Prevalence and risk factors for the use of restraint in psychiatry:
a systematic review
Fattori di prevalenza e rischio per l’uso della contenzione in psichiatria:
una rassegna sistematica

1Department of Neurosciences, University of Milano-Bicocca, Monza, Italy
2Department of Mental Health, G. Salvini Hospital, Rho, Italy
3Department of Psychiatric Rehabilitation, Zucchi Clinical Institute, Carate Brianza, Italy
4Department of Human Sciences, University of Milano-Bicocca, Milano, Italy

SUMMARY. Aim. Despite the poor evidence supporting the use of coercive procedures in psychiatry wards and their “psychological damage” on patients, the practice of restraint is still frequent (6-17%) and varies 10-20 times among centers. Methods. We searched the PubMed, Embase and PsychInfo databases for papers published between January 1 1990 and March 31 2010 using the key words “restraint”, “constraint”, “in-patient” and “psychiatry wards” and the inclusion criteria of adult samples (studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescence or the elderly, men/women only, personality disorders and mental retardation were excluded), the English, French, Italian or German languages, and an acute setting. Results. The prevalence of the use of restraint was 3.8-20% (not different from previous data), despite the attempts to reduce the use of restraint. The variables most frequently associated with the use of coercive measures in the 49 studies included in this review were male gender, young adult age classes, foreign ethnicity, schizophrenia, involuntary admission, aggression or trying to abscond, and the presence of male staff. Conclusions. Coercive measures are still widely used in many countries (albeit to a greater or lesser extent) despite attempts to introduce alternatives (introduction of special protocols and nurses’ training courses) in some centers that should really be tested in large-scale multicentre studies in order to verify their efficacy.

KEY WORDS: coercive measures, epidemiology, predictors.

RIASSUNTO. Scopo. Nonostante non vi sia attualmente una chiara evidenza scientifica sull’utilizzo dei metodi coercitivi nei reparti di psichiatria e sul loro “danno psicologico” sui pazienti, l’utilizzo della contenzione è ancora frequente (6-17%) e presenta una variazione di 10-20 volte tra i vari centri. Metodi. Abbiamo effettuato una ricerca bibliografica nei database PubMed, Embase e PsychInfo per manoscritti pubblicati dal 1 gennaio 1990 al 31 marzo 2010 utilizzando le parole chiave “restraint”, “constraint”, “in-patient” e “psychiatry wards” e i criteri di inclusione “campione di popolazione adulta” (studi su popolazioni selezionate come una diagnosi psichiatrica specifica che non sia psicosi/disturbo psicotico, anziano o adolescente, solo maschi/solo femmine, disturbi di personalità o ritardo mentale sono stati esclusi), manoscritti in lingua italiana, inglese, francese o tedesca, e setting acuto. Risultati. La prevalenza dell’utilizzo della contenzione è del 3,8-20% (che non differisce dai dati precedenti), nonostante i tentativi di riduzione dell’utilizzo della contenzione. Le variabili risultate più frequentemente associate nei 49 studi inclusi nella rassegna sono sesso maschile, classi di età medio-giovani, un’etnia straniera, schizofrenia, un ricovero non volontario, aggressività o tentativi di fuga e la presenza di staff maschile. Conclusioni. Le misure coercitive anche se in percentuali in alcuni casi simili, in altri differenti sono ancora molto utilizzate in numerosi paesi nonostante alcuni tentativi di trattamento alternativo all’uso di questa tecnica (attraverso l’introduzione di protocolli speciali e corsi di training dell’équipe infermieristica). Questi metodi dovrebbero essere sperimentati su larga scala e in studi multicentrici per valutarne l’efficacia.

PAROLE CHIAVE: metodi coercitivi, epidemiologia, predittori.

