Seclusion or restraint is used as an intervention of last resort in the management of severe agitation (e.g., violence) in patients. Both are highly regulated by local, state, and federal law and other health care accreditation organizations. Patients, families, and psychiatrists may be concerned about these interventions as they can cause significant psychological distress and/or physical injury as well as perpetuate the stigma of mental illness. The American Psychiatric Association (APA) recognizes these concerns, and its Patient Safety Work Group (of the APA Council on Quality Care) has developed a resource document on seclusion or restraint (.pdf) to provide practical advice to psychiatrists and other mental health care workers to promote safe and quality mental health care.

“Seclusion or restraint (S/R) may only be used as interventions of last resort in the management of severe agitation in patients. Both carry risks to patients and staff that must be considered in deciding which one or whether to use them at all in a given clinical situation. Restraint should be used rarely. Seclusion should be minimized. Both S/R episodes should be as short as possible, dignified, and as safe as possible for all involved. Patient preference should always be considered when feasible.” APA Resource Document: Seclusion or Restraint

Psychiatrists strive to avoid the use of seclusion or restraint (S/R) and work with patients, their family members, and care teams to find alternatives that help calm agitation and prevent injury to patients and staff as well as maintain the patient’s dignity and ability to participate in the choices for their care. This new APA resource document outlines several areas for psychiatrists and other mental health care workers to consider in order to minimize its use and to ensure safety if used.

Major themes of this resource document are standardization of care to promote patient safety, understanding risks and preventing harm, reducing the overall S/R use, patient-centered care, and mental health equity. Increasing awareness and providing education to current and future psychiatrists and other mental health care workers are also important goals of this resource document. Tools to help in patient care decisions regarding S/R and further reading are also provided.

In summary, the Patient Safety Work Group of the APA Council on Quality Care recommends “a comprehensive approach to preventing the use of seclusion and restraints, and emphasize appropriate clinical education, standardized processes for patient safety, and attention to health equity when such interventions of last resort are necessary.”

Psychiatric advance directives

Another area highlighted in this resource document is the importance of and the ability of patients to express their preferences, ahead of time, regarding psychiatric treatment, including agitation. This can be done using a psychiatric advance directive (PAD). A PAD can include:

1. Preference of medications that are known to have been effective for agitation in the past.
2. A list of people who can participate in the patient’s care while in an acute mental health crisis.
3. Preference of seclusion or restraints if used, etc.

Psychiatrists and other mental health care workers can use PADs to preserve the patient’s autonomy as much as possible. More on advance planning and psychiatric advance directives

More on advance planning and psychiatric advance directives

• National Resource Center on Psychiatric Advance Directives - provides links to state-by-state information
• American Psychiatric Association
  • Putting a Care Plan in Place Before a Mental Health Crisis
  • Advanced Care Planning – It’s Not Just for Your Grandparents
• National Alliance on Mental Illness (NAMI) - Psychiatric Advance Directives

By: Patient Safety Work Group of the APA Council on Quality Care:

• Jose A. Arriola Vigo, M.D., M.P.H.
• Erick H. Cheung, M.D.
• Molly T. Finnerty, M.D.
• Jeffrey Rado, M.D., M.P.H.
• and Jacqueline A. Hobbs, M.D., Ph.D. (Chair)