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

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Use of coercive measures in mental health practice and its impact on outcome: a critical review Expert Rev. Neurother. 14(2), 131–141 (2014)

Mario Luciano*1, Gaia Sampogna1, Valeria Del Vecchio1, Luca Pingani2,3, Claudia Palumbo4, Corrado De Rosa1, Francesco Catapano1 and Andrea Fiorillo1 1 Department of Psychiatry, University of Naples SUN, Naples, Italy 2 International PhD School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy 3 Human Resource Development, Local Health Agency of Reggio Emilia, Reggio Emilia, Italy 4 Department of Neuroscience and Sense Organ, University of Bari, Bari, Italy *Author for correspondence: [email protected]

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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

In mental health practice, coercive measures may be necessary when patients with mental disorders cannot make autonomous decisions about the treatment to be received, and are acceptable only to promote patient’s health [1]. Moreover, coercive interventions can be defined either as therapeutic when they are applied in the patient’s interests or as containment interventions when they are applied in order to protect patients or others from aggressive behavior [2]. Some coercive measures, such as mechanical restraint, can be primarily defined as containment measures, and others such as involuntary admission to psychiatric wards, as mainly therapeutic [3]. However, this distinction largely depends on country jurisdiction [2], and a consensus has not been achieved, with the consequence that most papers do not distinguish among the different coercive measures. At the current level of knowledge, although coercive measures have always been part of the psychiatric practice, the balance between the use of coercion and the loss of patients’ autonomy is still one of 10.1586/14737175.2014.874286

the major controversial issues in mental health research and practice [4]. According to the international guidelines, coercive measures should be adopted only when all the other less restrictive approaches failed [5] and should be considered as the ‘least restrictive alternative’ [6–11]. However, several intercountry differences have been found and international attempts to ‘harmonize best clinical practice in coercion’ have been recently made [5,12]. Although coercive measures are frequently used in mental health settings [13–15], their effect on patients’ social and clinical outcome is not clear [16]. In fact, while some authors argue that the use of coercive measures results in a positive outcome [17], others suggest that patients receiving coercive measures do not establish a long-term engagement with mental health services [18]. Several reviews and meta-analyses have already been published on coercion [19–23]. Some of them are focused on the impact of a specific coercive measure on the course of a

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given psychiatric disorder [19,20]; others dealt with organizational and ethical aspects related to the use of coercive measures such as the quality of institutional care [21], the procedural justice in psychiatric care [22] or the provision of involuntary treatment in special settings [23]. However, none of them have extensively analyzed the current status of knowledge on coercion in terms of effectiveness, impact on patient outcome and satisfaction with treatment in recent years. Finally, the importance of the identification of the predictive factors associated with higher rates of use of coercive measures has not been taken into account by previous reviews. Their importance has been recently acknowledged in order to identify patients who are at high risk of being coerced during hospitalization and to plan preventive interventions and to reduce rates of use of coercive measures in psychiatric practice. The aim of the present paper is to review the existing literature on the predictors of the use of coercive measures and on the relationship between the use of coercive measures and patients’ outcome. Materials & methods

The papers search was carried out using MEDLINE, PsychINFO, Scopus, Web of Knowledge and Cochrane Central Register of Controlled Trials. The following terms were used to identify relevant articles: ‘severe mental disorder,’ ‘mental health,’ ‘mentally ill patients,’ ‘treatment satisfaction,’ ‘patient satisfaction’ and ‘psychiatry.’ All these terms were matched with: physical restraint, mechanical restraint, seclusion, forced medication, involuntary hospital admission, coercive measures, coercive treatments and perceived coercion. Search strategy was adapted for each database. Papers were included in the review if they were: published between January 2007 and November 2013; written in English; peer reviewed; and carried out in adult psychiatric settings. In order to identify other possible studies, references of identified papers were cross-checked. A structured data extraction tool was created with headings including the year of publication, first author’s name and country where the study was carried out, sample size, adopted methodology, study aims, primary outcomes and main results. Three independent researchers reviewed the papers and selected only those dealing with predictors of coercion or with outcome of coercion. For each study, only primary aims were used to categorize papers. In case of disagreement between researchers, papers were discussed and reanalyzed with the presence of an expert researcher and then included or removed from the final list of papers. The review is not intended to be systematic, but to shed light upon the use of coercion in mental health practice in order to provide useful suggestions for improving current practice and research on this debated topic. Summary of findings from the existing literature Paper selection

