Mental health care is coercive. Most of our practices can be considered coercive. Ranging from formally detaining and treating someone under the Mental Health Act to more subtle forms of coercion including blanket restrictions and pressure to comply with treatments.
Increasingly, the ability to make autonomous decisions about the care and treatment that individuals agree to is seen as essential. This is endorsed in the Conventions of Rights of Persons with Disabilities (CRPD) and human rights legislation.
Undoubtedly, coercion in psychiatry negatively impacts on the person using services and the person attempting to enforce treatment (Baker, 2017). Attempts to reduce coercion in mental health services appear to be failing, for example, a clear trend of increasing detentions under the Mental Health Act (CQC, 2018), and failure to enshrine rights to the voluntary patient.
This blog summarises the paper by Barbui et al., (2020) who aimed to examine the efficacy of interventions to reduce coercive treatment in mental health services.
Barbui et al., (2020) described this study as an umbrella review of previously conducted systematic reviews. The original protocol can be found here.
This study focused on any non-pharmacological intervention to reduce the use of coercion. Coercion was very broadly defined to include detentions, restraint, community treatment orders.
The broad search only included publications from the last 10 years, and only if meta-analysis had previously been undertaken. Quality was assessed using AMSTAR 2. Calculations were undertaken to measure the efficacy of interventions and classify the strength of their associations.
This is a summary of 3 systematic reviews of 5 meta-analyses, which includes 23 primary studies of 8,554 people.
Of those, 19 primary studies were from European countries and 4 from the USA. These studies were from across community and inpatient settings.
The numbers of studies per domain of coercive treatment were:
- 3 studies of Community Treatment Orders
- 2 of integrated care
- 2 studies of adherence
- 6 studies of shared decision making (advance statements, crisis cards and patient-held information)
- 10 studies of staff training to reduce physical restraint (all had a nursing home focus in one meta-analysis).
The re-analysis of the data demonstrates that:
- Staff training to reduce restraint had the most robust evidence (relative risk RR = 0.74, 95% CI 0.62 to 0.87; suggestive association, GRADE: moderate)
- Shared decision-making interventions to reduce involuntary admissions (RR = 0.75, 95% CI 0.60 to 0.92; weak association, GRADE: moderate)
- Integrated care interventions (RR = 0.66, 95% CI 0.46 to 0.95; weak association, GRADE: low)
There may be some benefit in training staff, sharing decisions and providing integrated care to reduce coercion.
The authors concluded:
Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.
The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence, followed by the evidence on the efficacy of shared decision-making interventions and integrated care to reduce involuntary admissions in adults with severe mental illness. By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.
Strengths and limitations
This review focuses on a relatively small selection of studies which have focused on aspects of coercion, and have already been subjected to meta-analysis. Obviously the design of the study has narrowly defined the inclusions. There are already a range of Mental Elf blogs, which focus in on aspects of these practices/studies, for example, Community Treatment Orders and Adherence therapy. The aspect of practice which has the most robust evidence is training staff to reduce restraint, but these papers focused only on nursing homes so the relevance to mainstream inpatient mental health care is probably limited. However, some evidence shows that if you train staff to reduce restraint they tend to do this more frequently, as opposed to teaching them the skills not to restrain people, which are far more complex and poorly described in the literature.
The authors propose that things that may work to reduce restrictive interventions probably won’t be subjected to RCTs. Just because they haven’t been done yet, doesn’t mean that they can’t be tried. However, applied mental health research in secondary care is very much under-resourced, and probably needs more radical thinking in terms of those studies which are funded. Evaluation of adopting a human rights approach to the care we provide would certain change our focus and could be evaluated. For example, Scotland is trying to develop a human rights approach to mental health care. Whether this will lead to improvement in the quality and safety of care is yet to be seen. Finally, it’s not clear if the areas that are the focus of this review would be the priorities for those with lived experience who have been subjected to restrictive interventions and practices.
Implications for practice
Clinicians need to consider how they can reduce all aspects of coercion across their practice. This will be enhanced by considering a human rights approach, or the removal of blanket restrictions. Greater involvement of patients to identify and challenge these practices is also likely to help. It’s unlikely that research in this area will be sufficiently funded, but whilst we’re waiting for creative researchers to prove that less coercion is a good thing, clinicians can change their practice.
Statement of interests
Barbui C, Purgato M, Abdulmalik J, Caldas-de-Almeida JM, Eaton J, Gureje O, Hanlon C, Nosè M, Ostuzzi G, Saraceno B, Saxena S, Tedeschi F, Thornicroft G. Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence. Br J Psychiatry. 2020 Aug 27:1-11. doi: 10.1192/bjp.2020.144. Epub ahead of print. PMID: 32847633.