Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Abstract

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.

Perspectives on Involuntary Treatment of Anorexia Nervosa

“…Reports of this typically negative perception of involuntary treatment are well-known from general psychiatric patients also (38,39,42). The impact of different involuntary measures on these patients seems to vary by measures, with seclusion and restraint having an especially negative impact (6,39,42). The subjective implications of nasogastric feeding specifically have in a small qualitative study been reported to increase rebellious behavior as well as involuntary measures such as restraint and forced medication (23).…”

“…As described below, involuntary treatment is usually evaluated negatively by patients, professionals, and relatives (6)(7)(8)(9)(10). Inpatient care must thus always aim to find alternative strategies and interventions to involuntary treatment, reducing it whenever possible without neglecting its lifesaving purpose and outcome.…”

Correlates of psychiatric staff's attitude toward coercion and their sociodemographic characteristics

“…Accordingly, ethical and legal questions raises from overriding a person's will. These coercive measures limit several fundamental human rights, such as liberty of choice or movement, autonomy, and physical integrity 9,10 . An estimated 10% of psychiatric patients in Jordan were restrained or secluded at least once during their admission to psychiatric settings, and countless others are injured or traumatized 11 .…”

“When They Restrain You They Ignore You”—What We Should Learn From the People We Restrain in Emergency Departments

“…2 When participants offered analogies to the ED experiences in which they were restrained, they compared them to incarceration or childhood abuse, not a therapeutic encounter; many described lingering problems with hypervigilance and flashbacks, 2 symptoms of incipient posttraumatic stress disorder that can be induced by physical restraints. 4 Some patients said they had learned that being restrained is an inevitable outcome of receiving treatment in the ED. The study did not report how many participants had been restrained previously, but the perception that a negative outcome is inevitable is reminiscent of the learned helplessness Such conversations might lead to restorative justice approaches, during which patients and staff could come together after an event in a therapeutic encounter that would acknowledge the potential necessity of coercive acts within medicine while working together to avoid future negative outcomes.…”