One in every four psychiatric patients who is hospitalized is subdued using "methods of last resort," such as mechanical restraints or fast-acting sedatives, a new study shows.
The research, conducted by the Canadian Institute for Health Information, is the first in-depth look at the common but controversial "control interventions" used in response to acute psychotic episodes.
The data reveal that 30,117 of the 125,134 patients admitted to mental-health beds in Ontario hospitals between 2006 and 2010 were restrained.
"The numbers are quite startling," said Debra Churchill, director of professional practice at Ontario Shores Centre for Mental Health Sciences in Whitby, Ont.
Restraints are far more likely to be used in general hospitals than in specialized psychiatric hospitals, the CIHI study shows. (About 80 per cent of hospitalizations for mental health problems are in general hospitals, many of which have small psychiatric wards.)
Ms. Churchill, a veteran psychiatric nurse, said that likely reflects the fact that mental health patients can be far more disruptive and at risk of harming themselves in a regular hospital, and that those with specialized mental health training are less likely to rely on restraints to calm a patient.
"We want to minimize these measures, but you have to realize that, in some cases, they are employed for the safety of clients and staff," she said.
The research shows that restraints are used principally to prevent patients from harming themselves, and, secondarily, to keep them from harming others.
Victoria Maxwell, a playwright and mental health educator, agreed that the issue is not black-and-white.
As someone who has been living with bipolar disorder for two decades, she has been admitted to psychiatric beds for care a number of times. She has also been restrained on a couple of occasions – experiences she remembers vividly.
"One time I was having manic psychosis and hallucinating. I wanted to cut out my ego and was running around the ER looking for scissors," she said. Ms. Maxwell said hospital staff restrained her physically then strapped her to a gurney.
Another time, after running naked down a busy street, she was restrained by police and given a shot of haloperidol (brand name Haldol), a powerful anti-psychotic.
"It's horrible to watch but I can tell you restraints are not always inappropriate. Listen, I was out of control. I was a danger to myself," she said.
Ms. Maxwell, who speaks and performs plays about her experience, said what is important is not that restraints are used but that patients are treated respectfully.
"I may be crazy but I'm not deaf," she said. "Good caregivers can be forceful and still respectful."
The data show that restraints are used principally on people with severe psychiatric disorders such as schizophrenia and bipolar disorder, and that most of the time patients are incapable of understanding instructions because of psychosis.
"Although some patients who experience a control intervention exhibit violent behaviour, most do not," said Nawaf Madi, program lead for mental health and addictions at CIHI.
"An inability to communicate or to make decisions can result in confusion, both for the patient and the provider, and limit the effectiveness of more moderate approaches. Understanding such risk factors can help defuse a potentially difficult situation before it is aggravated," he said.
The report examined three principal types of control interventions:
- Medication: 59 per cent of the interventions consisted of psychotropic medication to subdue the patient.
- Mechanical and physical restraint: 21 per cent of patients were placed in mechanical restraints such as wrist restraints or physically held to restrict movement for a brief period of time.
- Seclusion: 20 per cent of patients were placed in a quiet room.
Ms. Churchill said she and others in the mental health field are pleased this kind of data is being published because "it's like bearing witness. This gives us some evidence-based perspective that can help us learn and provide better care."