A total of 1350 papers were identified. By analyzing the abstracts, 1332 papers were removed because they were either 132

considered not relevant for the purpose of this review, or they were duplicates. Reviews, case reports, editorials, letters to the editor and other non-research papers were also removed. Twelve more papers were added to the list deriving from the analysis of papers’ references. The final list includes 30 papers subdivided as follows: 17 papers in ‘Predictors’ category and 13 in ‘Effects of use of coercive measures on outcome’ (FIGURE 1). Predictors of use of coercive measures

The 17 papers included in this category are detailed in TABLE 1. Five of them had a retrospective design, 11 were observational in nature (8 cross-sectional and 3 prospective cohort studies) and only one was a randomized controlled trial (RCT). Three factors that predict the use of coercive measures were identified: patients’ characteristics, staff composition and wardrelated factors. Patients’ characteristics associated with the use of coercive measures include: male gender [24–28]; younger age [24–29]; having a psychotic disorder [24–28,30–33]; belonging to an ethnic minority [26,28,34–37]; being homeless [30,33]; suffering from substance abuse [29]; being cognitively impaired or having no insight of illness [24,33]; having had a traumatic event [38]; and having a low satisfaction with treatments [36]. The most frequent clinical condition correlated with the use of coercive measures was the presence of aggressive behaviors [29–33]. With regards to staff attitudes, there was no association of the use of coercive measures with staff educational level, professional role and gender. De Benedictis et al. [39] found that coercive measures were more frequently adopted when staff perceived great expressions of anger and aggression in other team members and when safety measures in the workplace were insufficient. As regards staff composition, Bowers et al. [40] reported an inverse association between the number of junior medical doctors and the use of restraint, while the number of nurses was positively associated with a higher use of restraint. As regards ward-related factors, higher rates of seclusion and restraint was found in wards located in urban areas and in locked-door wards [31,40]. Impact of coercive measures on outcome

All papers exploring the relationship between coercion and outcome are described in TABLE 2. Of the 13 included studies, 2 were RCTs and 11 were observational studies (1 crosssectional study and 10 cohort studies). The RCT, carried out by Huf et al. [41], compared the effect of two different coercive measures (restraint vs seclusion) in 105 patients admitted to an emergency room. In this study, patients receiving seclusion did not differ, from those receiving restraint, in terms of time spent under coercion, compliance with the received measures (evaluated as the need to change the used coercive measure) and the need to be coerced again after 4 h. However, secluded patients tended to be more satisfied with received treatment although this difference did not reach a significant level. Expert Rev. Neurother. 14(2), (2014)

