Context

While the percentages of coercive interventions in psychiatry vary in different countries and clinical settings, global initiatives are increasingly aimed at preventing and reducing these interventions in the mental health and community settings.1–3 Policymakers, academics, healthcare leaders and clinicians urge on reducing restrictive practices that are often harmful and contradict trauma-informed care and human rights.2 4 Hospitals and community mental health settings (CMHS) should apply for government grants to reduce coercive treatments such as seclusion and involuntary medication through developing integrated care interventions and interprofessional training.1 Haines et al aimed to ‘systematically search the literature on how nurses identify and manage harms associated with using coercive interventions in the CMHS and explore the ethical challenges in this practice’.2

Findings

The literature review revealed three main themes: (1) maintaining therapeutic relationship as nurses recognise that developing a therapeutic relationship with clients and their families is crucial in CMHS, (2) promoting autonomy as nurses encourage individuals with mental illness live an independence life as they assume responsibility and (3) using subtle form of control in a sense that nurses realise that they need to reduce their level of control in the CMHS.2

Commentary

Coercive treatment is common in mental health context and encompasses wide range of the use of forced practices including involuntary admission, seclusion and restraint.2 3 5 Haines et al’s review revealed a dearth of research about the ethical challenges associated with the use of coercion by nurses in CMHS and contended that nurses play certain roles in CMHS and experience ethical challenges.2 Another scoping review focused on ‘empirical studies on preventing and reducing coercive practices in mental health settings while acknowledging lack of systematic review of efforts to prevent and reduce coercive practices in the mental health field’.1

One comprehensive umbrella review employed an ‘independent assessment of quality and risk of bias in all reviews and then categorised them into the following two categories: (1) evidence of specific coercive measures (eg, forced treatment, involuntary admissions, seclusion, restrictions and informal coercions) considering their prevalence, related factors, harmful effects and options to reduce them and (2) experiences, perceptions and attitudes related to coercion of professionals, mental health service users and their caregivers or relatives’.5 Notably, seclusion and restraints were the main research topics of the systematic reviews included in the umbrella review.5 To sum up, findings of the scoping reviews call for further research on current and recent efforts to prevent and reduce coercive and compulsive practices in mental health context and to introduce legislation, national policy and hospital and community initiatives with the goal of advocating for consumer’s autonomy and human rights.1 2 Future qualitative (most importantly phenomenological research1), quantitative and mixed-method studies in both low-income and high-income countries should focus on strengthening the credibility of the evidence related to efficacy of interventions to reduce coercive treatments.1 3