Trends in the use of coercive measures in Finnish psychiatric hospitals: a register analysis of the past two decades

Effect of Seclusion on Mental Health Status in Hospitalized Psychiatric Populations: A Trial Emulation using Observational Data

The use of coercive practices, i.e., interventions against a person's will, is controversial. Recent observational studies highlighted their potential detrimental effects on patients' mental health, but this topic remains understudied. This study investigated the effect of a common coercive practice, seclusion (i.e., being locked in a closed room), on mental health using a trial emulation of observational data to allow causal inference. We used data from 1200 psychiatric inpatients, classified as being either secluded or non-secluded during their hospital stay. Inverse probability of treatment weighting was used to emulate the random assignment to the intervention. The primary outcome was the Health of the Nations Outcome Scales (HoNOS). The secondary outcome was the first item of the HoNOS, which focuses on overactive, aggressive, disruptive, or agitated behavior. Both outcomes were assessed at hospital discharge. There was a significant effect of seclusion with increases in both total HoNOS score (p = .002) and item 1 of the HoNOS (p = .01). Seclusion may have a negative causal effect of patients' mental health status and should therefore be avoided in mental health care settings. Training efforts should raise the awareness of the medical staff about potential adverse effects instead of therapeutic benefits.

Post‐incident debriefing for people with schizophrenia after coercive measures

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To investigate the effects of post‐incident debriefing after coercive measures for people with schizophrenia or schizophrenia‐type psychosis.

Predictors of the use of restraint in inpatient psychiatric care among patients admitted via the emergency department

BACKGROUND

Coercive measures are associated with negative consequences for both patients and hospital staff. The aim of the study was to identify predictors for the use of restraints in the emergency department and in subsequent inpatient care.

METHOD

Retrospective routine clinical data of all patients admitted to the psychiatric departments of Vivantes Klinikum Am Urban in Berlin via the emergency department in 2019 was examined case-wise (n = 2584) as well as patient-wise (n = 2118).

RESULTS

Of all cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. Of the 2584 cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. These 195 cases experienced a total of 358 restraints and were distributed across 159 individuals. Multivariate regression analyses on patient-level show that age (p < .001), judicial placement (p < .001), and police referral in the presence of others (p < .001) had a statistically significant effect on the use of restraint.

DISCUSSION

The results indicate that certain patient characteristics increase the risk of restraints. A majority of the findings of this study underline previous research findings. However, ICD-10 diagnosis and gender do not prove to be significant variables, contrary to expectations based on previous.

Living with restraint: Reactions of nurses and lived experience workers to restrictions placed on the use of prone restraint

Despite recent changes to mental health policy in Australia and overseas, physical restraint continues to be widely employed in mental health services. While mental health nurses have a critical role to play in supporting initiatives designed to reduce restraint, it is unclear how they feel about moves to restrict the use of prone restraint. In this qualitative study, focus group interviews were conducted with mental health nursing staff and lived experience workers (LEWs) to gain their perspectives on the use of physical restraint in general and the restrictions being placed on prone ('face down') restraint. Five themes emerged: justifying the need for restraint, reliance on the prone position, the position is not the issue, time limits, and the psychological impact. Although mental health nurses were concerned about the risks associated with physical restraint, they provided strong justification for continued use of the prone position. LEWs raised concerns about the psychological impact of prone restraint and noted the need for a greater emphasis on de-escalation and other restraint avoidance strategies. The findings highlight the complexities and challenges to be considered when developing initiatives to reduce reliance on the use of restraint in general, and prone in particular.