Coercion in psychiatry: a critical review

Review

Screening

Eligibility

Included


Identification

Kjellin et al. [42] in a study, aimed at Papers identified evaluating the impact of coercive treatthrough database ments on short-term outcome, meassearching (n = 1350) ured either as patients’ subjective experience or as objective improvement in Global Assessment of Functioning, did not find any association between the use of coercive measures and patients’ short-term clinical outcome. Papers excluded Opjordsmoen et al. [43] did not find based on title and any difference in terms of improvement abstract (n = 1332) in clinical status or in global functioning between voluntarily and involuntarily admitted patients with a first episode of psychosis. Similar results have been reported by Seo et al. [44] Eligible papers who in a 1-year follow-up study did (n = 18) not report any positive impact of the use of coercive measures in improving patients’ clinical outcome and insight of illness. Papers from other Georgieva et al. [45] tested the efficacy papers’ references (n = 12) of seclusion, mechanical restraint and forced medication on psychological functioning, insight of illness, uncooperativeness with treatment and aggressive Full-text articles behavior, by rating patients’ behaviors included in the after the use of coercive measures and review (n = 30) 24 h later. Results of this study showed that lower psychological and physical burden were significantly associated with the use of forced medication compared Full-text articles with the other coercive measures. Authors Full-text articles included in ‘outcome included in underlined that forced medication is of coercive ‘Predictors’ (n = 17) effective to improve patient’s clinical stameasures’ (n = 13) tus and should be the first choice when a coercive intervention is unavoidable. Figure 1. The selection process to identify the relevant literature. Kallert et al. [46] assessed symptom change over a 3 month period following coerced hospital admission and tried to identify patient terms of treatment engagement and medication adherence characteristics associated with outcomes in a sample of compared with those who were voluntarily admitted. patients from 11 countries. A significant improvement in symptoms’ level was reported. Moreover, being unem- Expert commentary & five-year view ployed, living alone, having frequent hospitalizations and Although the use of coercion in mental health practice is still being initially less satisfied with treatments were associated controversial, it is a surprisingly understudied and underresearched area. In fact, one of the main findings of this review with less symptom improvement after 1 month. Several papers have investigated the impact of coercive is that only a few studies have been carried out and mainly measures on the therapeutic relationship [16,18,47,48]. Some without a sound and rigorous methodology such as the authors found that the use of coercive measures is related to EUNOMIA study [3,5,12,32,46,52–56]. This study, funded by the a more negative patient–therapist relationship [16,49], leads European Commission, has been the first (and the only) to negative feelings of patients toward clinicians [49] and attempt to harmonize clinical practice about coercion, by proreduces satisfaction with treatments [50,47,48], thus reducing viding data about the use of coercive measures in European patients’ engagement with the service [18]. Only one recent countries, by describing the differences in jurisdiction in Europaper [51] found that patients who were involuntarily admit- pean countries and by providing international guidelines based ted did not show any statistically significant difference in on consensus. www.expert-reviews.com

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Table 1. Predictors of the use of coercive measures in psychiatric practice. Study (year), country

Aims of the study

Sample and type of study

Main findings

Hustoft et al. (2013), Norway

To describe which factors predict the use of involuntary hospital admission

3332 patients. Cross-sectional study

Predictors of involuntary hospital admission were: being homeless, having hallucinations or delusions and a higher score on aggression, and a poor global functioning

[33]

Tarsitani et al. (2013), Italy

To explore differences in the use of physical restraint and rate of compulsory admissions in migrants


Migrants had 3.7-fold increased risk of being restrained

[35]

Bowers et al. (2012), UK

To assess the impact of staff characteristics and staff group variables on the use of coercion

136 acute mental health wards. Cross-sectional study

The availability of junior medical staff was associated with lower rates of coercion. An inverse association was found between the number of nurses and use of coercion

[40]

Hunt et al. (2012), Australia

To identify patient characteristics related to the involuntary admission in an acute adult psychiatric unit

100 patients. Prospective cohort study

Patients were more likely to be admitted if they were experiencing psychosis or an exacerbation of schizophrenia-like illness, or if they were homeless. Patients with an overall high level of risk of violence were more likely to be secluded during hospitalization

[30]

Taylor et al. (2012), USA

To identify risk factors associated with multiple seclusion/restraint

63 patients. Retrospective study

Patients who were male, with a history of aggressions and with cognitive impairment had a higher risk of being coerced.

[24]

De Benedictis et al. (2011), Canada

To identify predictors of the use of coercion in psychiatric wards

309 staff members. Cross-sectional study

Predictors of the use of coercion were greater expression of anger and aggression in staff members, and insufficient safety measures in the workplace

[39]

Dumais et al. (2011), Canada

To assess: the prevalence of seclusion with or without restraint and whether sociodemographic and clinical characteristics are related to coercion


Risk factors of seclusion were male gender, younger age, diagnosis of schizophrenia, bipolar disorder or personality disorder and longer length of hospitalization

[25]

Lay et al. (2011), Switzerland

To determine how frequently and to whom coercive measures are applied in hospitals


Risk factors of coercion were male gender, younger age and a diagnosis of psychotic disorder

[27]

Knutzen et al. (2011), Norway

To examine: differences in sociodemographic and clinical characteristic of restrained patients; whether any of these variables predicted the use of restraint