The question of physical restraint has a long and contentious history among physicians working in psychiatric hospitals. At its first meeting in 1844, the new Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association) made this declaration: «It is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane». On the other hand, 19th century British psychiatrists were opposed to physical restraint, although attendants were allowed to “tackle” (1). Some of the procedures used in the past have been abolished (punishments, blood-letting, lobotomies, and insulin therapy) but the act of physical restraint has remained more or less unchanged (2).
The rates, duration and methods of seclusion and restraint vary enormously. A review by Mion et al. (3) found that the incidence of the use of physical restraint in hospitals varied from 6% to 17%, and was even higher in subjects aged more than 65 years (18-20%). The Joanna Briggs Institute Best Practice (4) similarly found that restraint was used in 3.4-21% of hospitalized patients. Stewart et al. (5) have shown that 45 empirical studies carried out by psychiatric services led to an average of up to five episodes of restraint a month in wards with an average of 20 beds; the episodes lasted about 10 minutes and the restrained patients tended to be younger, male and hospitalized against their will.
The experimentation of new drugs can lead to nothing less than “pharmacological restraint”, an alternative to physical restraint based on typical and atypical antipsychotics and benzodiazepines, even though the scientific evidence concerning their efficacy is rather limited (6).
Fisher (7) sustains it is impossible to have a psychiatric treatment that does not take into account the possibility of restraining patients, but other authors, above all in Italy (8) have begun to experiment with treatments that do not foresee the use of these techniques, and obtained some encouraging results. In support of them, three recent systematic reviews of the literature (9-11) and a general consensus (12) do not show any scientific evidence concerning the higher (or lower) efficacy of restraint in comparison with other methods of treating aggressiveness because currently available comparative studies are characterized by numerous methodological defects (non-randomized trials, small patient samples); there is therefore a need to conduct randomized trials comparing restraint with alternative treatments that are less traumatic for patients. It has in fact been shown that restraint and seclusion have deleterious physical and psychological effects on both patients and staff (7,13). In particular, the experience of restraint in women who have suffered previous sexual abuse exacerbates traumatic emotional reactions such as fear, anxiety and anger (14).
A review by Huckshorn (15) underlines the fact that the use of seclusion and restraint is also dangerous in disabled subjects as it increases the risk of death and serious accidents, in addition to causing “psychological damage”. Seclusion and restraint are rarely triggered by the demographic and clinical condition of the patients, as is confirmed by two important reviews of the literature (7,16). The patients who have suffered physical restraint tend to be in their thirties, have a diagnosis of schizophrenia, a bipolar disorder or other psychotic disorders, and have often been hospitalized against their will. The most frequent reasons for the use of coercive measures are episodes of aggressiveness or the fear of episode of aggressiveness (17).
The opinions of staff and patients concerning the causes leading to restraint are generally very different (18): in this study, the majority of staff (53/81) cited reasons of safety, whereas this reason was given by only 33 of the 81 patients, and 23 cited a “lack of compliance”. Similar results were found by Outlaw and Lowery (19) and by Duxbury and Whittington (20). Aggressiveness against staff is much more frequently punished with restraint and seclusion than aggressiveness against other patients (35% vs 25%) (21).
This review began with a search of the PubMed, Embase and PsychInfo databases for English, Italian, French or German language papers published between January 1 1990 and December 31 2010 using the key words “restraint” or “constraint” and “in-patient” or “psychiatry wards”.
The inclusion criteria were adult samples representative of the entire population of psychiatric in-patients and papers written in English, French, Italian or German.
The exclusion criteria were selected patient samples (a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation or intellectual disability), studies of alternatives to restraint/seclusion, studies of staff/patient views and studies carried out in non-acute settings.
Studies of psychotic diagnoses were included because psychosis accounts for a large proportion of the restrained population.
We initially considered 842 studies: 338 were excluded because they did not fit the objectives of the review; 240 because they involved special populations (the elderly, children/adolescents, men/women only, or patients with personality disorders or mental retardation); 61 because they had not been carried out in acute psychiatry wards; 58 because they concerned the use of alternatives to seclusion or restraint; 31 because they represented staff/patient opinions; 26 because they were in languages other than English, Italian, German or French; 9 because they were not found; and 6 because they concerned the physical complications of restraint.
The final analysis was therefore based on 74 studies: the 49 included in the table, and a further 25 used as references for the introduction and discussion.
As underlined by Betemps (22), Needham (23), Husum (24) and Korkeila (25) in multicenter studies, the number of coercive measures (seclusions) varies widely from center to center (with the difference sometimes as much as 10 times) and they very often depend not on the type of patient but on specific methodological approaches to the subject.
If compared as a whole, similar prevalence rates have been found in the United States [8% by Hendryx (26), and 13.6% of men and 9.2% of women by Minnick (27)], Australia [9.4% by Irwing (28), 12.5% by Whitehead (29), and 12% of reclusions by Roberts (30)], Germany [7% by Hübner-Liebermann (31)], and 10.4% by Martin (32)], and Switzerland [6.6% by Martin (32)], whereas lower rates were found by Korkeila (25) in Finland (3.8%) and by Tavcar (33) in Slovenia (5%). Higher rates have been found by Knutzen (34) in Norway (14.1%), Kostecka and Zardecka (35) in Poland (15.7%), and Porat (36) in Israel (14,2%), and higher rates in Japan [20% by Hübner-Liebermann (31) and 18% by Odawara (37)].
The demographic, clinical and social variables associated with the use of restraint are summarised in Tables 1 (38-72) and 2.