[Monitoring of coercive measures and compulsory treatment in Germany]

Epidemiological registers on the burden of disease and adverse events (deaths, serious side effects, etc.) play an important role in the management, evaluation, and improvement of healthcare treatment for the population. This also applies to coercive measures in the psychiatric healthcare system. Such registers only became feasible on a broad basis due to the availability of electronic medical records and steadily increasing computing capacities; however, in most German states, registers have not been implemented. Data protection problems must be taken into account in the collation of person-related data but can be solved by appropriate pseudonymization procedures taking the prerequisites of data parsimony into account. Extensive data are now available from the Baden-Wuerttemberg register for coercive measures, which has been in existence since 2015 and which enabled, for instance, evaluating the consequences of the changes to the law following the 2018 ruling of the Federal Constitutional Court on mechanical restraint and the consequences of the coronavirus pandemic. In the meantime, there are also state-wide data collections in some other German states; however, unlike in Baden-Wuerttemberg, these registers do not include measures under guardianship law. A nationwide register for coercive measures, compulsory treatment and involuntary detention has justifiably repeatedly been demanded for a long time. A major obstacle is the historically developed separation between the responsibility of the German states for the detention regulated by public law and the Federal State for the scope of application of the guardianship law.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

The use of coercive measures in a high security setting in Belgium: Prevalence and risk factors

Coercive measures are often used in forensic psychiatric settings as a strategy to manage violent and other problematic behavior. Few studies have been published regarding the use of coercive measures in high security populations. This is the first empirical study on this subject in Belgium. The aim of the present study was to examine the prevalence rates of coercive measures in Flanders' two high security settings and to identify individual patient risk factors for being subjected to a coercive measure. The study included all patients (N = 654) who were admitted in the Forensic Psychiatric Centres of Antwerp or Ghent over a six-year period. Data on the use of coercive measures (seclusion, mechanical restraint, and chemical restraint) were registered prospectively. Several regression analyses were conducted with multiple independent variables. The results show that half of the population (50.3%) was subjected to at least one coercive measure during admission in one of the high security settings. A small subgroup of patients (6.4%) was the subject of half of all coercive measures (50,4%). Seclusion was the most frequently used coercive measure (48.3%), followed by chemical restraint (20.2%). The prevalence rate of mechanical restraint was very low (0.8%) compared to previous research in similar populations. Various individual risk factors were significantly associated with a higher use of coercive measures. Clinical implications are discussed and the importance of developing international standards on recording and reporting on coercive measures is highlighted.

Measurement Properties of the Staff Attitude to Coercion Scale: A Systematic Review

OBJECTIVE

The Staff Attitude to Coercion Scale (SACS) was developed to assess mental health care staff's attitudes to the use of coercion in treatment. The staff's attitudes to the use of coercion may also influence their willingness to engage in professional development projects aimed at reducing use of coercion. This study systematically reviews the existing evidence related to the measurement properties of the SACS in papers published since the publication of SACS in 2008.

METHODS

Seven databases were searched for studies published until October 2021 assessing the measurement properties of SACS or using SACS. All original studies reporting data relevant for the assessment of measurement properties of the SACS were eligible for inclusion. The methodological quality of the studies was assessed and rated using the COnsensus-based Standard for the selection of health Measurement INstruments (COSMIN).

RESULTS

Of the 81 identified publications, 13 studies with a total of 2,675 respondents met the inclusion criteria. Most studies reported data on structural validity and internal consistency, with high methodological quality, but there were almost no data on any other measurement properties.

CONCLUSION

We found evidence for adequate structural validity and internal consistency of the SACS, while other important measurement properties were not addressed in any of the reviewed studies. Caution is needed when interpreting results of the SACS in terms of aspects such as reliability, criterion validity and measurement error. The relationship between staff attitudes to coercion and the actual use of coercion also remains unclear and needs to be further investigated.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021239284.

Quality of mental health services and rights of people receiving treatment in inpatient services in Finland: a cross-sectional observational survey with the WHO QualityRights Tool Kit

BACKGROUND

This article aims to review the quality of mental health services and the rights of the people receiving treatment in inpatient hospital care in Finland using the World Health Organization's QualityRights Tool Kit as a part of a randomized controlled trial VIOLIN. So far, reports on the QualityRights Tool Kit have mainly been from low- and middle-income countries or countries lacking resources for health services. Reports from countries with well-resourced health care systems, such as the Nordic countries, are still quite few.