749 patients. Retrospective case–control study

Restrained patients had significantly longer hospitalizations and a higher number of (mainly involuntary) admissions. Patients were predominantly male, with younger age, immigrant and with a psychotic disorder

[26]

Hendryx et al. (2010), USA

To identify risk factors for being coerced


Predictors of seclusion were male sex, younger age, greater number of previous hospitalizations and longer length of hospitalization. Predictors of restraint were younger age, black race and a greater number of previous hospitalizations

[28]

Husum et al. (2010), Norway

To assess: the frequency of use of coercion; the predictors of the use of coercion; whether staff attitudes influence the use of coercion


Risk factors of seclusion were aggressive behaviors, self-injury/suicidal behavior and hallucinations/delusions. Wards located in urban areas had higher levels of seclusion and restraint. Coercion is not predicted by staff attitudes

[31]

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Table 1. Predictors of the use of coercive measures in psychiatric practice (cont.). Study (year), country

Aims of the study

Sample and type of study

Main findings

Lawlor et al. (2010), UK

To explore ethnic variations in compulsory detentions of women

287 female patients. Cross-sectional study

Black women were more likely to be compulsorily admitted. Black African women were also more likely to have police or criminal justice system involvement in their route to care

[34]

Norredam et al. (2010), Denmark

To explore differences in coercion practice in psychiatric emergency wards in refugees and migrants

312,300 patients. Retrospective study

Both refugees and migrants had a higher risk of: involuntary detention; coercive treatments; and use of physical pressure or acute medication

[37]

Raboch et al. (2010), Europe

To assess the use of coercion in psychiatric inpatient facilities in 10 European countries


The provision of a coercive measure was associated with the diagnosis of schizophrenia and with a higher symptoms’ severity. Aggressive behavior was the most frequent reason for the use of coercion

[54]

Priebe et al. (2009), UK

To identify factors associated with involuntary readmissions


Lower level of initial treatment satisfaction and being African and/or Caribbean were associated with higher involuntary readmission rates

[36]

Migon et al. (2008), Brazil

To investigate frequency and factors associated with the use of coercion

301 patients. Randomized controlled trial

Physical restraint was more frequent in patients with aggressive behaviors, substance disorder, dementia, learning disability, organic brain disorders and younger age

[29]

Steinert et al. (2007), Germany

To investigate factors associated with the use of coercion in a diagnostically homogenous sample of patients


Physical aggressive behavior and higher PANSS hostility score were associated with occurrence of seclusion or restraint; lifetime history of trauma was associated with lifetime risk to be secluded or restrained

[38]

As regards the first research question (i.e., what does predict the use of coercion?), several factors have been identified as possible predictors, which may be grouped into three categories: .

.

Patients’ sociodemographic and clinical characteristics such as male gender, diagnosis of psychotic disorder or of substance abuse, history of trauma in the lifetime and low satisfaction with previous treatments; Characteristics of mental health staff. The reviewed studies have found that the use of coercion in psychiatric wards is reduced if the mental health staff includes a lower number of nurses and a higher number of junior doctors. The inverse association of the availability of junior medical staff with restraint suggests that junior doctors are more accessible to patients and provide 24-h hospital coverage. Their availability might improve constancy and continuity of care. It might also mean that they can more promptly hear patients’ complaints, allowing greater dispute resolution through negotiation. Changes in the allocation of junior doctors occur often, and the arrival of new junior doctors has been associated with lower rates of physical aggression and absconding, perhaps because as new staffs, they are keener to respond to patients’ needs [57];


.

Ref.

Environmental and ward-related factors such as locked door wards or hospitals located in urban areas. This may indicate that patients living in urban areas have a greater number and range of problems. Furthermore, there may be more problems with drug use, homelessness and lack of social networks [31,58–60].

