The 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.
Combined 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 Unpublished study was detected by contacting authors of conference presentations.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.
There 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.
Databases 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.
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Jones K (1984) Robert Gardiner Hill and the non-restraint movement. Can J Psychiatry 29:121–124
Colaizzi J (2005) Seclusion and restraint: a historical perspective. J Psychosoc Nurs mental Health Serv 43:31–37
Sailas E, Fenton M (2000) Seclusion and restraint for people with serious mental illnesses. The cochrane database systematic reviews p.CD 001163
Hem E, Steen O, Opjordsmoen S (2001) Thrombosis associated with physical restraints. Acta Psychiatr Scand 103:73–75
Fisher WA (1984) Restraint and seclusion: a review of the literature. Am J Psychiatry 151:1585–1591
Needham I, Abderhalden C (2002) Coercive procedures and facilities in Swiss psychiatry. Swiss Med Wkly 132:253–258
Salib E, Ahmed AG, Cope M (1998) Practice of seclusion: a five-year retrospective review in North Cheshire. Med Sci Law 38:321–327
Savage L, Salib E (1999) Seclusion in psychiatry. Nurs Stand 13:34–37
Bloch S, Green SA (2006) An ethical framework for psychiatry. Br J Psychiatry 188:7–12
European Commission (2005) Improving the mental health of the population. Towards a strategy on mental health for the European Union. Green Paper http://ec.europa.eu/health/ph_determinants/life_style/mental/green_paper/mental_gp_en.pdf
Steering Committee on Bioethics of the Council of Europe (2005) White paper on the protection of the human rights and dignity of people suffering from mental disorders, especially those placed as involuntary patients in a psychiatric establishment. Council of Europe. http://www.ijic.org/docs/psychiatry.pdf. Accessed 28 Aug 2009
Committee for the Prevention of Torture and Inhumane or degrading Treatment or Punishment. http://www.cpt.coe.int/en/. Accessed 28 Aug 2009
Donat DC (2003) An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Serv 54:1119–1123
Martin V, Kuster W, Baur M, Bohnet U, Hermelink G, Knopp M, Kronstorfer R, Martinez-Funk B, Roser M, Voigtländer W, Brandecker R, Steinert T (2007) Die Inzidenz von Zwangsmaßnahmen als Qualitätsindikator in psychiatrischen Kliniken. Probleme der Datenerfassung und–verarbeitung und erste Ergebnisse. Psychiat Prax 34:26–32
International Quality Indicator Project IQIP. http://www.internationalqip.com/
Steinert T, Martin V, Baur M, Bohnet U, Goebel R, Hermelink G, Kronstorfer R, Kuster W, Martinez-Funk B, Roser M, Schwink A, Voigtländer W (2007) Diagnosis-related frequencies of compulsory measures in 10 German psychiatric hospitals and correlates with hospital characteristics. Soc Psychiatry Psychiatr Epidemiol 42:140–145
Keski-Valkama A, Sailas E, Eronen M, Koivisto AM, Lönnqvist J, Kaltiala-Heino R (2007) A 15-year national follow-up: legislation is not enough to reduce the use of seclusion and restraint. Soc Psychiatry Psychiatr Epidemiol 42:747–752
Ketelsen R, Zechert C, Klimitz H, Rauwald C (2001) Entwicklung eines Kooperationsmodells zwischen 3 psychiatrischen Kliniken mit dem Ziel der Qualitätssicherung bei Zwangsmaßnahmen am Beispiel der Fixierungsdokumentation. Psychiat Prax 28:69–74
Martin V, Bernhardsgrütter R, Goebel R, Steinert T (2007) The use of mechanical restraint and seclusion in patients with schizophrenia: a comparison of the practice in Germany and Switzerland. Clin Pract Epid Ment Health 3:1
Bowers L (2000) The expression and comparison of ward incident rates. Issues Ment Health Nurs 21:365–374
Steinert T, Sippach T, Gebhardt RP (2000) How common is violence in schizophrenia despite neuroleptic treatment? Pharmacopsychiat 33:98–102
Smith GM, Davis RH, Bixler EO, Lin HM, Altenor A, Altenor RJ, Hardentstine BD, Kopchick GA (2005) Pennsylvania state hospital system’s seclusion and restraint reduction program. Psychiatr Serv 56:1115–1122
Berghmans R, Elfahmi D, Goldsteen M, Widdershoven G (2001) Quality of coercion in general psychiatry (Kwaliteit van dwang en drang in de psychiatrie). Instituut voor gezondheidsethiek Universiteit van Maastricht (Dutch), Maastricht
CBO Verpleegkundig Wetenschappelijk Raad (2001) Directives for freedom restrictions (Richtlijnen voor vrijheidsbeperkende interventies). Kwaliteitsinstituut voor gezondheidszorg CB (Dutch), Utrecht
