Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint , seclusion , psychiatry , effect , harm , efficiency , efficacy , effectiveness , and quality of life . Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as “non-invasive.” Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients’ preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Energy homeostasis is achieved by the integration of peripheral metabolic signals by the neural circuits involving specific hypothalamic nuclei and brain stem regions. These neural circuits mediate many of the effects of the adipocyte-derived hormone leptin and gut-derived hormone ghrelin. The former is strongly anorexigenic while the latter is the only orexigenic agent active when administered by a peripheral route. Abnormal regulation of these 2 antagonistic regulatory peptides in patients with schizophrenia could play a role in the impairment in the regulation of food intake and energy balance. This bibliographical analysis aims to compare 27 prospective and cross-sectional studies published on circulating leptin and ghrelin levels during acute and chronic administration of antipsychotics treatment, especially atypical ones. Fasting morning leptin levels of schizophrenic patients increase rapidly in the first 2 weeks after atypical antipsychotic (AAP) treatment (mostly olanzapine and clozapine) and remain somehow elevated after that period up to several months. On the contrary, conventional antipsychotics (such as haloperidol) do not interfere with leptin levels. In contrast to leptin, fasting morning ghrelin levels decrease during the first few weeks after the beginning of AAPs treatment while they increase in the longer run. Surprisingly, body weight gain and correlations between the variation of these 2 peptides and adiposity and metabolism-related parameters such as the body mass index and abdominal perimeter were not systematically considered. Finally, an objective evaluation of feeding behavior during antipsychotic treatment remains to be determined.

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Many aspects of the motivation to eat are involved in the impairment of adequate food intake and body weight control. The aim of this study was to evaluate, by adopting widely used eating questionnaires, the Three Factors Eating Behaviour Questionnaire (TFEQ) and the Dutch Eating Behavior Questionnaire (DEBQ), the associations of different antipsychotic medications with the food attitudes of 153 schizophrenic patients: we compared 93 individuals treated with atypical antipsychotics, 27 treated with conventional neuroleptics and 33 untreated patients. We did not find any difference according to sex, but the mean body mass index varied significantly among the three groups of patients. The DEBQ external eating factor was higher in patients treated with atypical antipsychotics than in patients who received conventional neuroleptics (P=0.035). The TFEQ disinhibition and DEBQ emotional eating scores tended to change among the three types of treatment. Patients with metabolic syndrome (19%) had lower DEBQ external eating scores (P=0.044) and a tendency of higher TFEQ disinhibition scores. The TFEQ disinhibition and hunger scores increased according to the body mass index (P=0.003; P=0.017). The main outcome of this study is that the patients treated with atypical antipsychotics were more reactive to external eating cues, which could partly explain the higher weight gain often reported in these patients.

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