LAST UPDATE | 19 Oct 2018
PHYSICAL RESTRAINT AND seclusion was used in 79% of in-patient mental health services in 2016.
This is according to the Mental Health Commission (MHC) which is calling for a reduction in the use of these practices following the publication of its report into the use of restrictive practices in approved centres in 2016.
Physical restraint was used in the majority of approved centres and accounted for almost 70% of all interventions, while seclusion accounted for almost 30% of restrictive interventions, the regulator for mental health services found.
The College of Psychiatrists of Ireland has said it is disappointed to see the results of the data published today but said the results are another manifestation of the under-resourcing of services for people with serious psychiatric illness.
The College says that the current experience of frontline psychiatrists in Ireland is that they lack the resources in trained personnel to ensure all people in need get the variety of evidenced-based interventions they require.
“The recently announced larger amounts of money in Budget 2019 for mental health services still do not bring Ireland up to the level of required funding for psychiatric services in line with the Sláintecare recommendation of 10% of the overall Health budget and when compared to other countries,” Dr John Hillery, President of the College said.
No evidence of a therapeutic benefit
In total, there were over 5,000 cases of seclusion and/or physical restraint accounted for.
But the MHC has said there is no therapeutic benefit to restrictive practices and an increasing focus is needed on the use of preventive approaches.
“The Commission is not in favour of such practices and encourages other measures to de-escalate situations,” Rosemary Smyth, Interim Chief Executive, Mental Health Commission said.
“Intervention that compromises a person’s liberty is very serious and should only ever be used as a last resort.
“We know that there is no evidence of a therapeutic benefit associated with the use of restrictive practices and there is also limited evidence of restrictive practices reducing behaviours of violence and aggression.”
According to the Commission, most centres do not have access to a psychiatric intensive care unit and in a situation where de-escalation techniques are not effective, centres can be left with last resort options of seclusion, physical restraint or rapid tranquillisation.
A Vision for Change, the government policy on mental health services, recommended 30 psychiatric intensive care beds per 1,000,000 population. Based on the current population this would amount to 140 beds.
The Commission said it is aware of only 42 such beds nationally.
Seclusion
The MHC defines seclusion as “the placing or leaving of a person in any room alone, at any time, day or night, with the exit door locked or fastened or held in such a way as to prevent the person from leaving”.
Its report found that seclusion was used in 42% of approved centres in 2016, an increase of 3% compared to 2015.
In 2016 there were 1,475 episodes of seclusion, involving 636 people, a decrease from 1,485 episodes in 2015.
The HSE Community Healthcare Organisations (CHO) with the highest rate of episodes of seclusion were in South Tipperary, Carlow, Kilkenny, Waterford, and Wexford.
Services where the average duration of seclusion was greater than 24 hours:
There were 213 episodes where a person was locked in seclusion for over 24 hours, while there were 43 episodes where a person was held for over 72 hours.
The MHC also found that more male residents (64%) than female residents were secluded while the majority of those secluded were under 40 years old.
The Commission has warned that the number of episodes of seclusion varied across approved centres and in some cases, the rate was skewed by frequent use in relation to a small number of residents.
Its report added that there was considerable variation between approved centres in the average duration of seclusion.
At a national level, physical restraint is used more frequently and widely than seclusion.
Physical Restraint
In 79% of approved centres in 2016 physical restraint was used, compared to 75% in 2015.
The report found that 1,155 people were physically restrained in 2016.
Similar to seclusion, the number of episodes of physical restraint and residents restrained varied across approved centres and in some cases, the rate was skewed by frequent use in relation to a small number of residents.
The period between 10am and 11am saw the highest proportion of episodes of physical restraint.
One in four of those restrained was aged between 18 and 29 with 1% of them restrained for 60 minutes or more.
‘Focus is needed on the use of preventive approaches’
The Commission has an oversight role to ensure that restrictive interventions are only used where strictly necessary and safely undertaken in line with codes of practice.
In 2017, it set mandatory training for all healthcare professionals in approved centres to be trained in the prevention and management of violence and aggression.
We are hopeful that increased training levels will contribute to the reduction of restrictive practices and we will continue to monitor the situation closely.
The MHC has advocated for the use of de-escalation measures over restrictive practices but says for these to be successful it is “essential that staff are appropriately trained in de-escalation and in clinical risk management”.
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