreased markedly, from 41.6 +/- 52 to 2.7 +/- 4.5 hours/month. Adverse outcomes (elopements and fights/assaults) also decreased significantly over the follow-up period.

CONCLUSIONS

Interventions were successful in decreasing use of restraint and seclusion on both clinical and research units over more than 5 years of follow-up. Such interventions may be adapted to other settings.

Use of restraint in a general hospital psychiatric unit in Japan

Few analyses have been carried out in Japan concerning factors contributing to physical restraint of patients. We compared demographic data for 241 inpatients who were restrained during a 4-year period with data for 1093 inpatients who were not restrained in a general hospital psychiatric unit in Japan. Increased likelihood of restraint use was associated with older age, male gender, off-hours admission, involuntary hospitalization, transfer from other departments of the hospital, frequent hospitalization, absence of previous treatment, physical complications, history of suicide attempts, organic mental disorders, mental and behavioral disorders from psychoactive substance use, schizophrenia, schizotypal and delusional disorders. Importantly, physical complications not only were more prevalent among restrained than unrestrained patients, but additionally in restrained patients physical complications were associated with more prolonged hospitalization and periods under restraint than were associated with assaultive behavior or periods of unconsciousness. In conclusion, general hospital psychiatric units in Japan often treat patients with psychiatric disorders or symptoms that were associated with physical problems. Particular caution is needed in deciding whether such patients should be restrained since hospitalization may be prolonged or functional status compromised.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital

The aim of this study was to examine staff strategies for applying emergency procedures with patients who were violent or threatening. The study addressed those situations where verbal intervention, voluntary medication, and other interventions had been tried unsuccessfully and where staff found it necessary to apply emergency procedures in the shape of forced emergency medication (pharmacological restraint), physical restraint, and seclusion. The study was conducted in a 100-bed Norwegian university psychiatric hospital. By retrospectively examining hospital records we found there were 797 episodes of physical restraint, 384 episodes of pharmacological restraint, and 88 episodes of seclusion during a five and a half year period. The preferred emergency procedures varied significantly with patients' sex, age, and diagnoses. Physical restraint was preferred more often with male, younger, and nonpsychotic patients. Pharmacological restraint was preferred more often with female patients and older patients with a nonorganic psychotic disorder. Seclusion was preferred more often with older male patients with an organic psychotic disorder.

Nursing Staff's Attitudes Toward Seclusion & Restraint

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.

Aversiveness of traditional psychiatric patient restriction

This article is a literature review of traditional psychiatric patient restriction and the consequential harm that the patient experiences. Though the obtainment of theoretical objectives and short-term overt behavioral results appear to be gained through psychiatric constraint measures, injurious effects to the patient have been recorded with resultant impediment to the restoration of psychological health. This article asserts the necessity for the use of alternative measures, which have been shown to be successful in restoring control while maintaining and promoting the dignity and psychological health of the patient.

Psychiatric nurses' thoughts and feelings about restraint use: a decision dilemma

Patients continue to be physically restrained in psychiatric in-patient units. Studies concerned with staff-related variables have suggested that the emotional reactions of professionals to violent or potentially violent patients may influence their use of restrictive measures. However, no research existed that described psychiatric nurses' thoughts and feelings while they were involved in restraint situations nor what effects their thoughts and feelings had on their decision to restrain. Therefore, an ethnographic qualitative study was conducted in order to describe systematically nurses' thoughts and feelings toward restraint use in the in-patient psychiatric setting. The conceptual approach guiding the study was Etzioni's (1992) theoretical work on the role of normative-affective factors in decision making. Following ethical approval of the study, ethnographic interviews were conducted with six nurses from an in-patient psychiatric unit who had participated in a situation involving the physical restraint of a patient. The analysis of the nurses' thoughts and feelings revealed that the restraint situation represented a decision dilemma for them. This overall finding was supported by four themes: (1) the framing of the situation: the potential for imminent harm; (2) the unsuccessful search for alternatives to physical restraints; (3) the conflicted nurse; and (4) the contextual conditions of restraint. The results indicated that restraint use is more complex than is currently conveyed in the literature in that normative-affective factors influenced nurses' restraint decisions. The findings advance our understanding of why restraints continue to be used in psychiatric units. Further research is necessary to examine the findings in other settings and with a larger and more diverse population in order to draw definitive conclusions about the continued use of physical restraints in the care of patients on psychiatric units in hospitals.

Seclusion and restraint for people with serious mental illnesses

BACKGROUND

Seclusion and restraint are interventions used in the treatment and management of disruptive and violent behaviours in psychiatry. The use of seclusion varies widely across institutions. The literature does offer numerous suggestions for interventions to reduce or prevent aggression.

OBJECTIVES

1. To estimate the effects of seclusion and restraint compared to the alternatives for those with serious mental illnesses. 2. To estimate the effects of strategies to prevent seclusion and restraint in those with serious mental illnesses.

SEARCH STRATEGY

Electronic searches of The Cochrane Controlled Trials Register (Issue 1, 1999) and The Cochrane Schizophrenia Group's Register (January 1999) were supplemented with additional searches of Biological Abstracts (1989-1999), CINAHL (1982-1999), EMbase (1980-1999), MEDLINE (1966-1999), MEDIC (1979-1999), PsycLIT (1974-1999), Sociofile (1974-1999), SPRI & SWEMED (1982-1999), Social Sciences Citation Index (1996-1999), and WILP (1983-1999). In addition, trials were sought by hand searching the reference lists of all identified studies and conference abstracts and contacting the first author of each relevant study.

SELECTION CRITERIA

Randomised controlled trials were included if they focused on the use (i) of restraint or seclusion; or (ii) of strategies designed to reduce the need for restraint or seclusion in the treatment of serious mental illness.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data relative risks (RR) with 95% confidence intervals (CI) were estimated. Normal continuous data were summated using the weighted mean difference (WMD).

MAIN RESULTS

1. Effect of seclusion and restraint The search strategy yielded 2155 citations. Of these, the full articles for 35 studies were obtained. No studies met minimum inclusion criteria and no data were synthesised. Most of the 24 excluded studies focused upon the restraint of elderly, confused people and preventing them from wandering or falling. 2. Prevention of seclusion and restraint Work ongoing.

REVIEWER'S CONCLUSIONS

No controlled studies exist that evaluate the value of seclusion or restraint in those with serious mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews. Alternative ways of dealing with unwanted or harmful behaviours need to be developed. Continuing use of seclusion or restraint must therefore be questioned from within well-designed and reported randomised trials that are generalisable to routine practice.