The identification of predictors of coercion is crucial to identify those patients who are at high risk to be coerced, and to set the bases for the development of programs or interventions to reduce the use of coercive measures in psychiatric practice. In fact, some interventions, such as psychoeducation, debriefing techniques and changes in the organization of mental health facilities, could lead to the reduction of rates of use of coercion in mental health. The other research question of this review (i.e., what is the impact of coercion on outcome of patients with severe mental disorders) has been explored in few studies, reporting controversial findings. In fact, while some authors [45,46] found a positive association between the use of coercion and symptom reduction, others [16,18,41–43,47,48,49,50] found a negative impact on the therapeutic relationship if they received a coercive measure. One of the most well-established finding is that coercive measures have a negative impact on patients’ adherence to 135

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Table 2. Impact of coercion on clinical and social outcome of patients with severe mental disorders. Study (year), country

Aims

Sample size and type of study

Explored outcome measures

Main findings

Seo et al. (2013), South Korea

To assess the impact of the use of coercive measures on patients’ clinical status and insight of illness


Symptom levels; insight of illness

At 1-year follow-up, the use of coercion was neither associated with symptoms reduction nor with improvements of patients’ insight

[44]

Strauss et al. (2013), USA

To assess the relationship between the use of involuntary hospital admission and satisfaction with treatment


Patients’ satisfaction with treatments; history of coercive treatment; perceived coercion

Patients’ who were involuntarily admitted reported a significantly lower satisfaction with received care at follow-up

[48]

Jaeger et al. (2013), Germany

To investigate the influence of an involuntary hospital admission on medication adherence, treatment engagement and perceived coercion


Medication adherence; level of engagement in psychiatric care; perceived coercion

The involuntary admission did not have any impact on medication adherence, treatment engagement and perceived coercion among groups

[51]

Georgieva et al. (2012), The Netherlands

To compare the effectiveness of four coercive measures


Patient’s well-being and level of functioning; positive symptoms; patient’s perception of restriction

Personal functioning and symptom levels improved regardless of the coercive measure applied. Involuntary medication should be the treatment of choice since it was considered by patients as less restrictive

[45]

Huf et al. (2012), Brazil

To compare the effects of physical restraint and seclusion


Symptom levels; time in restriction

No differences were found between the two coercive measures on outcome

[41]

Theodoridou et al. (2012), Switzerland

To investigate the relationship between coercion and therapeutic relationship


Therapeutic relationship

The use of coercive measures was related to a more negative patient–therapist relationship

[49]

Petkari et al. (2011), Europe

To explore differences between patients who were legally coerced and felt coerced, those who were legally coerced but did not feel coerced and those who were voluntarily admitted but felt coerced


Symptom levels

The use of any coercive measure was associated with a significant improvement of symptom levels after 1 month and further improvements were found at 3 months. Being unemployed, living alone and being initially less satisfied with the treatment were associated with less symptom improvement after 1 month

[55]

O’Donoghue et al. (2011), Ireland

To determine levels of procedural justice during involuntary admission and its influence in future engagement with mental health services


Engagement with mental health services; insight of illness

An association between the use of coercive measures and lack of insight was found. Higher levels of procedural justice at admission predicted the likelihood of not being engaged with mental health services

[18]

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Table 2. Impact of coercion on clinical and social outcome of patients with severe mental disorders (cont.). Study (year), country

Aims

Sample size and type of study

Explored outcome measures

Main findings

Priebe et al. (2011), UK

To explore whether patients’ sociodemographic and clinical features, reasons for admission and initial hospital experiences were associated with outcomes


Symptom levels; global functioning; subjective quality of life

Patients who felt more coerced tend to have a better social outcome. Patients’ clinical and sociodemographic characteristics did not have a predictive value on outcome

[47]

Sheehan et al. (2011), UK

To investigate the association between therapeutic alliance and perceived coercion


Therapeutic relationship

Patients who experienced higher levels of coercion tend to poorly rate their relationship with clinician

[16]

Kjellin et al. (2010), Sweden

To examine the impact of accumulated coercive incidents on outcome


Global functioning; subjective experience of coercion

Number of coercive incidents did not predict subjective or assessed improvement in symptomatology. Coercion was not related to outcome

[42]

Opjordsmoen et al. (2010), Norway and Denmark

To compare the effect of the use of coercion on outcome in patients with a first episode of psychosis who are voluntarily or involuntarily admitted