None of the studied demographic variables seems to be a very robust predictor of restraint. However, in the light of the findings, restrained patients tend to be more frequently male (a statistically significant variable in 4 of the 8 multivariate, and 6 of the 16 univariate analyses), young adults (statistically significant in 3 of the 7 multivariate, and 6 of the 18 univariate analyses), and non-autochthonous (statistically significant in 1 of the 4 multivariate, and 3 of the 5 univariate analyses).
In terms of diagnosis, patients with schizophrenia are more likely to be restrained than those with anxiety, personality or mood disorders, or disorder due to alcohol or substance abuse (statistically significant in 4 of the 5 multivariate, and 9 of the 17 univariate analyses).
In the majority of cases, the reason for restraint was aggressiveness against others (statistically significant in all of the 5 multivariate, and 8 of the 12 univariate analyses) or an attempt to abscond (statistically significant in 2 of the 3 multivariate, and both of the univariate analyses). Episodes of restraint are more frequent among patients hospitalized against their will (statistically significant in 2 of the 3 multivariate, and 3 of the 4 univariate analyses).
Male nurses have a greater propensity to use restraint that female nurses (statistically significant in 2 out of 3 multivariate analyses).
On the basis of the findings described in this review, restraint is still widely used in psychiatry wards (3.8-20%) even though its efficacy has not been demonstrated, and our data are in line with those of other reviews by Mion (3) (6-17%) and the Johanna Brings Institute (4) (3.4-21%). This means that the attempts to reduce the use of restraint by means of the introduction of special protocols, nurses’ training courses, etc., are limited to local level and have not been extended nationally: for example, there are still no nationally recognised protocols concerning the use of coercive measures in Italy (73).
Particularly in the United States, numerous attempts have been made over the last ten years to implement projects aimed at reducing the number of episodes of physical restraint in a bid to find new ways of dealing with violence (especially violence in psychiatry wards), all of which require a multi-professional approach.
On the basis of scientific evidence, some authors (74,75) say that suitable training for nursing staff, an assessment of the risk of aggressiveness, and adequate alternative resources are essential factors for reducing the number of seclusions and episodes of physical restraint. The results of these studies seem to be very encouraging in terms of the actual medium/long-term reduction and in terms of the fact that the introduction of “softer” strategies did not increase the number of episodes of aggressiveness and violence. Comparison of studies carried out in different countries indicates that coercive measures are used in 100% of the wards in Germany, 60% of those in Switzerland, and in none of the wards in Great Britain, where physical restraint is applied only along with pharmachological restraint and for a very short period of time (mean 12 minutes) (76).
Calculations of the incidence of the use of physical restraint measures vary widely from study to study. The high prevalence in Japan may be explained by its relatively recent use of outpatient clinics (about 10 years) or the recent introduction of atypical neuroleptics but, in any case, merits further study as the published figures are based on relatively small patient populations (31,37).
In terms of age, our findings differ from those of Mion (3), who found a greater prevalence of the use of restraints among elderly subjects. However, it must be remembered that we only considered psychiatry wards and it is obvious that, in the case of general medicine and geriatrics, restraints are used not only following episodes of aggressiveness against others, but also in order to prevent falls or to deal with consciousness impairment, which are very frequent in the elderly.
Concerning the other risk factors, it is interesting to note that restraining measures are used more frequently in the case of immigrants, as was also found in the interesting study by Price et al. (57) in which the incidence of seclusion proved be statistically higher among Asians and blacks than among whites, even though there was no race-related difference in the episodes of aggressiveness against others. This suggests that the actions of someone who is little known are more frightening and, therefore, the consequent reaction “must” be more drastic. Difficult communications is another factor that can induce staff to be more interventional.
Another interesting finding of this review is that a male staff is more likely to use restraint that a female staff. As we found in a previous study (77), aggressiveness tends to be directed against people of the same gender and, given that more male patients are restrained, this is more likely to be done by male staff.
Aggressiveness against others is robustly associated with the use of restraint, but this partially conflicts with the demographic variable described by us in a previous review (77), which did not find any clear prevalence of male gender, although there was a correlation with a young age. In both cases, the presence of schizophrenia was found to increase the risk of aggressiveness and restraint, but this seems to be more robust in relation to restraint, which may mean that an episode of aggressiveness involving a patient with a psychotic disorder is more alarming for the healthcare team. However, this clearly conflicts with Binswanger’s phenomenological theory (78) that “psychosis is essentially a different way of being in the world” without the degree of lucidity that may be encountered in patients with personality or mood disorders.
Both reviews also found that involuntary hospitalization is associated with a higher risk of episodes of aggressiveness or coercive measures. By definition, patients admitted against their will do not accept the admission, and consequently tend to be more hostile towards their “jailers”; furthermore, involuntary admission seems to make staff more predisposed to adopt a more negative view of the patient than in the case of those who agree to be admitted.
In conclusion, the results of our review show that coercive measures are still widely used in many countries (albeit to a greater or lesser extent) despite attempts to introduce alternatives in some centres that should really be tested in large-scale multicentre studies in order to verify their efficacy. To prevent the risks associated with the use of restraint in psychiatry, it is necessary to intervene on the staff by means of training courses designed to encourage the use of different ways of managing aggressive patients. Finally, our findings suggest the importance of studying the use of restraint in greater detail by extending the investigation to other wards (geriatric, general medicine, etc.), involving larger numbers of patients, and bearing in mind the demographic and clinical variables that seem to be most significant.
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