MADRID – The use of coercive interventions–such as physical or mechanical restraint–to control imminent and actual dangerous behavior by people with acute mental illness was discussed at a symposium at the 15th European Congress of Psychiatry.
Dr. Tilman Steinert, of the University of Ulm (Germany), presented data obtained by the European Violence in Psychiatry Research Group. Those data looked at the way in which violent patients are managed across Europe, and whether real-life practice followed legislative guidelines.
The researchers prepared three representative case vignettes and asked experts from 14 European countries (Ireland, Scotland, Wales, England, the Netherlands, Luxembourg, Germany, Switzerland, Austria, Italy, Slovenia, Turkey, Finland, and Estonia) to describe how they would treat each patient and whether legislation in each country would allow the use of different forms of restraint.
The first case was that of a voluntary inpatient who assaults a staff member. Experts from all of the countries except Switzerland would treat such a patient with an involuntary intramuscular injection, but experts from only five of the countries would use an involuntary intravenous medication. Physical restraint was used in five countries and mechanical restraint in seven. Net beds are banned by legislation in most European countries, but psychiatric staffs in Luxembourg and Austria use them.
The second case involved that of an involuntary patient who does not behave violently, but who refuses medication. In cases like this, involuntary intramuscular injection is given in seven European countries, and involuntary intravenous medication is given in just two. Any form of involuntary medication is banned in the Netherlands and in Switzerland.
The researchers concluded that there is wide diversity of legislation and practice across Europe, and, importantly, in the way in which psychiatric professionals interpret their own legislation. “We need evidence on what is the best practice before we enforce uniformity,” Dr. Steinert said.
In a separate presentation, Richard Whittington, Ph.D., of the health and community care research unit at the University of Liverpool (England), presented data on the psychological and social context surrounding the decision by staff to restrain a patient on the floor.
Dr. Whittington and his colleagues did an audit study of 20,000 incident forms, describing incidents involving 5,000 patients from 46 secure and general wards over a 5-year period. They looked to see how often control and restraint procedures were used, and found that 20% of all incidents were managed in this way. However, 50% of reported incidents involving interpersonal violence resulted in the use of control and restraint procedures.
Interestingly, restraint was used in 42% of “first incidents” but was used only 24% of the time when the patient had been involved in more than five incidents in the past. “If a staff member does not know a patient, he or she is more likely to use control and restraint,” he said.