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Original article

Vol. 148 No. 1920 (2018)

Clinical course and prevalence of coercive measures: an observational study among involuntarily hospitalised psychiatric patients

  • Florian Hotzy
  • Sonja Mötteli
  • Anastasia Theodoridou
  • Andres R. Schneeberger
  • Erich Seifritz
  • Paul Hoff
  • Matthias Jäger
Cite this as:
Swiss Med Wkly. 2018;148:w14616



In daily clinical work, coercion continues to be highly prevalent, with rates differing between countries and sometimes even within countries or between wards of the same hospital. Previous research found inconsistent characteristics of individuals who underwent coercive measures during psychiatric treatment. Furthermore, there continues to be a lack of knowledge on the clinical course of people after being involuntarily committed. This study aimed to describe the rate and duration of different coercive measures and characterise a cohort of involuntarily committed patients regarding sociodemographic and clinical variables.


In this observational cohort study, we analysed clinical data from the patients’ medical files, the use of coercive measures (seclusion, restraint, coercive medication) and other procedural aspects in involuntarily hospitalised patients (n = 612) at the University Hospital of Psychiatry Zurich. For analysis, we used cross-tabulation with chi-square tests for categorical variables and, owing to a non-normal distribution, the Mann-Whitney U-test for interval variables.


Coercive measures were documented in 170 patients (28% of those who were involuntarily hospitalised). The total number of seclusions was 344, with a mean duration of 9 hours per seclusion. A total of 89 patients (15%) received 159 episodes of coercive medication (oral and intramuscular). Also, 11 episodes of restraint were recorded in 7 patients (1%) with a mean duration of 12 hours per restraint. Patients subjected to coercion were significantly more often male, violent prior to admission, diagnosed with psychosis or personality disorder, and had a history of frequent hospitalisations with long durations of hospitalisation.


The prevalence of coercive measures is still high in involuntarily hospitalised patients. Seclusion was the most frequently used coercive measure, which may be based on cultural and clinical aspects and differs from findings in other countries where restraint is more frequently used. Some sociodemographic and clinical characteristics were associated with the use of coercion. This underlines the importance of developing treatment strategies for patients at risk to prevent situations in which the use of coercion is necessary. To enable comparison between different study sites, standardised protocols should be used to document frequency and duration of coercive measures.


