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Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature

  • Cadeyrn J. Gaskin (a1), Stephen J. Elsom (a1) and Brenda Happell (a1)

Abstract

Background

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

Aims

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

Method

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

Results

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

Conclusions

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.

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Copyright

Corresponding author

Dr C. J. Gaskin, Centre for Psychiatric Nursing, University of Melbourne, Level 1, 723 Swanston Street, Carlton, Victoria 3053, Australia. Email: cjgaskin@unimelb.edu.au

Footnotes

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Declaration of interest

None.

Footnotes

References

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Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature

  • Cadeyrn J. Gaskin (a1), Stephen J. Elsom (a1) and Brenda Happell (a1)
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eLetters

But seclusion necessary for needy ones?

Om Prakash, Assistant Professor of Psychiatry
27 February 2008

I read the review by Gaskin et al (2007) (1) of interventions to reduce use of seclusion with a great interest.

I agree with comments by Scott and Deans (2) for the developmental needs between different patient populations. I feel this area still need more research in order to develop the need-based programs for the patients.

One of the neglected area which needs more exploration is that the number of patients brought to hospitals under seclusion which at times applied by relatives or unprofessional staff. Due to this practice, the patients suffer from injuries or insufficient blood supply to that body area. There is a need to start public health campaign related to proper seclusion among health professionals.

Lastly, I would say that seclusion should applied to patients judiciously rather stopping them in the name of human rights.

References:1. Gaskin, C. J., Elsom, S. J. & Happell, B. (2007) Interventions for reducing the use of seclusion in psychiatric facilities. British Journal of Psychiatry, 191, 298-303.2. Scott, J. G. & Dean, A. J. (2007) Developmental needs of patients must be considered when developing policies on seclusion (letter). BritishJournal of Psychiatry, 191.
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Conflict of interest: None Declared

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Seclusion and Physical Restraint in Developing Countries

Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry
31 January 2008

The review article on “Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature� by GaskinCJ et al1 (2007) was read with interest .Its contents are very relevant tothe practice of Psychiatry in developing countries like Sri Lanka as seclusion and physical restraint seems still to be widely used in this part of the world. This may be because of poor staff training, and/or unawareness with regard to other methods of managing such patients. Low staff to patient ratio and lack of proper mental health acts may also contribute to the above.The other important contributing factor leading to increased use of physical restraint and seclusion in our part of the world, may be the lackof resistance from the patients, relatives and other professionals with regard to the use of above methods.Most psychiatry units in our countries do not have properly designed seclusion areas and even with the existing seclusion areas there seems to be very poor patient monitoring. Improper seclusion and particularly physical2 restraining techniques can lead to deleterious adverse effects both physically and psychologically.Changes should be made to the existing mental health acts addressing the management of violent patients and there should be clear guidelines, e.g. the NICE3 guidelines for management of such patients.Until we improve the other facilities, including the human resources this trend seems to continue. Staff should be educated about the other methods that can be employed in managing violent patients and for proper implementation of the best policies, state level support and development of other resources are essential.

References1.Gaskin CJ, Elsom SJ, Happel B. Interventions for reducing the use of seclusion in psychiatric facilities. Review of the literature. British Journal of Psychiatry.2007;191:298-3032.Mohr WK, Petti TA, Mohr BD. Adverse Effects Associated With Physical Restraint. Canadian Journal of Psychiatry.2003;48:330-3373.Violence. The short- term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. Clinical guidelines 25. National Institute of Clinical Excellence. February 2005. NHS
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Conflict of interest: None Declared

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Seclusion-Reduction Interventions Need to be Individualised to Each Facility

Cadeyrn J. Gaskin, Research Fellow
06 December 2007

Reducing seclusion in psychiatric facilities often involves the co-ordination of a range of interventions to meet the needs of such organisations and their staff (Gaskin, Elsom & Happell, 2007). In their response to our review, Scott and Dean (2007) have helpfully highlighted the need to tailor suites of interventions to suit specific facilities through reminding readers of the differing determinants of emotional distress and aggression that are present for children and adults. These differences influence the reasons why children and adults are secluded.

In combining the literature on seclusion reduction initiatives at child, adolescent, and adult psychiatric facilities, we do not contend that seclusion practices across these facilities, or the reasons for seclusion, are the same. We did, however, find no meaningful differences in the employment of seclusion reduction interventions between child, adolescent, and adult facilities. Many of the interventions we found (e.g., monitoring seclusion episodes, staff education, changing the therapeutic environment) were used equally as often in child psychiatric units as they were in adult facilities.

Although the broad interventions for seclusion reduction appear similar between child and adult psychiatric facilities, the content of each type of intervention is likely to differ between facilities that serve specific populations. For example, staff education conducted at a child psychiatric unit to reduce seclusion may well be different to that provided at an adult psychiatric unit.

Our paper has provided the bare bones of a range of interventions that have been successfully used to reduce seclusion in psychiatric facilities. We welcome further comment, such as that from Scott and Dean (2007), and the publication of seclusion reduction initiatives to help to describe the ways in which these interventions can be applied in various types of facilities.

Cadeyrn J. GaskinStephen J. ElsomBrenda Happell

Declaration of Interests: None

Gaskin, C. J., Elsom, S. J. & Happell, B. (2007) Interventions for reducing the use of seclusion in psychiatric facilities. British Journal of Psychiatry, 191, 298-303.

