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Cluster-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men With Schizophrenia
Anu Putkonen, M.D., Ph.D.; Satu Kuivalainen, R.N., M.Sc.; Olavi Louheranta, Th.M., Ph.D.; Eila Repo-Tiihonen, M.D., Ph.D.; Olli-Pekka Ryynänen, M.D., Ph.D.; Hannu Kautiainen, B.A.; Jari Tiihonen, M.D., Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200393
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Dr. Putkonen, Ms. Kuivalainen, Dr Louheranta, and Dr. Repo-Tiihonen are affiliated with the Department of Forensic Psychiatry, University of Eastern Finland (UEF), Kuopio, where Dr. Tiihonen is affiliated, and with Niuvanniemi Hospital, Kuopio. Dr. Tiihonen is also with the Department of Clinical Neuroscience, Karolinska Institutet, Stockholm. Dr. Ryynänen is with the Department of Public Health and Clinical Nutrition, Primary Health Care, UEF. Mr. Kautiainen is with the Unit of Primary Health Care, Helsinki University Central Hospital, and with the Department of General Practice, University of Helsinki in Finland. Send correspondence to Dr. Putkonen, Niuvanniemen sairaala, Niuvankuja 65, 70240 Kuopio, Finland (e-mail: putkonen@niuva.fi).

Copyright © 2013 by the American Psychiatric Association


Objective  This randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence.

Methods  Over the course of a year, 13 wards of a secured national psychiatric hospital in Finland received information about seclusion and restraint prevention. Four high-security wards (N=88 beds) for men with psychotic illness were then stratified by coercion rates and randomly assigned to two equal groups. In the intervention wards, staff, patients, and doctors were trained for six months in applying six core strategies to prevent seclusion-restraint; six months of supervised intervention followed. Poisson’s regression analyses compared monthly incidence rate ratios (IRRs) of coercion and violence (per 100 patient-days).

Results  The proportion of patient-days with seclusion, restraint, or room observation declined from 30% to 15% for intervention wards (IRR=.88, 95% confidence interval [CI]=.86–.90, p<.001) versus from 25% to 19% for control wards (IRR=.97, CI=.93–1.01, p=.056). Seclusion-restraint time decreased from 110 to 56 hours per 100 patient-days for intervention wards (IRR=.85, CI=.78–.92, p<.001) but increased from 133 to 150 hours for control wards (IRR=1.09, CI=.94–1.25, p=.24). Incidence of violence decreased from 1.1% to .4% for the intervention wards and from .1% to .0% for control wards. Between-groups differences were significant for seclusion-restraint-observation days (p=.001) and seclusion-restraint time (p=.001) but not for violence (p=.91).

Conclusions  Seclusion and restraint were prevented without an increase of violence in wards for men with schizophrenia and violent behavior. A similar reduction may also be feasible under less extreme circumstances.

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Figure 1 Proportion of patient-days with seclusion, restraint, or room observation for intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p=.001 for the difference between the groups).

Figure 2 Time spent in seclusion-restraint in intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p≤.001 between groups).

Figure 3 Number of violent incidents in intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p=.91 between groups).

Figure 4 Time patients spent in seclusion-restraint at Niuvanniemi Hospital, 2006–2009a

aThe right panel shows the incidence rate ratios (IRRs), with 2007 as the reference year. Error bars indicate 95% confidence intervals. In 2008 the full hospital staff was informed of the need for and strategies of seclusion-restraint prevention, and hospital leadership started to work as a steering group. In 2009 the intervention took place in two high-security wards.



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