METHODS

A cross-sectional observational survey was conducted on 13 closed inpatient psychiatric wards (acute, rehabilitation, forensic psychiatric) at eight hospitals in Finland. The data for the survey were gathered through a document review, observations, and group interviews among staff members, service users and family members. The STROBE checklist for cross-sectional studies was followed in the reporting.

RESULTS

Finnish mental health services are partially or fully achieving the standards set by the WHO QualityRights Tool Kit (final scores: 2.5-2.9 out of 3). The highest final score out of the five themes (2.9/3) was achieved under Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse. The lowest final score out of the five themes (2.5/3) was achieved under the right to exercise legal capacity and the right to personal liberty and the security of person.

CONCLUSIONS

According to the findings, Finnish mental health services appear to be of high quality. However, we have identified some gaps in quality, which we have addressed in a national randomized controlled trial VIOLIN. Improvements can be realized through shared decision making and relaying information to service users.

[Gender-Related Differences Regarding Aggressive Behaviour and Coercive Measures in Psychiatric Inpatients]

OBJECTIVE

Examination of gender-related differences of aggressive incidents and the use coercive measures within a whole psychiatric hospital with a catchment area of 339.000 inhabitants over a period of fifteen years.

METHODS

Recording of aggressive incidents using the Staff Observation Aggression Scale-Revised (SOAS-R) as well as coercive measures by a clinically developed record sheet and analysing gender-related differences from 2005 to 2019.

RESULTS

82 833 inpatients (male: 55.3 %; female: 44.7 %) are included. Between 2005 and 2019, 60.1 % of the aggressive events involved male patients and 39.9 % involved female patients; however, regarding cases of treatment no gender-related difference existed (odds ratio: 1.1). The SOAS-R-severity score of women was significantly higher, while aggressive incidents of men were subjectively graded more serious by staff. The number of coercive measures and the mean duration of restraint and seclusion episodes were significantly higher and longer, respectively, in male inpatients.

CONCLUSION

Differences in frequency and duration of coercive measures between male and female patients could be influenced by the subjective perception of staff that male patients behave more aggressively.

Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program

Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.

Prevention and management of aggressive behaviour in patients at psychiatric hospitals: a document analysis of clinical practice guidelines in Hong Kong

Patient aggressive behaviour remains a significant public health concern worldwide. The use of restraint and seclusion remains a last resort but not an uncommon practice in clinical psychiatry in the management of aggressive events. There seems to be a paucity of evidenced-based research examining the policy framework guiding the use of restraint and seclusion in Asia contexts. The purpose of this study was to conduct an analysis on the guidelines in psychiatric hospitals in Hong Kong, and to explore the extent to which these guidelines were aligned with the international clinical guidelines for the prevention and management of patient aggression in psychiatry. A descriptive document analysis was used to analyse the guidelines from four psychiatric hospitals in Hong Kong in comparison with the NICE (National Institute of Health and Care Excellence UK) guidelines. Data were collected from December 2017 to June 2018. A total of 91 written documents were retrieved. Preventing violence and aggression has the highest level of agreement (31%,) while the use of restrictive interventions has the lowest level of agreement (12%). The sub-recommendation with most in line with the NICE guidelines were restrictive interventions, de-escalation, and improving service users' experiences. However, for example, staff training, working with police, and reduced use of restrictive interventions seemed to have no agreement with the NICE guidelines. Variation exists between the Asian (Hong Kong) local policy framework/guidelines and the European (UK) national policy framework. There are also large discrepancies in the written guidelines on patient aggressive behaviour when comparing local policy frameworks, cluster-based documents, and departmental practices.

A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders)

BACKGROUND

Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others.

METHODS

In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions.

RESULTS

A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours.

CONCLUSION

Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.