Tilman Steinert

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

ObjectiveThe aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions.MethodsCombined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas.ResultsThere are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries.ConclusionsDatabases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

The use of mechanical restraint and seclusion in patients with schizophrenia: A comparison of the practice in Germany and Switzerland

BackgroundThe use of coercive measures is an indicator of the quality of psychiatric inpatient treatment. To date, there is no data available to European comparisons on the incidence of such measures.MethodsThe frequency and duration of mechanical restraint and seclusion on patients with a diagnosis of F2 ICD-10 was analysed in seven German and seven Swiss psychiatric hospitals in the year 2004 using three indicators. Differences between German and Swiss hospitals regarding the indicators were tested for statistical significance using Mann-Whitney-U-tests.Results6.6 % (Switzerland) and 10.4 % (Germany) of admissions respectively were affected by mechanical restraint and 17.8 % (Switzerland) and 7.8 % (Germany) respectively by seclusion. Seclusion as well as mechanical restraint per case were applied significantly more often in German than in Swiss hospitals and were of significantly longer duration in Swiss than in German hospitals.ConclusionThe results showed different patterns in the use of seclusion and mechanical restraint across Swiss and German hospitals. For future European research on the use of compulsory measures in routine psychiatric care, there is a need for uniformed definitions, reliable documentation of coercive measures as well as for an identical way of data analysis. To meet these conditions is the first step to achieve European standards for the use of coercive measures.

Legal provisions and practice in the management of violent patients. a case vignette study in 16 European countries.

AIM To compare the clinical management of typical scenarios by using three case vignettes in a substantial number of European countries. METHOD Three case vignettes and an associated questionnaire, filled in and finalised by at least two experts from each country. RESULTS Legislation and clinical practice varies widely across the 16 included countries. No specific pattern emerged. Certain practices (intravenous medication, mechanical restraint, net beds and forensic transfers, respectively) only exist in few countries. Legislation for involuntary medication is most restrictive in the Netherlands. CONCLUSIONS There is little harmonisation and a lack of consistent standards within and across European countries regarding treatment and management of violent patients.

Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates.

Seclusion and restraint represent adverse experiences that cause negative attitudes against psychiatric treatment and psychopathologic sequels such as posttraumatic stress disorder. We examined 117 consecutive admissions with schizophrenia, with an average of 8.7 previous admissions. Positive and Negative Syndrome Scale and Global Assessment of Functioning were obtained at admission and discharge, and traumatic events in the biography were recorded using the Posttraumatic Diagnostic Scale. Twenty-four men (42.9%) and 18 women (29.0%) had experienced seclusion or restraint in their psychiatric history. Seclusion or restraint during the present admission was best predicted in a logistic regression model by physical aggressive behavior [odds ratio (OR), 11.5] and the Positive and Negative Syndrome Scale hostility item at admission (OR, 23.6). Seclusion or restraint ever in the psychiatric history, however, was mostly associated with lifetime exposure to life-threatening traumatic events (OR, 7.2). We conclude that exposure to traumatic events in the biography severely enhances the risk of revictimization and retraumatization during inpatient treatment.

Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

Längle G, Steinert T, Weiser P, Schepp W, Jaeger S, Pfiffner C, Frasch K, Eschweiler GW, Messer T, Croissant D, Becker T, Kilian R. Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany

Abstract.Background:Several first-episode studies of schizophrenia suggest that many patients experience psychotic symptoms for a long time before receiving appropriate treatment. To reduce the time of untreated psychosis, it is necessary to know the patients’ pathways to psychiatric care. This study was designed to examine patients’ help-seeking contacts and the delays on their pathways to psychiatric care in Germany.Method:Sixty-six patients with first episode of schizophrenia spectrum psychosis were assessed by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) and were interviewed about their helpseeking contacts before psychiatric admission.Results:In contrast to other findings of long duration of untreated psychosis (DUP), 53% of our patients were admitted after 8 weeks (median) of untreated positive symptoms, although the mean value of 71 weeks corresponds well with the results of other studies. There were important differences in DUP depending on which kind of statistical parameter (median or mean) was used. In contrast to studies from other countries, only 18% of our patients had their first contact with a general practitioner. However, this was the fastest way to psychiatric admission. No differences were found between patients with short (< 1 year) and long (> 1 year) DUP in the duration of time from the first help-seeking contact up to admission.Conclusion:In Germany, a large number of mental health professionals in private practice or different services of psychosocial contact facilities exist in every region and general practitioners are not so important as a link to psychiatric care, although they seem to be functioning well if it is necessary. Therefore, programs designed to reduce the delay of treatment should focus less on general practitioners than on other health services.

Methodological issues in monitoring the use of coercive measures

PURPOSE In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework. METHODS Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used. RESULTS Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institutes catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective. CONCLUSION Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

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.

Compulsory admission and treatment in schizophrenia: a study of ethical attitudes in four European countries.

This study was conducted to compare attitudes of psychiatrists, other professionals, and laypeople towards compulsory admission and treatment of patients with schizophrenia in different European countries. Three case reports of patients with schizophrenia were presented to N=1,737 persons: 235 in England, 622 in Germany, 319 in Hungary, and 561 in Switzerland; 298 were psychiatrists, 687 other psychiatric or medical professionals, and 752 laypeople. The case reports presented typical clinical situations with refusal of consent to treatment (first episode and social withdrawal, recurrent episode and moderate danger to others and patient with multiple episodes and severe self-neglect). The participants were asked whether they would agree with compulsory admission and compulsory neuroleptic treatment. The rates of agreement varied between 50.8 and 92.1% across countries and between 41.1 and 93.6% across the different professional groups. In all countries, psychologists and social workers supported compulsory procedures significantly less than the psychiatrists who were in tune with laypeople and nurses. Country differences were highly significant showing more agreement with compulsion in Hungary and England and less in Germany and Switzerland (odds ratios up to 4.33). Own history of mental illness and having mentally ill relatives had no major impact on the decisions. Evidence suggests that compulsory procedures are based on traditions and personal attitudes to a considerable degree. Further research should provide empirical data and more definite criteria for indications of compulsive measures to achieve a common ethical framework for those critical decisions across Europe.

No correlation of serum cholesterol levels with measures of violence in patients with schizophrenia and non-psychotic disorders.

Epidemiological studies, animal studies, and clinical studies yielded conflicting results concerning a supposed association between increased risk for suicide and violence, and low serum cholesterol levels. Until now, no data has been available for patients with schizophrenia, a disorder with a well-known increased risk of violence. Correlations of serum cholesterol levels at admission and measures of violence were investigated in 103 consecutively admitted patients (44 males, 59 females) of a general psychiatric admission unit. Seventy subjects were diagnosed as suffering from schizophrenia or schizoaffective disorder (ICD-10 F 20, F25), and 33 were diagnosed as suffering from non-psychotic disorders (mainly personality disorders). The level of total exhibited violence during the inpatient treatment period was measured in each patient by the Modified Overt Aggression Scale (MOAS), the Social Dysfunction and Aggression Scale (SDAS), the Staff Observation Aggression Scale (SOAS), and the Violence Scale (VS). Correlations of all violence measures were high (0.75-0.90), but no correlation was found with cholesterol levels, neither for psychotic nor for non-psychotic subjects, neither for men nor for women. The hypothesis of associations of violence and cholesterol levels is not supported by the data.