ZfP Südwürttemberg, Klinik für Psychiatrie und Psychotherapie I der Universität Ulm, Weissenau.
Dtsch Arztebl Int. 2019 May 10;116(19):336-343. doi: 10.3238/arztebl.2019.0336.
Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry.
This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content.
Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%.
Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.
约束和隔离等强制措施侵犯了患者的人权，并可能产生从情绪创伤到身体伤害甚至死亡等严重的不良后果。 同时，这些措施可能是避免患者和/或医护人员面临急性危险的唯一方法。 本文概述了迄今为止为避免精神科强制手段而进行的措施的疗效。
本综述基于在 Medline 和 Cinahl 数据库中进行系统检索的出版物，并辅以对这些出版物的参考文献列表的搜索。 我们提供了一个叙述性综述，按内容对干预措施进行分类。
在纳入本综述的 84 项研究中，有 16 项研究有对照组；其中 6 项为随机对照试验 (RCT)。 干预措施分为七种不同的内容：组织、员工培训、风险评估、环境、心理治疗、汇报和预先指示。 每个类别中的大多数干预措施在各自的研究中均被证明是有效的。 38 项研究调查了复杂的治疗方案，这些方案结合了一个以上类别的元素；其中 37 项（包括一项 RCT）显示出强制手段频率的有效降低。 两项关于使用评估工具评估攻击性行为风险的 RCT 显示，约束措施的数量相对减少了 27%，约束时间的累计持续时间减少了 45%。
避免强制措施的复杂干预方案，结合了上述多个类别的元素，似乎特别有效。 未来，进行集群随机试验以研究干预措施的个别类别将是可取的。
