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Research overview

Interventions for reducing seclusion and restraint in mental health care for adults: a systematic review

We summarized 21 studies about interventions for reducing seclusion and restraint in mental health care for adults. The report is an update of a previous systematic review on the same topic conducted in 2012.

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  • Year: 12/2017
  • By: Norwegian Institute of Public Health
  • Authors Dahm KT, Steiro AK, Leiknes KA, Husum TL, Kirkehei I, Dalsbø TK, Brurberg KG.

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Key message

There are substantial regional differences in the use of  coercive measures in mental health in Norway. The Norwegian Directorate of Health is working with a national standardized package of procedures for improving and reducing use of coercion in mental health care and commissioned an updated systematic review to support this work. We summarized 21 studies about interventions for reducing seclusion and restraint in mental health care for adults. The report is an update of a previous systematic review on the same topic conducted in 2012. We included eight new studies in the updated report.

Main findings:

  • Joint crisis plans probably reduce the number of compulsory admissions.
  • Systematic evaluation of aggressive behaviour in patients admitted to an acute psychiatric ward, may reduce the use of restraint and seclusion.
  • Counselling towards staff in high security wards may reduce seclusion and restraint.
  • For the other interventions (such as community-care network, involuntary outpatient commitment program and personal advocacy for inpatients) 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 f

We included 21 studies, of which two were conducted in Norway. All included studies, examined the effect of interventions that are used in Norway, for example joint crisis plans, risk assessment, Assertive Community Treatment teams (ACT-teams), crisis resolution teams and use of written patient contracts. 

Summary

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Background

Treatment and examination of patients in health care are primarily based on voluntary participation, both in somatic medicine and mental health care. The 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. Several changes have been made to the law from 1. September 2017. Substantial regional differences as well as variation between mental health care institutions in use of coercive measures have been reported in Norway.

Objective

In 2012 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.

At present the Norwegian Directorate of Health is working with a national standardized package of procedures for improving and reducing use of coercion in mental health care. In October 2016, the Norwegian Institute of Public Health received a request from the Norwegian Directorate of Health to update a systematic review to support the work. We updated the report from 2012: Interventions for reducing seclusion and restraint in mental health care for adults.

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 updated in March 2017. We also searched for ongoing and unpublished studies in the WHO International Clinical Trials Registry Platform August 2017.

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). 

Intervention: All types of interventions meant to reduce compulsory admission or reduce the use of coercion for people in institutional setting.

Outcome: Primary: Compulsory admission, involuntary treatment, mechanical/physical restraint, involuntary medication.

Secondary: Social functioning (e.g. aggressive behavior, feelings of humiliation, 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: Abstracts had to be in English or Scandinavian languages. No articles was excluded because of language.

Two authors independently assessed reviews and studies for inclusion and assessed methodological quality by using pre-defined inclusion forms and check lists.

Results

We identified 5438 citations, 4361 from 2012 and 1077 from the updated search in 2017. We reviewed titles, abstracts, articles in full text and assessed methodological quality and included 21 single studies in the report.  Eight of the studies were new and thirteen were included in the report from 2012.

We divided the interventions in three categories: Interventions towards: patients in the community, patient in institutional settings and in-patient about to be discharged.

Main results:

Interventions towards patients in the community

  • Joint crisis plans probably reduce the number of compulsory admissions.

Interventions towards patient in institutional settings

  • Regular and systematic evaluation of aggressive behaviour in patients admitted to an acute psychiatric ward, may reduce the use of restraint and seclusion.
  • Counselling towards staff in high security wards may reduce seclusion and restraint.
  • We can not conclude whether rehabilitation in hospitals reduces the number of compulsory admission, forced medication and the use of mechanical restraint for young patients with the onset of schizophrenia.

Interventions for in-patient about to be discharged

  • We can not conclude whether advance directives for patients compulsorily admitted to hospital leads to lower rates of compulsory readmission to hospital.

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. Implementation of 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. Counselling towards staff in high security wards seemed to reduce the use of seclusion and restraint. For other interventions,the evidence of effects is uncertain.

We graded the quality of the evidence for most of the outcomes as low, indicating that the results are less trustworthy; however it does not necessarily mean that the intervention does not work.

We have looked at the effect of interventions and have only included studies with a control group. Qualitative research on the patient's views and experience of being exposed to coercion is very important to increase knowledge in this field, but this is not included in this report.

Further research is needed in order to draw more robust conclusions about the effect of interventions intended to reduce coercion in mental health care, for example studies that evaluate the impact of crisis plan, Assertive Community Treatment teams (ACT-teams), crisis resolution team and treatment contracts. There is a particular need of intervention intended to reduce forced medication.

Conclusion

Joint crisis plans probably reduce the number of compulsory admissions in mental health care for adults. Systematic evaluation of aggressive behaviour in acute psychiatric wards and counselling towards staff in high security wards may reduce the use of restraint and seclusion. 

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