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Systematic review

Interventions for reducing seclusion and restraint in mental health for adults

In this systematic review interventions intended to reduce the use of coercive measures in mental health services for adults have been examined.

In this systematic review interventions intended to reduce the use of coercive measures in mental health services for adults have been examined.


Key message

In Norway there are substantial regionale differences in the use of coercive measures in mental health care. There is also variation in use of coercion between mental health care institutions. At present Norwegian Authorities are revising an Action Plan from 2006, aiming to reduce the use of coercion and to improve the quality of mental health services when coercive measures are used in accordance with the mental health act.

In this systematic review interventions intended to reduce the use of coercive measures in mental health services for adults have been examined.

Main findings:

  • Joint crisis plans may reduce the number of compulsory admissions, but the documentation was of low quality.
  • Systematic evaluation of aggressive behaviour in patients admitted to an acute psychiatric ward, may reduce the use of restraint and seclusion, but the documentation was of low quality.
  • For the other interventions conclusions could not be drawn.

Further research is needed in order to draw more robust conclusions about the effect of interventions intended to reduce coercive measures, seclusion and restraint, in mental health services for adults. 

We included 12 studies. None of the included studies were conducted in Norway. However, the studies, examined the effect of interventions that are used in Norway such as joint crisis plans, risk assessment, Assertive Community treatment teams (ACT-teams), crisis resolution teams and use of written patient contracts, such as booklet containing treatment options.

Summary

Background

Treatment and examination of patients in health care are primarily based on voluntary participation, both in somatic medicine and mental health care. Patients´ Rights Act promotes the patients self- determination and autonomy. Coercion is in conflict with this principle. Use of coercive measures in mental health care in Norway is therefore regulated by the Norwegian Mental Health Act.

Substantial regional differences as well as variation between mental health care institutions in use of coercive measures have been reported in Norway.

Objective

The Norwegian Knowledge Centre for the Health Services was commissioned by the Norwegian Psychological Association to systematically review the available research on interventions intended to reduce coercion in mental health care.

Method

We searched the literature systematically in the following databases: Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, CRD DARE, CRD HTA, SveMed+, Norart, CINAHL, ISI Social Science/Science Citation Index and TvangsPub. The search was finished June 2012. We also searched for ongoing and unpublished studies in the WHO International Clinical Trials Registry Platform February 2012.

The inclusion criteria were:

  • Study Design: Systematic reviews of high quality, randomized controlled trials, prospective controlled trials and interrupted time series.
  • Population: Adult patients with severe mental disorder (18 to 65 years ), e.g. schizophrenia, bipolar disorder or severe personality disorder according to ICD- 10 and DSM-IV. Patients with dual diagnosis (e.g. substance use and serious mental
  • illness, primary diagnosis had to be serious mental illness). Adult patients compulsory admitted and patients voluntary admitted, exposed to coercion (e.g. mechanical restraint, physical restraint, involuntary medication and open area seclusion) after being admitted. 
  • Intervention: All kinds of interventions meant to reduce compulsory admission or reduce the use of coercion for people at hospital. The interventions were divided into the following groups:
      • Organization of the care: Increased availability in acute crisis, ambulant team, improved monitoring, change of ward environment. 
      • Staff: Education of staff, improving attitudes, staff competence.
      • Patient: Client participation and autonomy.
  • Outcome: Primary: Compulsory admission, involuntary treatment, mechanical/ physical restraint, involuntary medication.
  • Secondary: Social functioning (e.g. aggressive behavior, feelings of powerlessness, anxiety, medication use), quality of life, satisfaction with care, perceived coercion, number of inpatient days, readmission, crime and adverse events ( e.g. suicide, injuries to staff and episodes of violence).
  • Language: All, except abstract, had to be in English or one of the Scandinavian languages.

Two authors independently assessed reviews and studies for inclusion and assessed methodological quality by using pre-defined inclusion forms and check lists. The quality of the evidence was assessed using the Grades of Recommendations Assessment, Development and Evaluation (GRADE).

Results

We identified 3361 citations in the search. We reviewed titles, abstracts, articles in full text and assessed methodological quality and included 12 single studies in the report.

We divided the interventions in three categories: Interventions towards A) patients in the community, B) patient at hospital and C) in-patient about to be discharged.

Main results:

  • Joint crisis plans may reduce the number of compulsory admissions, but the documentation was of low quality.
  • Regular and systematic evaluation of aggressive behaviour in patients admitted to an acute psychiatric ward, can reduce the use of restraint and seclusion, but the documentation was of low quality.
  • For the other interventions conclusions could not be drawn.
  • Further research is needed in order to draw more firm conclusions about the effect of interventions intended to reduce coercion in mental health services for adults.

Discussion

Interventions to reduce the use of seclusion and restraint in mental health care have been in focus for several years. This systematic review indicates that the current available research on effectiveness of interventions meant to reduce coercion is scarce. Results from twelve studies are summarized here. Joint crisis plans may reduce compulsory admission. Regular evaluation of aggressive behaviour in acute psychiatric wards may also reduce the use of restraint and seclusion. For other interventions the evidence of effects is uncertain.

Joint crisis plans are produced and formulated by patient, caregivers and health professionals in an atmosphere of safe and close collaboration. There is a need for further research to be certain about the effect and to clarify factors which enhance the cooperation and are important for such a complex intervention.

Most of the quality of the evidence is graded low, indicating that the results are less trustworthy; however it does not necessarily mean that the intervention does not work.

We have conducted an extensive systematic search of international databases and included twelve studies. None of the studies were conducted in Norway. The studies however, examined the effect of interventions that are used in Norway such as joint crisis plans, risk assessment, ACT-team, crisis resolution team and use of written patient contracts, such as booklet containing treatment options.

Conclusion

Joint crisis plans may reduce the number of compulsory admissions in mental health for adults. Systematic evaluation of aggressive behaviour in acute psychiatric wards may also reduce the use of restraint and seclusion. Further research is needed in order to draw more robust conclusions about the effect of interventions intended
to reduce coercion in mental health care.

There is a need for more comparative studies in Norway.

    About this publication

  • Year: 2012
  • By: The Knowledge Centre for the Health Services
  • Authors Dahm KT, Leiknes KA, Husum TL, Kirkehei I, Hofmann B, MyrhaugHT, Brurberg KG, Dalsbø, TK, Reinar LM.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-484-2