Background
The deinstitutionalisation of psychiatric services has led to an increase in international discussion [
1‐
3] about human rights and coercive practices in psychiatric hospitals. The degree of deinstitutionalisation in psychiatric services in Finland has been among the highest across Europe [
4]. As a result of this, the number of psychiatric beds decreased by about 50% between the years 1993 and 2011 [
5]. Rapid changes in the treatment system have meant new opportunities for reformed out-patient care and patient social participation [
6]. Currently, the number of out-patient treatment periods in psychiatric specialised care is almost 12 times the number of treatment periods in hospital care (2.25 million treatment periods versus 195 000 periods, respectively) [
7].
Despite of structural and ideological changes in mental health service, seclusion, restraint, and forced medication is being used in many psychiatric hospitals [
8‐
11]. However, the recent results in reducing the use of coercive measures are promising [
12‐
15]. Less restrictive interventions have been used to prevent and manage patient violent behaviour, including de-escalation techniques [
16], improving collaboration between patients and nurses, developing organisational culture and safe ward environments [
17‐
20] and training staff members [
21]. Although patient-related factors, like psychotic symptoms [
22], organic mental disorder [
23], young age [
24] and perceived coercion [
22] have been found to increase the risk to be coerced during hospital admission, the factors associated with patient coercion are more complex. For example, the staff’s priority in treatment may emphasise safety issues and would therefore have a higher acceptance for intrusive measures than patients [
25,
26]. Other factors related to the treatment environment were found in a study by Pettit et al. [
27]. Based on their findings, the authors concluded that the availability of a seclusion room may be related to the use of seclusion, as staff members are more likely to consider seclusion as an acceptable method of managing aggressive incidents when there is a designated space for it.
On the other hand, understanding the realities of patient coercion is challenging due to differing registration systems, daily practices [
28,
29] and staff attitudes towards the use of coercion [
30,
31]. Therefore, decreasing the use of coercive measures in daily practice may be challenging. In Finland, the Ministry of Social Affairs and Health launched the National Mental Health Policy in 2009 to reduce the need for using coercive measures in psychiatric services [
32]. After strong initiatives and the implementation of the national strategy between 2006 and 2013, substantial decreases in the use of seclusion rooms (incidence rate ~ 30%, a prevalence of 40 to 27/100,000 inhabitants) and mechanical restraints (incidence rate ~ 38%, a prevalence of 24 to 14/100,000 inhabitants) were reported [
33], although there is still room for improvement, considering the corresponding numbers in other Scandinavian countries. On the other hand, in the broader international context, the use of coercive measures in Finland is at a satisfactory level [
28,
34].
Despite a reduction in the prevalence of coercion practices in Finland, there is still a need to better understand the current trends of the use of patient coercive measures due to ethical and practical issues [
35]. Further, a systematic review has concluded [
36] that more research is needed to formally evaluate the outcomes of the implementation of risk monitoring systems and to assess their effectiveness in health services regarding use of coercive measures. Therefore, in this study we ask three specific research questions. First, are the change trends for the different coercive measures similar? Second, is the use of coercive measures the same in different regions? Third, if the use of coercive measures is not the same in the different regions, how does it vary? The answers to these questions may fill the gap in our understanding of the context and lead to the future improvement of service at the national level. To our knowledge, this is the first nationwide study based on non-selected register data on actual use of coercive measures and its variation over two decades. We focus on inpatient psychiatric care because, in these services, the use of coercive measures is allowed under the Mental Health Act, 1116/1990 [
37]. We examined trends between 1995 and 2014 because, for that time period, the reporting system of patient coercive practices is more consistent between hospitals and years.
In this study and for the psychiatric patient population, we first examined the overall prevalence rates of coercive use, both generally and by specific type of coercive measures. Based on the strong emphasis in Finland to decrease the use of coercive measures in psychiatric hospitals [
32], we assumed that we would find evidence that the prevalence of coercive measures used in psychiatric hospitals had decreased during the last two decades. We further identified the trends in prevalence rates of coercive measures use on all inpatients admitted during 1995 to 2014, stratified by gender. Finally, we used a multilevel modelling approach, which took into account that patients were nested within care providers, and that patient age was confounded with the treatment period. We investigated the trends in the change of prevalence rates, looking at the difference between gender and geographic areas, and variations across psychiatric care providers.
Discussion
Our study provides novel insight into how coercive measures have been used during the last two decades in Finnish psychiatric treatment services. This is the first study where coercive measures have been analysed, in detail and over such a long period of time, based on national register data. We assumed that we would find evidence that the prevalence of coercive measures used in psychiatric hospitals has decreased during the last two decades. Despite a decline in the number of patients admitted into psychiatric hospitals, the number of coerced patients has not decreased in the same manner. This finding is somewhat contradictory to our preliminary assumption.
