Concern at rise in physical restraint in mental health centres in 2020

A total 1,880 people were restrained or secluded across Ireland's mental health centres last year, according to a report from the Mental Health Commission.

In response to an increase in the use of mechanical restraint – hand and leg cuffs – by a child and adolescent service in relation to one person, the commission sought specific assurances about the circumstances and manner in which that was being used, the report discloses.

The commission expressed concern about an overall upward trend in the use of physical restraint across centres, with the numbers higher last year than when it began recording use of restrictive practices in 2008, but noted the use of mechanical restraint here was “relatively uncommon”.

It welcomed an overall decline in the use of seclusion since 2008 and said that may be a result of its restraint reduction strategy, introduced in 2014 with the aim of ensuring restrictive practices are only used as “a last resort”.

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"It is encouraging once again to see a reduction in the overall use of restrictive practices in 2020," said the commission's director of regulation, Gary Kiernan.

“We know that there is no evidence of a therapeutic benefit associated with the use of seclusion, mechanical restraint or physical restraint, and they should never be regarded as a therapeutic practice.”

The commission “strongly advocates for the use of de-escalation measures over restrictive practices” and has since 2017 required mandatory training for all healthcare professionals in approved centres in the prevention, de-escalation and management of violence and aggression, he said.

Pandemic impact

The report, concerning 66 inpatient mental health centres in the State, is the 11th annual examination by the commission of the use of restrictive practices.

Covid-19 had a significant impact on how the centres operated last year and may have impacted on the operation and frequency of restrictive practices, it noted.

A public consultation process and review of the 2010 rules and code of practice governing the use of restrictive practices is expected to be completed by the commission by mid-2022.

According to the latest report, 5,830 episodes of restrictive practices were reported to the commission in 2020, with 1,880 people secluded and/or restrained during that time.

This was down from 6,741 combined episodes of seclusion and physical restraint, involving 1,796 residents, in 2019. Males accounted for 62 per cent of those secluded and 51.7 per cent of those physically restrained.

There was a 21 per cent decrease in episodes of physical restraint in 2020, with 3,990 episodes involving 1,211 people recorded, compared with 5,029 episodes involving 1,443 people in 2019.

Physical restraint was the most frequently used restrictive intervention, used in 48 centres and accounting for 68 per cent of all interventions in 2020, down from 75 per cent in 2019.

There were 1,840 episodes of seclusion involving 699 people in 41 per cent of centres in 2020, an increase on 1,719 episodes in 2019.

There were 243 episodes in 2020 where a person was secluded for more than 24 hours (up from 225 episodes in 2019), and 74 episodes for over 72 hours (up from 61 episodes in 2019).

Average seclusion

The average seclusion duration across all approved centres (excluding the Central Mental Hospital) was 14 hours and 12 minutes; 38 per cent of the secluded were secluded for eight hours or less.

While the use of mechanical restraint was higher in 2020 than in 2019, this practice continues to be “relatively uncommon”. Two centres – the Central Mental Hospital and a child/adolescent centre – reported the use of mechanical restraint, use of hand and leg cuffs, to prevent harm to self or others. The reported 150 episodes lasted a total 3,452 hours, compared with 18 episodes lasting 34 hours in 2019.

The number of recorded episodes of mechanical restraint remains low but there was a significant increase in episodes involving a small number of residents in 2020, he said.

“The MHC is hopeful that in 2021 and beyond, the frequency of mechanical restraint returns to the low numbers observed in previous years.”