Measures to Avoid Coercion in Psychiatry and Their Efficacy

Sophie Hirsch · Tilman Steinert

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Healthcare Decision-Making and Restraints Psychiatric care and mental health services Electroconvulsive Therapy Studies

Abstract

BACKGROUND: Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry. METHODS: This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content. RESULTS: Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%. CONCLUSION: Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.

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References

2008Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial 2011Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives 2011Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment 2013Cluster-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men With Schizophrenia 2006Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses 2003An Analysis of Successful Efforts to Reduce the Use of Seclusion and Restraint at a Public Psychiatric Hospital 2008Eliminating Seclusion and Restraint in Recovery-Oriented Crisis Services 2011Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital

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