People admitted to hospital for mental illness more likely to experience control intervention

The use of control interventions, including physical and mechanical restraints, acute control medications and seclusion, is intended to be a method of last resort in Ontario care facilities, including hospitals. However, according to a new analysis from the Canadian Institute for Health Information (CIHI), nearly one in four (24%) individuals admitted to a designated mental health bed in Ontario experienced at least one type of control intervention during their hospitalization.

Between 2006-2007 and 2009-2010, more than 30,000 individuals experienced control interventions. Acute control medications (59%) were used most often, followed by the use of physical/mechanical restraint (21%) and seclusion (20%). Restraint Use and Other Control Interventions for Mental Health Inpatients in Ontario is the largest study of its kind in Canada to examine the use of control interventions on people admitted to hospital for mental illness.

Patients admitted to a general hospital more likely to experience restraint use

CIHI's study found that people admitted to a general hospital for mental illness were over one and a half times as likely to experience some form of control intervention and over two and a half times as likely to experience a physical or mechanical restraint specifically, than those admitted to a psychiatric hospital.

Although general hospitals are often a first point of contact for patients experiencing psychiatric instability, this difference was observed after adjusting for variations in the types and characteristics of patients admitted in both types of hospitals (general versus psychiatric).

"Restraint measures have historically been employed for the safety of clients and staff; however, minimizing their use continues to be our ultimate goal," says Debra Churchill, Director of Professional Practice with Ontario Shores Centre for Mental Health Sciences. "There is an opportunity to look at the strategies and lessons learned by psychiatric hospitals that are successfully limiting their restraint use and to see how these lessons can be adopted more broadly."

Close to 80% of mental health inpatients in Ontario are admitted to general hospitals, while approximately 20% are admitted to psychiatric hospitals.

Difficulty communicating, violent behaviour greatly increase chances of patients experiencing control interventions

CIHI's analysis also looked at patient characteristics that were most closely associated with experiencing restraint use. Individuals who had difficulties making themselves understood were more than twice as likely—and those who were incapable of consenting to treatment were 39% more likely—to have experienced a control intervention than those who had no such difficulties.

Violent behaviour was also closely associated with control interventions; of those who experienced control interventions, more than half (54%) were assessed as posing a threat or danger to themselves, while one-third (33%) were recorded as posing a potential danger to others. Although patients who experienced control interventions were almost twice as likely to have engaged in recent violent behaviour, the majority (71%) had not displayed violence toward others, and 63% had not experienced a police intervention.

"Although some patients who experience a control intervention exhibit violent behaviour, most do not," says Dr. 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."

Other risk factors include the following:

• More than 40% of mental health inpatients who experienced a control intervention had been diagnosed with schizophrenia and psychotic disorders.
• Those who were diagnosed with organic disorders, bipolar disorder, or schizophrenia and psychotic disorders were all significantly more likely to experience a control intervention, when compared with those diagnosed with depression.
• Individuals who were incapable of caring for themselves due to their mental illness were 60% more likely to experience control interventions than individuals who did not have these difficulties.

"Minimizing restraint use can improve the experience of both clients and care providers," says Douglas Yeo, Director of Methodologies and Specialized Care for CIHI, "and our study highlights areas, such as increased treatment compliance, where improvements can lead to significant reductions in control interventions."

Those individuals who were least compliant with prescribed psychiatric medication were almost twice as likely to have experienced control interventions as those who were fully compliant.