Symptom levels; global functioning

No significant differences were found in terms of level of psychopathology and functioning between voluntarily and involuntarily admitted patients at followup

[43]

Iversen et al. (2007), Norway

To explore the impact of coercion on patient satisfaction


Patient satisfaction

Overall satisfaction was significantly reduced with the growing number of coercive events

[50]

psychiatric care [16,18,49,47], with a negative feeling toward clinicians and an early dropout rate from mental health services. Although we believe that this is a very important point, it obviously needs replication and confirmation since the relationship between coercion and poor outcome may be causal, given the lack of RCTs in this area. Moreover, a possible strategy to reduce the negative impact of the use of coercion is the implementation of psychiatric advanced directives (PADs), which in many countries, have been proved to be effective in promoting a patient-centered treatment, in respect of patients’ therapeutic choices [61]. PADs are legal documents that allow competent individuals to declare their treatment preferences in advance of a mental health crisis [62]. PADs offer individuals suffering from a mental illness a practical means to express their treatment preferences when in crisis, and they have been found to be particularly useful for treatments such as electroconvulsive therapy [63], psychosurgery [64] and coercive measures. Currently, PADs are used only in few countries although their benefits in terms of patient’s perceptions and compulsory admissions are promising [65]. However, the studies carried out to explore the relationship between coercion and outcome have several pitfalls, which limit www.expert-reviews.com

Ref.

the generalizability of the findings. In particular, the most significant limitations of these studies are: .

.

. .

The absence of a standardized definition of coercion in mental health practice [16]; although many papers with suggestions and consensus of definitions have been published, a general standardized definition of coercion is not possible due to the very different aspects of coercion; The different types of coercive measures used in different institutions and countries [32,66–70]. In fact, a compulsory admission or forced medication may be perceived by patients as less detrimental than restraint or seclusion, and therefore a comparison of studies using different coercive measures may be biased. However, according to Georgieva et al. [43], the effects of coercive measures on outcome are similar, with the exception of forced medication; The procedural, legal and ethical differences, which that make multicenter comparisons difficult [71]; The heterogeneity of considered outcomes [22].

The vast majority of reviewed studies have been carried out in Western countries, and only a few trials have been conducted in developing countries such as Brazil [29] and Indonesia [72]. However, what emerges is that the practice of coercion 137


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reflects cultural factors, which need to be taken into account in developing treatment recommendations and guidelines. In the next years, research on coercion should be strengthened, in particular, as regards the use of coercive measures in special population, such as geriatric patients [73], adolescents [74], migrants [35], and in patients with specific disorders, such as forensic patients (i.e., those living in secured institutions) [75], those with eating [32,76,77] or addictive [78] disorders. Eating disorders were excluded from this review since in many countries they are treated using coercive measures (such as doors locked after meals, forced nutrition, etc.), which do not represent necessarily an index of illness severity. Moreover, the use of coercive measures has been explored mainly in inpatient settings, where coercive measures are more often applied [79–81], while little is known about the use of coercion in patients treated in outpatients units. It may be that coercion is perceived as less detrimental by patients if it is applied in outpatients settings. Of course, this remains speculative and requires further confirmation. At the current level of knowledge, although several trials have been conducted, the picture that emerges is still unclear. The research in coercion and its impact on outcome and on adherence to pharmacological treatment is still a priority in mental health, as reported by several authors and [82] large multicenter

studies with long-term follow-ups and homogeneous methodologies are needed, if we want to really understand how coercion is used in psychiatry. Such studies may also allow analysis of patients with different clinical, sociodemographic and contextual factors, helping to clarify the phenomenon of coercive treatments in psychiatric population. 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.

regulations related to involuntary admissions and hospital stay in twelve European countries. In: Kallert T, Torres-Gonzales F, editors. Legislation on coercive mental health care in Europe. Peter Lang, Frankfurt am Maine; Germany: 2006. p. 375-400

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Notice of correction

The version of this article published online on 2 January 2014 contained a number of minor typographical and referencing errors. These have been corrected in this version.


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