Jan Bergk

Subjective Distress After Seclusion or Mechanical Restraint: One-Year Follow-Up of a Randomized Controlled Study

OBJECTIVE Patients who participated in a randomized controlled trial comparing subjective distress and traumatic impact after seclusion or mechanical restraint were interviewed about the coercive measure about one year later. METHODS Between May and December 2006, patients were interviewed about one year after experiencing seclusion or mechanical restraint as an inpatient. Items from the Coercion Experience Scale (CES) were used in the original and the follow-up studies to assess distress on a 5-point scale, with higher scores indicating greater distress. Patients were also asked about subjective feelings about the coercive measure and completed the Impact of Event Scale-Revised (IES-R) to assess symptoms of posttraumatic stress disorder (PTSD). RESULTS Sixty (59%) of the 102 patients in the original sample were included for follow-up. Although the original study found no differences between patients who experienced seclusion or mechanical restraint, the follow-up study found significantly higher mean scores for CES items among patients who had experienced mechanical restraint (2.5 and 3.7, respectively, p<.001). IES-R scores did not differ significantly. IES-R scores for two patients who experienced mechanical restraint and one who experienced seclusion indicated probable PTSD. Patients reported experiencing a wide range of negative feelings during the measure, most frequently helplessness, tension, fear, and rage. However, 58% reported some positive effects. Contact with staff was most helpful in alleviating distress during the coercive measure. CONCLUSIONS Contrary to the original study, the follow-up study suggested that seclusion might be a less restrictive alternative for most patients. The incidence of PTSD seemed lower than expected.

Ratings of coercive interventions by inpatients and staff in Germany.

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[Aggressive and violent behaviour. Diagnosis, prevention, and treatment].

ZusammenfassungManche psychische Störungen gehen mit einem erhöhten Risiko für gelegentliches krankheitsassoziiertes aggressives Verhalten einher. Epidemiologisch betrifft dies in erster Linie Störungen mit Substanzmissbrauch, in geringerem Ausmaß auch psychotische Erkrankungen. Die Auseinandersetzung mit der Problematik von Gewalt und Zwang ist das älteste Problem psychiatrischer Institutionen. Auch heute stellen aggressive Übergriffe von Patienten ein typisches Risiko für die Beschäftigten dar. Assoziationen mit bestimmten Patientenmerkmalen wie Diagnose, Geschlecht oder Alter sind nicht konsistent belegt. Psychiatrische Interventionen umfassen präventive Aspekte wie eine auf Kooperation und Partizipation ausgerichtete Gestaltung der institutionellen Prozesse und systematische Schulungen des Personals, notfallmäßige und präventive Pharmakotherapie und notfalls auch Zwangsmaßnahmen wie Fixierung oder Isolierung. Der „state of the art“ in diesen Bereichen wird dargestellt. Ethischen Abwägungen und Fragen der Verhältnismäßigkeit kommt dabei eine große Bedeutung zu.SummarySome mental disorders are associated with an increased illness-related risk of aggressive behaviour. Epidemiologically, substance abuse disorders are most frequently implicated, followed by psychotic disorders. Dealing with the problems of violence and coercion is the oldest problem of psychiatric institutions. Aggressive patient behaviour still represents a typical risk for staff in psychiatric institutions. Associations with patient characteristics such as diagnosis, gender, and age have not been consistently confirmed. Preventive aspects comprise interventions such as adapting institutional processes to patients’ needs, patients participating in decisions, and systematic training for staff. Emergency medication and preventive pharmacotherapy are also important. As last resort coercive measures such as involuntary medication, seclusion, or mechanical restraint can be applied. The state of the art in these areas is presented. Ethical considerations and questions of adequateness have a significant effect.

Staff members' attitudes towards coercive measures

Methods Interviews with staff members were conducted focusing on a coercive measure they had carried out shortly before. The half-structured interview questioned how severely the patients human rights were restricted during the coercive measure. We measured the restriction of human rights by a scale developed for this purpose, Human DIgnity during COercive Procedures, DICOP. It consists of the aspects human dignity, ability to move, autonomy, coercion applied at the beginning of the measure, and restriction of contact. In addition staff members estimated the restriction of human rights by seclusion and mechanical restraint in general. Interviews of 39 staff members referring to 94 coercive measures were obtained.

Restriction of human rights during seclusion and mechanical restraint. Results of a randomized controlled study

Background Seclusion and restraint are widely used for people with serious mental disorders. In most countries one intervention is preferred while the other is considered as inhuman or not sufficiently safe, but identical arguments refer to different preferences. There is a lack of evidence from welldesigned studies on compulsory measures in psychiatry. In a Cochrane Review on seclusion and restraint no article met the inclusion criteria of a RCT.