title: Seclusion and enforced medication in dealing with aggression: A prospective dynamic cohort study.
abstract: In the Netherlands, seclusion is historically the measure of first choice in dealing with aggressive incidents. In 2010, the Mediant Mental Health Trust in Eastern Netherlands introduced a policy prioritising the use of enforced medication to manage aggressive incidents over seclusion. The main goal of the study was to investigate whether prioritising enforced medication over seclusion leads to a change of aggressive incidents and coercive measures.
  
  
  
  The study was carried out with data from 2764 patients admitted between 2007 and 2013 to the hospital locations of the Mediant Mental Health Trust in Eastern Netherlands, with a catchment area of 500,000 inhabitants. Seclusion, restraint and enforced medications as well as other coercive measures were gathered systematically. Aggressive incidents were assessed with the SOAS-R. An event sequence analysis was preformed, to assess the whether seclusion, restraint or enforced medication were used or not before or after aggressive incidents.
  
  
  
  Enforced medication use went up by 363% from a very low baseline. There was a marked reduction of overall coercive measures by 44%. Seclusion hours went down by 62%. Aggression against staff or patients was reduced by 40%.
  
  
  
  When dealing with aggression, prioritising medication significantly reduces other coercive measures and aggression against staff, while within principles of subsidiarity, proportionality and expediency.
authors.affiliation: Mediant mental health trust, 1050 7546 TA Broekheurnering, The Netherlands.
authors.forename: A A
authors.initials: AA
authors.lastname: Verlinde
authors.affiliation: Forensic ward and long stay ward, Ggnet mental health trust, 12, Vordenseweg, 7231 DA Warnsveld, The Netherlands; VU medical centre, Amsterdam, The Netherlands; Dutch information centre of coercive measures, Bilthoven, The Netherlands. Electronic address: Enoorthoorn@hotmail.com.
authors.forename: E O
authors.initials: EO
authors.lastname: Noorthoorn
authors.affiliation: Mediant mental health trust, 1050 7546 TA Broekheurnering, The Netherlands.
authors.forename: W
authors.initials: W
authors.lastname: Snelleman
authors.affiliation: Mediant mental health trust, 1050 7546 TA Broekheurnering, The Netherlands.
authors.forename: H
authors.initials: H
authors.lastname: van den Berg
authors.affiliation: Forensic ward and long stay ward, Ggnet mental health trust, 12, Vordenseweg, 7231 DA Warnsveld, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Snelleman-van der Plas
authors.affiliation: Wrexham community mental health team, Betsi Cadwaladr university health board, Ty Derbyn, Wrexham Maelor hospital, Wrexham, Wales, United Kingdom; Centre for mental health and society Bangor university, Bangor, county of Gwynedd North Wales, United Kingdom; Mysore medical college and research institute, Mysore, India.
authors.forename: P
authors.initials: P
authors.lastname: Lepping
mesh_terms: D000328:Adult; D000374:Aggression / Q000523:psychology; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003068:Coercion; D015331:Cohort Studies; D005260:Female; D006778:Hospitals, Psychiatric / Q000592:standards; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D008297:Male; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy*; D028642:Persons with Psychiatric Disorders / Q000523:psychology*; D009426:Netherlands; D010356:Patient Isolation / Q000706:statistics & numerical data; D011446:Prospective Studies; D012149:Restraint, Physical / Q000706:statistics & numerical data*
chemical_list: D014150:Antipsychotic Agents; D006993:Hypnotics and Sedatives
keywords: Emergency; Law ethics and human rights; Quality of care; Violence