Coercion in psychiatry: the importance of extramural factors.
BACKGROUND
Mechanical restraints and forced procedures in psychiatric wards are of major concern in Denmark and there is a desire to reduce these procedures to a minimum. So far, focus has primarily been on identifying and changing internal (intramural) factors when seeking to reduce coercion.


OBJECTIVE
To identify possible external (extramural) factors that may increase the risk of coercion during admission to a closed psychiatric ward.


METHODS
Using a retrospective case-controlled design, 235 patients admitted to a closed ward during 2011-2013 were randomly selected. Coercion comprised belt restraint, physical restraint, and forced medication. The data source was the electronic patient records, which include statutory information on all forced measures. Multiple logistic regression analyses were applied to calculate the risk (odds ratio, OR (95% confidence interval)) of forced measures being used.


RESULTS
Out of the 235 patients, 66 (28%) were subject to coercion. The time of forced procedures was predominately during the first hours after admission. The risk of forced measures being applied was significantly higher if patients were involuntarily admitted (OR = 6.4 (3.4-11.9)), or were acutely intoxicated by substances at the time of admission (OR = 3.7 (1.7-8.2)).


CONCLUSIONS
Extramural factors should be included when mental health authorities plan efforts to reduce coercion during admission to psychiatric wards. A reduced threshold for admission and improved integrated effort between mental health services and treatment for substance abuse could improve the course of disease for this group of patients and reduce the need for involuntary admissions and subsequently coercion.
a Psychiatry in Southern Denmark, Department of Psychiatry Odense , University Function , Denmark ;
Kjeld
K
Andersen
b Institute of Clinical Research , University of Southern Denmark , Odense , Denmark.
Bent
B
Nielsen
D000328:Adult; D016022:Case-Control Studies; D003068:Coercion; D003134:Commitment of Persons with Psychiatric Disorders; D003718:Denmark / Q000453:epidemiology; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology* / Q000628:therapy*; D008605:Mental Health Services; D008875:Middle Aged; D011567:Psychiatric Department, Hospital; D011570:Psychiatry / Q000379:methods*; D012149:Restraint, Physical / Q000523:psychology; D012189:Retrospective Studies
Mechanical restraint; coercion; extramural factors; forced medication; risk factors