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A B S T R A C TAims: The aim of this review was to assess whether restraint and seclusion are safe and effective interventions for the short-term management of disturbed/violent behaviour. Staff and service user perspectives on the use of these interventions were also considered. The review was undertaken as part of the development process for a national guideline on the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings and emergency departments in the United Kingdom.Method: An exhaustive literature search was undertaken. Systematic reviews, before and after studies, as well as qualitative studies were included. Searches were run from 1985 to 2002.Findings: Thirty-six eligible studies were identified. However, none were randomised controlled trials. Most of the included studies had many limitations, such as small sample sizes, confounders not adequately accounted for, potential selection bias, poorly reported results, and lack of clarity as to whether mechanical restraints were used. This review must therefore be viewed as a mapping exercise, which illustrates the range and quality of studies that have been undertaken in this area to date.Conclusions and Implications for Practice: Insufficient evidence is available to determine whether seclusion and restraint are safe and/or effective interventions for the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings. These interventions should therefore be used with caution and only as a last resort once other methods of calming a situation and/or service user have failed.

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Peter Scott's (1975) characterisation of the concept of dangerousness as potentially dangerous in itself could not be more relevant than today. The principal focus of mental health policy over the last six years has been the care and treatment of seriously mentally ill people and mentally disordered offenders, and central to the successful care of the former and many of the latter is the competent assessment of the risk they pose: mostly to themselves, but occasionally to others.

Managing patients with deliberate self harm who refuse treatment in accident and emergency departmentsEducation and debate p 905 Advice and procedure require correctionEditor-In their lesson of the week on managing patients with deliberate self harm who refuse treatment in the accident and emergency department Hassan et al recommend that doctors must be fully conversant with the law on assessing capacity to consent to treatment and its application. 1 It is equally important in these difficult cases to be familiar with the application of the Mental Health Act 1983 or Mental Health (Scotland) Act 1984, which Hassan et al seem not to be. They state: "If the overdose is considered to be a consequence of a mental disorder then the patient can also be treated medically for the overdose under the terms of the Mental Health Act." This statement is reiterated in their proposed algorithm, recommended for use at accident and emergency departments. This is simply not the case.The Mental Health Act is for the treatment of mental disorders. It does not authorise the treatment of a physical disorder even if it arises as a consequence of a mental disorder. Therefore the Mental Health Act is of no help in the immediate medical management of patients presenting with deliberate self harm and refusing treatment, other than to permit detention in hospital if the patient is considered to be suicidal as a result of mental disorder.Treatment for the overdose will remain under common law based on assessment of competency to refuse treatment and the need to preserve life.The Mental Health Act states that treatment can be administered only if a patient is not capable of giving informed consent, provided that it is in the patient's best interest, is urgently necessary, and is in accordance with a practice accepted at the time by a responsible body of medical opinion skilled in the particular form of treatment in question. 2 A study by the MacArthur group found that only a minority of psychiatric patients had significant impairment in ability to provide valid informed consent for treatment. 3 The advice of Hassan et al and their algorithm require correction.