High prevalence of coercive measures in psychiatry
MedWire News: The overall prevalence of coercive measures in psychiatry is high, although there is significant variation between centers, results from a Swiss study suggest.
"Involuntary placement and use of coercive measures are largely accepted as necessary in certain situations in clinical psychiatry: compulsory admission is justified by the law of most countries in cases of considerable danger to oneself or to others due to psychiatric illness," explain B Lay and colleagues from the Psychiatric University Hospital Zurich.
"Likewise, use of coercive psychiatric measures during hospitalization is regarded as indispensable to cope with violence and to prevent possible physical and psychological damage to the patient and/or others," they say.
However, the researchers add that little is known about the prevalence of coercive measures in psychiatry or factors that predict such measures.
The team therefore used data from six psychiatric hospitals in the Canton of Zurich to investigate the use of coercive measures among 9698 inpatients, aged 18-70 years, who were treated in 2007.
Most of the patients were middle aged (mean age 40.4 years), had basic or vocational education, were unemployed, were living at home, and suffered from substance use disorders, affective disorders, or psychotic disorders.
The researchers found that 2406 (24.8%) patients were admitted involuntarily, 625 (6.4%) had been subjected to some form of restraint or seclusion while in hospital, and 412 (4.2%) had been given medication involuntarily after admittance. In total, 709 (7.3%) were exposed to at least one compulsory measure during hospitalization.
However, there was significant variation in the use of coercive measures between centers, ranging from 10.6-34.1% for involuntary admission, 4.5- 10.2% for restraint/seclusion, and 2.8-5.5% for involuntary medication.
Factors associated with compulsory admission included a diagnosis of psychotic disorder (odds ratio [OR]=2.6) and organic mental disorder or mental retardation (OR=2.7). Other factors associated with an increased risk for compulsory admission included having a substance abuse or personality disorder, being of foreign nationality, and not living at home.
Predictors of restraint/seclusion during hospitalization included a diagnosis of organic mental disorder or mental retardation (OR=2.9), psychotic disorder (OR=2.5), and personality disorder (OR=2.0), and the risk increased with disorder severity. Other predictors included male gender, younger age, and not living at home.
Factors associated with an increased risk for involuntary medication included a diagnosis of organic mental disorder or mental retardation (OR=2.7), and psychotic disorder (OR=2.3). In contrast, patients with a diagnosis of substance use disorder or neurotic disorder were less likely to receive involuntary medication than other patients, at ORs of 0.4 and 0.5, respectively. Other risk factors included male gender, younger age, unemployment, and not living at home.
Lay and team conclude in the journal European Psychiatry: "High prevalence of coercive measures in psychiatric care constitutes a major public health issue. Our results demonstrate that there is a group of patients with serious chronic mental illness (most often suffering from psychotic or organic mental disorder) who are at an increased risk of being exposed not only to compulsory admission but also to other forms of coercion in psychiatric care."
They add: "In order to better understand and to eventually reduce excessive use of compulsion in psychiatry, further research should examine more closely different configurations of mental health services with regard to variation in use of coercive measures and the relation to service components such as special programs for crisis intervention or cooperation procedures between inpatient and outpatient services."
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By Mark Cowen