Abma T, Widdershoven G, Lendemeijer B (2005) Restraint in psychiatric hospitals. The quality of interventions restricting patient’s freedom (Dwang en drang in de psychiatrie; kwaliteit van vrijheidsbeperkende interventies). Lemma (Dutch), Utrecht
National Institute for Clinical Excellence (NICE) (2005) Clinical practice guidelines for the violence: the short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. http://www.nice.org.uk/niceMedia/pdf/2005_003_NICE_launches_clinical_guideline_disturbed_violent_behaviour.pdf. Accessed 28 Aug 2009
National Institute for Mental Health in England (2004) Mental health policy implementation guide: developing positive practice to support the safe and therapeutic management of aggression and violence in mental health in-patient settings. http://www.positive-options.com/news/downloads/NIMHE_-_Developing_Positive_Practice_-_2004.pdf. Accessed 28 Aug 2009
Royal College of Psychiatrists (UK) (2009) http://www.rcpsych.ac.uk/clinicalservicestandards/centreforqualityimprovement/nationalauditofviolence.aspx. Accessed 28 Aug 2009
El-Badri S, Mellsop G (2008) Patient and staff perspectives on the use of seclusion. Australas Psychiatry 16:248–252
Kumar S, Ng B, Simpson A, Fischer J, Robinson E (2008) No evidence for restrictive care practices in Maori admitted to a New Zealand psychiatric inpatient unit: do specialist cultural teams have a role? Soc Psych Psychiatr Epid 43:387–391
Curie CG (2005) SAMHSA’s commitment to eliminating the use of seclusion and restraint. Psychiatr Serv 56:1139–1140
Huckshorn KA (2006) Re-designing state mental health policy to prevent the use of seclusion and restraint. Adm Policy Ment Health 33:482–491
National Association of State Mental Health Program Directors Research Institute, Inc (2009). http://www.nri-inc.org/. Accessed 28 Aug 2009
Joint Commission (USA) (2009) http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Hospital+Based+Inpatient+Psychiatric+Services.htm. Accessed 28 Aug 2009
Steinert T, Eisele F, Goeser U, Tschoeke S, Uhlmann C, Schmid P (2008) Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders. Clin Pract Epid Ment Health 4:27
Snorrason J (2007) Observations in acute psychiatric units in Landspitali University Hospital in Reykjavik. In Violence in clinical psychiatry. In: Callaghan P, Nijman H, Palmstierna T, Oud N (eds) Proceedings of the 5th European congress on violence in clinical psychiatry, Kavanah, Amsterdam, p 277
Steinert T, Lepping P (2009) Legal provisions and practice in the management of violent patients. A case vignette study in 16 European countries. Eur Psychiatry 24:135–141
Nijman HLI, Palmstierna T, Almvik R, Stolker JJ (2005) Fifteen years of research with the staff observation aggression scale—A review. Acta Psychiatr Scand 111:12–21
Janssen WA, Noorthoorn EO, de Vries WJ, Hutschmaekers GHM, Widdershoven GAM, Lendemeijer HHGM (2008) The use of seclusion in the Netherlands compared to countries in and outside Europe. Int J Law Psychiatry 31:463–470
Ryan C, Bowers L (2005) Coercive manoeuvres in a psychiatric intensive care unit. J Psychiatr Ment Health Nurs 12:695–702
Waaler AE, Morken G, Linaker OM (2005) Effects of different interior decorations in the seclusion area of a psychiatric acute ward. Nord J Psychiatry 59:19–24
Betemps EJ, Somoza E (1993) Hospital characteristics, diagnoses and staff reasons associated with use of seclusion and restraint. Hosp Comm Psychiatry 44:367–371
Crenshaw WB, Cain KA, Francis PS (1997) An updated national survey on seclusion and restraint. Psychiatr Serv 48:395–397
Hatta K, Nogi W, Igarashi Y, Kon H, Sawa Y, Seki K, Masuko S, Wakejima T, Asai K (2003) The review of seclusion and restraint in psychiatric practice. Seishin Shinkeigaku Zasshi 105:252–273 (Japanese)
El-Badri SM, Mellsop G (2002) A study of the use of seclusion in an acute psychiatric service. Aust NZ J Psychiatry 36:399–403
Pedersen, PB, Hatling T, Røhme K (2007) Bruk av tvangsmidler i psykisk helsevern i 2001, 2003 og 2005. Hva kan forklare institusjons—og avdelingsforskjeller? SINTEF Helse rapport A686 (Norwegian)
We thank Dr. Vimal Sharma, Ken Edwards, Gillian Carlyle, and Lisa Powell for their help in obtaining the restraint data for Cheshire and North Wales and Dr. Kotaro Hatta for translating and communicating central aspects of his report in Japanese.
Conflicts of interest statement
All authors declare that they have no conflicts of interest.
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Steinert, T., Lepping, P., Bernhardsgrütter, R. et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Soc Psychiat Epidemiol 45, 889–897 (2010). https://doi.org/10.1007/s00127-009-0132-3
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