Scott, J. G. & Dean, A. J. (2007) Developmental needs of patientsmust be considered when developing policies on seclusion (letter). BritishJournal of Psychiatry, 191.
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Conflict of interest: None Declared

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Developmental needs of patients must be considered when developing policies on seclusion

James G Scott
28 November 2007

We welcome the review by Gaskin et al (2007) of interventions to reduce use of seclusion. Although studies reviewed were conducted in adult and child settings, the authors did not differentiate the developmental needs between these patient populations.

The determinants of emotional distress and aggression may differ between children and adults. In adult psychiatric units, aggression is frequently associated with psychosis. Seclusion may reduce staff injury but increases patient distress (Steinert, Bergbauer et al. 2007).

In contrast, aggression is typically the most common reason for referral to child psychiatric units. Underlying diagnoses include disruptive behavioural disorders and developmental disorders, and are complicated by high rates of abuse and neglect (Dean, Duke et al. 2007). Admission goals may include learning prosocial behaviour, necessitating use of behavioural management. Community-based studies indicate that parent management training, using contingency reinforcement and consequences such as “closed time-out” are effective in reducing aggressive behaviours (Sanders 1999). Seclusion may function similarly to time out, in that it can take the child away from a situation reinforcing negative behaviour, and encourages the child self regulate.

We agree with Gaskin and colleagues that more evidence is needed to guide use of such interventions. We draw readers’ attention to a recent study reporting reductions in aggression in a child and adolescent inpatient unit, following introduction of behavioural management programme (Dean, Duke et al. 2007). The intervention incorporated staff training, contingency management and promoted used of least restrictive intervention. In keeping with current practice parameters (Masters, Bellonci et al. 2002), if a restrictive intervention was required, the preferred intervention was a form of seclusion. This intervention led to a significant reduction in aggressive incidents and injuries to staff or patients. Although the number of episodes of locked interventions did notdecrease, there was a significant reduction in the duration of time patients spent in seclusion, and a reduction in physical restraint. Theseoutcomes were achieved without reducing admission numbers, changing the types of admissions, increasing staff costs, or increasing utilisation of Pro Re Nata medication.

We concur with Gaskin and colleagues that seclusion may exert counter-therapeutic effects, and that effective alternatives should be identified(Gaskin, Elsom et al. 2007). However, we remain open to the possibility that predictable, time limited locked interventions may have therapeutic effects when used within a broader behavioural management programme in young patient populations. Additionally, the ultimate goal of interventions in this area should emphasise reducing the demand for seclusion, rather than just the use of seclusion per se. We need to acknowledge that some aspects of the inpatient environment can contribute to patient distress, and seek to optimise the therapeutic effects of the inpatient milieu. Protocols for use of seclusion, and for reduction in demand for seclusion need to be incorporate the developmental needs of thespecific patient group.

Dean, A. J., S. G. Duke, et al. (2007). "Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatientunit." Journal of the American Academy of Child and Adolescent Psychiatry 46(6): 711-20.

Gaskin, C., S. Elsom, et al. (2007). "Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature." TheBritish Journal of Psychiatry 191: 298-303.

Masters, K., C. Bellonci, et al. (2002). "Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint." Journal of the American Academy of Child and Adolescent Psychiatry 41: 4S-25S.

Sanders, M. (1999). "Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy forthe prevention of behavior and emotional problems in children." Clinical child and family psychology review 2(2): 71-90.

Steinert, T., G. Bergbauer, et al. (2007). "Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates." TheJournal of Nervous and Mental Disease 195(6): 492-6.

James Scott MBBS; FRANZCPChild and Adolescent PsychiatristEvolve Therapeutic ServicesRoyal Children’s HospitalBrisbane Qld, 4029Australia

Angela Dean PhD; B. Pharm.Kids in Mind ResearchMater Child & Youth Mental Health ServiceSouth Brisbane QLD 4101Australia

Declaration of Interest: Nil
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Conflict of interest: None Declared

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Use of Seclusion - is it justified

Aadil Jan Shah, Speciality Registrar
18 October 2007

The seclusion of the patients with mental health problems remains a controversial and a delicate subject. Despite this, it is widely practised, especially in the forensic settings. There was a desperate needto review the present literature in order to gain an understanding of the current knowledge base in this controversial area and to find empirically if there are any supported interventions that allow reduction in the use of seclusion in psychiatric facilities.I would like to congratulate the authors, Cadeyrn J.Gaskin,et.al., for increasing our insight into the present knowledge base and informing us about the other interventions which could be used to reduce seclusion. They have nicely discussed the other interventions under separate headings. The interventions reviewed were complex and involve changing several aspects of the organisation. It seems that we are in the incipientstage of using the other interventions and there is a need to use these interventions by different trusts in order to gain an understanding about their efficacy.It is the responsibility of the individual trusts to report the interventions that are effective or those which failed.Presently it appears that use of seclusion remains the most supported intervention than others. There is a concern that seclusion of mental health patients is unjustified and breach of their human rights but remains a best option in an emergency when a patient is unable to be nursed in an open environment without a high risk of physical injury to others. However, it is important to decide whether the continuation of seclusion is lawful and does not amount to breach of Article 3 of EuropeanConvention of Human Rights (ECHR).The Code of Practice, Department of Health-March 1999, NICE guidelines (Short Term management of Disturbed (Violent) Behaviour in Inpatient Settings & use of Local Trust Policy would be helpful to decide.

References

Cadeyrn J.Gaskin, Stephen J.Elsom, Brenda Happell (2007) Interventions for reducing the use of seclusion in psychiatric facilities.The British Journal Of Psychiatry 191 : 298 – 303.

Department of Health & Welsh Office (1999),Mental Health Act 1983,Code of Practice.

NICE (2004) Short term Management of Disturbed (Violent) Behaviour inInpatient Settings.
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Conflict of interest: None Declared

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