Use of coercive measures in mental health practice and its impact on outcome: a critical review

Abstract

Although coercive measures have always been part of the psychiatric armamentarium, the ethical dilemma between the use of a “therapeutic” coercion and the loss of patients' dignity is one of the major controversial issues in mental health research and practice. The aims of the present review are to explore the existing literature on predictors of use of coercive measures and to explore the relationship between coercive measures and patient outcome. A literature search was conducted using MEDLINE, PsychyINFO, Scopus, Web of Knowledge and the Cochrane Database. In all selected papers, references were cross-checked to identify other possible eligible papers. The use of coercive measures was predicted by patients' clinical and socio-demographic features, staff characteristics and ward-related factors. Coercive measures have only a limited impact on patients' clinical and social outcome. At the current level of knowledge, coercion is still a controversial issue in mental health practice. Only few studies with a solid methodology have been carried out. Large multicenter and rigorous studies, with long-term follow-ups, are highly needed.

Keywords::

• coercion in psychiatry
• coercive measures
• outcome
• perceived coercion
• predictors
• therapeutic relation

Acknowledgements

The authors are very grateful to Professors N Sartorius and G de Girolamo for their very useful comments on the initial drafts of the manuscript. This study was conceived during the First edition of the School on Research Methodology in Psychiatry organized by the Association for the Improvement of Mental Health Programme (AIMHP), chaired by Professor N Sartorius, who is hereby gratefully acknowledged.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The factors that predict the use of coercive measures are patients' sociodemographic and clinical characteristics, staff characteristics and ward-related factors.

• The relationship between the use of coercive measures and patients' outcome is still controversial.

• The comparison among available studies is limited by several factors, such as the different types of coercive measures used, the procedural, legal and ethical differences in countries, the lack of reliable assessment instruments to evaluate the effects of coercive measures and the absence of a standardized definition of coercion in psychiatry.

• In the next years, studies on the effect of the use of coercion in patients with eating disorders, addictive disorders and first episode psychosis are needed. Moreover, very few data are available about the use of coercive measures in outpatient settings, probably as a consequence of the heterogeneous legal, political, economical, social and medical factors in the countries where the studies were carried out.

• Studies on the impact of the use of coercion and outcome should be implemented in low-income countries, in order to provide a global perspective on this controversial issue.