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Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends
Objective
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.
Methods
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 Unpublished study was detected by contacting authors of conference presentations.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.
Results
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.
Conclusions
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.
Journal Article
Lunatic asylums in colonial Bombay : shackled bodies, unchained minds
This book traces the historical roots of the problems in India's mental health care system. It accounts for indigenous experiences of the lunatic asylum in the Bombay Presidency (1793-1921). The book argues that the colonial lunatic asylum failed to assimilate into Indian society and therefore remained a failed colonial-medical enterprise. It begins by assessing the implications of lunatic asylums on indigenous knowledge and healing traditions. It then examines the lunatic asylum as a 'middle-ground', and the European superintendents' 'common-sense' treatment of Indian insanity. Furthermore, it analyses the soundscapes of Bombay's asylums, and the extent to which public perceptions influenced their use. Lunatic asylums left a legacy of historical trauma for the indigenous community because of their coercive and custodial character. This book aims to disrupt that legacy of trauma and to enable new narratives in mental health treatment in India.
Book
Freedom and the Cage
Spurred by ideals of individual liberty that took hold in the Western world in the late nineteenth century, psychiatrists and public officials sought to reinvent asylums as large-scale, totally designed institutions that offered a level of freedom and normality impossible in the outside world. This volume explores the \"caged freedom\" that this new psychiatric ethos represented by analyzing seven such buildings established in the Austro-Hungarian monarchy between the late 1890s and World War I.
In the last two decades of the Habsburg Empire, architects of asylums began to abandon traditional corridor-based plans in favor of looser formations of connected villas, echoing through design the urban- and freedom-oriented impulse of the progressive architecture of the time. Leslie Topp considers the paradoxical position of designs that promoted an illusion of freedom even as they exercised careful social and spatial control over patients. In addition to discussing the physical and social aspects of these institutions, Topp shows how the commissioned buildings were symptomatic of larger cultural changes and of the modern asylum's straining against its ideological anchorage in a premodern past of \"unenlightened\" restraint on human liberty.
Working at the intersection of the history of architecture and the history of psychiatry, Freedom and the Cage broadens our understanding of the complexity and fluidity of modern architecture's engagement with the state, with social and medical projects, and with mental health, psychiatry, and psychology.
eBook
The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital
Background
To assess the reliability and validity of Patient Health Questionnaire-9 (PHQ-9) for patients with major depressive disorder (MDD) and to assess the feasibility of its use in psychiatric hospitals in China.
Methods
One hundred nine outpatients or inpatients with MDD who qualified the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria completed PHQ-9 and Hamilton Depression Scale (HAMD-17). Two weeks after the initial evaluation, 54 randomly selected patients underwent repeat assessment using PHQ-9. For validity analysis, the construct validity and criterion validity were assessed. The internal concordance coefficient and the test-retest correlation coefficients were used for reliability analysis. The correlation between total score and scores for each item and the correlation between scores for various items were evaluated using Pearson correlation coefficient.
Results
Principal components factor analysis showed good construct validity of the PHQ-9. PHQ-9 total score showed a positive correlation with HAMD-17 total score (
r
= 0.610,
P
< 0.001). With HAMD as the standard, PHQ-9 depression scores of 7, 15, and 21 points were used as cut-offs for mild, moderate, and severe depression, respectively. Consistency assessment was conducted between the depression severity as assessed by PHQ-9 and HAMD (Kappa = 0.229,
P
< 0.001). Intraclass correlation coefficient between PHQ-9 total score and HAMD total score was 0.594 (95% confidence interval, 0.456–0.704,
P
< 0.001). The Cronbach’s α coefficient of PHQ-9 was 0.892. Correlation coefficients between each item score and the total score ranged from 0.567–0.789 (
P
< 0.01); the correlation coefficient between various item scores ranged from 0.233–0.747. The test-retest correlation coefficient for total score was 0.737.
Conclusions
PHQ-9 showed good reliability and validity, and high adaptability for patients with MDD in psychiatric hospital. It is a simple, rapid, effective, and reliable tool for screening and evaluation of the severity of depression.
Journal Article
Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment
Short-term structured risk assessment is presumed to reduce incidents of aggression and seclusion on acute psychiatric wards. Controlled studies of this approach are scarce.
To evaluate the effect of risk assessment on the number of aggression incidents and time in seclusion for patients admitted to acute psychiatric wards.
A cluster randomised controlled trial was conducted in four wards over a 40-week period (n = 597 patients). Structured risk assessment scales were used on two experimental wards, and the numbers of incidents of aggression and seclusion were compared with two control wards where assessment was based purely on clinical judgement.
The numbers of aggressive incidents (relative risk reduction -68%, P<0.001) and of patients engaging in aggression (relative risk reduction RRR = -50%, P<0.05) and the time spent in seclusion (RRR = -45%, P<0.05) were significantly lower in the experimental wards than in the control wards. Neither the number of seclusions nor the number of patients exposed to seclusion decreased.
Routine application of structured risk assessment measures might help reduce incidents of aggression and use of restraint and seclusion in psychiatric wards.
Journal Article
Crisis versus extended care: bimodal distribution of length of stay in psychiatric inpatients
Background
The length of stay (LoS) in psychiatric facilities is a critical metric for healthcare planning and resource allocation. While previous research has established that LoS distributions are typically right-skewed across medical specialties, detailed characterizations of these distributions within psychiatric settings remain limited, particularly regarding variations across diagnostic categories.
Methods
We conducted a retrospective cross-sectional analysis of 17,687 psychiatric hospitalizations at the University Hospital of Psychiatry Zurich between 2013 and 2020. Using both linear and logarithmic visualizations, we examined LoS distribution patterns across diagnostic groups based on ICD-10 classifications.
Results
Following identified distribution patterns, patients could be categorized into short-stay (1–10 days) and long-stay (11–200 days) groups for comparative analysis. LoS distribution demonstrated a bimodal pattern when visualized on a logarithmic scale, with distinct peaks representing short-term crisis interventions and longer therapeutic hospitalizations. This bimodal distribution was particularly evident in anxiety and stress-related disorders and major depressive disorder. Diagnostic categories differed significantly in their LoS-distribution patterns, with schizophrenia spectrum disorders, organic mental disorders, and bipolar disorders more frequently requiring extended hospitalizations. Long-stay patients exhibited higher admission HoNOS scores (median 20 vs. 18) and were significantly older (median 49 vs. 39 years) than short-stay patients.
Conclusions
Our findings reveal that psychiatric hospitalization durations follow a bimodal rather than simply right-skewed distribution, suggesting two distinct patient populations requiring fundamentally different treatment approaches. This pattern varies systematically across diagnostic categories but transcends diagnostic boundaries, indicating that factors beyond primary diagnosis influence treatment duration. These results support the development of differentiated care structures addressing both acute crisis intervention and extended therapeutic needs within psychiatric care systems.
Journal Article