In our study, we did not observe a linear declining trend in the decrease of coercive measures. At the same time, the data showed that the trends in the use of different coercive measures are changing. Seclusion is still the most commonly used coercive measure in psychiatric hospitals, and the rate of limb restraints shows a consistent decline (1.86-fold reduction from 5.10 in 2001 to 2.74% in 2014). However, the use of forced injection and physical restraints rose from 2010 to 2013, but went down in 2014. There are a few assumptions which may shed some light on our findings. First, compared to many other countries, the proportion of psychiatrists and nursing staff in Finnish mental health services per 100,000 inhabitants is one of the highest in the world [
67]. Therefore, the high number of patient coercion cannot be explained by the lack of manpower. We can ask, though, whether staff have enough knowledge to use the alternative methods for managing patient aggression [
68]. On the other hand, the statistics show that in Finland approximately €150 million (including indirect costs) has already been invested in continuing education in health and social services for staff every year [
69], although in 2015, the average expenditure by enterprises on continuing vocational training courses in 28 EU countries was higher than that in Finland (1,418 purchasing power standards per participant vs. 1,257 in Finland) [
70]. Second, staff may have favourable attitudes toward intrusive measures because of a strong emphasis on safety issues at work [
25,
26]. However, in Finland, the decision of whether the need for treatment, or the harmfulness of the patient’s behaviour is serious enough to justify coercion to ensure safety is made based on clinical judgement [
71]. Therefore, a more systematic analysis of the use of coercive measures should be conducted on a national level. The development of the practices should also follow the principles set by the United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) [
72]. In addition, national clinical guidelines could harmonise practices by giving recommendations based on existing evidence at the highest level gathered from interventions that have already been carried out [
14,
19,
21].
Our model-estimated and adjusted trend shows an increased prevalence rate from 1995 to a peak in 2001, and a slow decline from 2002 to 2007, followed by a consistent linear decrease from 2007 to 2014. Radical changes in coercion rates from 2001 to 2002 may be the result of new regulations in the Mental Health Act, 1423/2001 [
73], specifically regarding the use of seclusion and restraint. An explicit regulation about the use of mechanical restraint and seclusion has been included in the Mental Health Act since 2002 [
28], which aims to define specific reasons for limiting the rights of involuntarily treated patients as well as to standardise coercive measures nationwide [
8]. Indications of using coercive measures may explain the sharp downturn in the rates of these measures, and the continuing declining trend in the rate of coercive measures after 2002. In 2008, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) once again visited Finland. As an outcome of the visit, the committee required Finnish authorities to urgently provide a detailed action plan to significantly reduce the frequency and duration of using patient seclusion [
74]; this could be another explanation for the downturn. Further, the national action plan for 2009–2015 [
75] aimed to increase awareness of the importance of reducing coercive measures by organising national meetings and workshops and increasing the awareness of staff about the need to decrease coercive measures. Still, the reduction in the overall use of coercive measures is quite small. From 1995 to 2014, there was a 1.11-fold reduction in the rate from 10.2 to 9.2/100 inpatients. Although national and regional guidelines and acts have offered a direction for the changes in clinical practices during the last two decades, these approaches may not be integrated into current practices.
We found in our study a significantly lower overall prevalence of seclusion and limb restraints use on female patients compared to that of males. On the contrary, female patients had a higher prevalence of forced injection. Georgieva et al. [
76] conducted a randomised clinical trial to evaluate whether seclusion and coercive incidents would be reduced by using involuntary medication. The authors conclude, based on their findings, that although the use of involuntary medication could successfully replace and reduce the number of seclusions, alternative interventions are needed to reduce the overall number and duration of coercive incidents [
76]. Therefore, keeping this finding in mind, a wider variation of treatment alternatives should be found to prevent and manage challenging situations on the wards. These alternatives could include non-invasive methods, such as the use of a ‘soft room’ or a one-on-one patient sitter, which may be more easily accepted by patients [
77]. Using alternative methods would be important because patients themselves have found the use of coercive measures to be frustrating, traumatising [
78], distressing [
79], and a less-than-humane experience [
80]. Having these negative experiences may increase the risk of non-adherence in treatment, especially for young males [
81]. On the contrary, if staff members perceive coercive measures as curative, not too much personal tension by staff members has been put on the current situation. We can also ask why changes in patient coercion practices have not happened in Finland corresponding with economic growth in the country [
82], higher education levels [
83] and the high level of well-being of residents [
84]. Finland also has the highest human capital in the world [
85], and the quality of health care and provisions are very good [
86]. Further, Finland has been named as the world’s safest country [
87], where people are highly satisfied with life [
88].
If a failure to markedly reduce the use of coercive measures is explained by the lack of awareness of the value of treatment culture or by the identification of those patients who are specifically at risk to be coerced, we urgently need to be aware of factors related to each patient’s risk to be coerced in order to develop interventions for reducing the use of coercion in the future [
22]. The importance of conducting meetings with psychiatrists, nurses and patients after the use of coercive measures has also been highlighted [
89]. Further, family members should also be included in the treatment system when aiming to reduce involuntary treatment [
90]. While several studies have shown that it is possible to develop treatment systems using novel interventions [
14,
19,
21], more emphasis should be put on evidence-based interventions to reduce coercion in psychiatry.
Strengths and limitations
Using data from a nationwide register gives the unique opportunity to get a deeper understanding of general trends in Finnish society. Our sample included all adult patients who were hospitalised as inpatients in a psychiatric care providers in Finland during a 20-year period. Methodological biases should be considered. First, the definitions [
3,
91] and legislations [
92] used to describe and guide patient coercive measures in psychiatric settings may vary, which may restrict the generalisability of the study results for various geographical areas such as in Åland, possibly due to the small number of patients each year. Second, our register data were retrospectively collected, and therefore the data may provide more a follow-up type of information, which always includes a risk for biases, such as mistakes in data collection [
93].
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