  1. Zinkler M, Priebe S. Detention of the mentally ill in Europe--a review. Acta Psychiatr Scand. 2002;106(1):3–8. doi:.
  2. Lay B, Salize HJ, Dressing H, Rüsch N, Schönenberger T, Bühlmann M, et al. Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring. BMC Psychiatry. 2012;12(1):136. doi:.
  3. Jäger M, Ospelt I, Kawohl W, Theodoridou A, Rössler W, Hoff P. Qualität unfreiwilliger Klinikeinweisungen in der Schweiz. Praxis (Bern). 2014;103(11):631–9. doi:.
  4. Salize HJ, Dressing H, Peitz M. Compulsory Admission and Involuntary Treatment of Mentally Ill Patients – Legislation and Practice in EU-Member States. 2002; Available from:
  5. Soininen P, Välimäki M, Noda T, Puukka P, Korkeila J, Joffe G, et al. Secluded and restrained patients’ perceptions of their treatment. Int J Ment Health Nurs. 2013;22(1):47–55. doi:.
  6. Molewijk B, Kok A, Husum T, Pedersen R, Aasland O. Staff’s normative attitudes towards coercion: the role of moral doubt and professional context-a cross-sectional survey study. BMC Med Ethics. 2017;18(1):37. doi:.
  7. Curran WJ. Comparative analysis of mental health legislation in forty-three countries: a discussion of historical trends. Int J Law Psychiatry. 1978;1(1):79–92. doi:.
  8. Hoff P. Zwangsmassnahmen in der Medizin. Schweiz Arzteztg. 2015;96(22):773–5. doi:
  9. Dressing H, Salize HJ. Zwangsunterbringung und Zwangsbehandlung psychisch Kranker in den Mitgliedsländern der Europäischen Union [Compulsory admission of mentally ill patients in European union member States]. Psychiatr Prax. 2004;31(1):34–9.
  10. Lauber C, Rössler W. Zwangsaufnahme in das psychiatrische Krankenhaus im Spiegel der öffentlichen Meinung und aus Sicht von Professionellen in der Psychiatrie [Involuntary admission and the attitude of the general population, and mental health professionals]. Psychiatr Prax. 2007;34(Suppl 2):S181–5. doi:.
  11. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Soc Psychiatry Psychiatr Epidemiol. 2010;45(9):889–97. doi:.
  12. Steinert T, Martin V, Baur M, Bohnet U, Goebel R, Hermelink G, et al. Diagnosis-related frequency of compulsory measures in 10 German psychiatric hospitals and correlates with hospital characteristics. Soc Psychiatry Psychiatr Epidemiol. 2007;42(2):140–5. doi:.
  13. Martin V, Bernhardsgrütter R, Göbel R, Steinert T. Ein Vergleich von Schweizer und deutschen Kliniken in Bezug auf die Anwendung von Fixierung und Isolierung [The use of mechanical restraint and seclusion: comparing the clinical practice in Germany and Switzerland]. Psychiatr Prax. 2007;34(Suppl 2):S212–7. doi:.
  14. Wierdsma AI, van Baars AW, Mulder CL. Psychiatrische voorgeschiedenis en nazorg bij dwangopneming. Zorggebruik als indicator van de kwaliteit van zorg bij inbewaringstellingen in Rotterdam [Psychiatric past history and health care after compulsory admission. Care use as an indicator of the quality of care for patients in compulsory care in Rotterdam]. Tijdschr Psychiatr. 2006;48(2):81–93.
  15. Knutzen M, Bjørkly S, Eidhammer G, Lorentzen S, Mjøsund NH, Opjordsmoen S, et al. Characteristics of patients frequently subjected to pharmacological and mechanical restraint--a register study in three Norwegian acute psychiatric wards. Psychiatry Res. 2014;215(1):127–33. doi:.
  16. Bilanakis N, Kalampokis G, Christou K, Peritogiannis V. Use of coercive physical measures in a psychiatric ward of a general hospital in Greece. Int J Soc Psychiatry. 2010;56(4):402–11. doi:.
  17. El-Badri SM, Mellsop G. A study of the use of seclusion in an acute psychiatric service. Aust N Z J Psychiatry. 2002;36(3):399–403. doi:.
  18. Migon MN, Coutinho ES, Huf G, Adams CE, Cunha GM, Allen MH. Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms. Gen Hosp Psychiatry. 2008;30(3):263–8. doi:.
  19. Larue C, Dumais A, Drapeau A, Ménard G, Goulet MH. Nursing practices recorded in reports of episodes of seclusion. Issues Ment Health Nurs. 2010;31(12):785–92. doi:.
  20. Happell B, Gaskin CJ. Exploring patterns of seclusion use in Australian mental health services. Arch Psychiatr Nurs. 2011;25(5):e1–8. doi:.
  21. Hendryx M, Trusevich Y, Coyle F, Short R, Roll J. The distribution and frequency of seclusion and/or restraint among psychiatric inpatients. J Behav Health Serv Res. 2010;37(2):272–81. doi:.
  22. Zhu XM, Xiang YT, Zhou JS, Gou L, Himelhoch S, Ungvari GS, et al. Frequency of physical restraint and its associations with demographic and clinical characteristics in a Chinese psychiatric institution. Perspect Psychiatr Care. 2014;50(4):251–6. doi:.
  23. Salize HJ, Dressing H. Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psychiatry. 2004;184(02):163–8. doi:.
  24. Riecher-Rössler A, Rössler W. Compulsory admission of psychiatric patients--an international comparison. Acta Psychiatr Scand. 1993;87(4):231–6. doi:.
  25. Faulkner LR, McFarland BH, Bloom JD. An empirical study of emergency commitment. Am J Psychiatry. 1989;146(2):182–6. doi:.
  26. Odawara T, Narita H, Yamada Y, Fujita J, Yamada T, Hirayasu Y. Use of restraint in a general hospital psychiatric unit in Japan. Psychiatry Clin Neurosci. 2005;59(5):605–9. doi:.
  27. Korkeila JA, Tuohimäki C, Kaltiala-Heino R, Lehtinen V, Joukamaa M. Predicting use of coercive measures in Finland. Nord J Psychiatry. 2002;56(5):339–45. doi:.
  28. Deutsche Gesellschaft für Psychiatrie und Psychotherapie. Psychosomatik und Nervenheilkunde. Praxisleitlinien in Psychiatrie und Psychotherapie Band 2: Therapeutische Maßnahmen bei aggressivem Verhalten in der Psychiatrie und Psychotherapie. Ed. Gaebel W, Falkau P. Berlin: Springer; 2010.
  29. Husum TL, Bjørngaard JH, Finset A, Ruud T. A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics. BMC Health Serv Res. 2010;10(1):89. doi:.
  30. Keski-Valkama A, Sailas E, Eronen M, Koivisto AM, Lönnqvist J, Kaltiala-Heino R. The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study. Nord J Psychiatry. 2010;64(2):136–44. doi:.
  31. National Institute for Mental Health in England. Results of a national census of inpatients in mental health hospitals and facilities in England and Wales. Available from:
  32. Beck NC, Durrett C, Stinson J, Coleman J, Stuve P, Menditto A. Trajectories of seclusion and restraint use at a state psychiatric hospital. Psychiatr Serv. 2008;59(9):1027–32. doi:.
  33. Knutzen M, Mjosund NH, Eidhammer G, Lorentzen S, Opjordsmoen S, Sandvik L, et al. Characteristics of psychiatric inpatients who experienced restraint and those who did not: a case-control study. Psychiatr Serv. 2011;62(5):492–7. doi:.
  34. Dumais A, Larue C, Drapeau A, Ménard G, Giguère Allard M. Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2-year retrospective audit. J Psychiatr Ment Health Nurs. 2011;18(5):394–402. doi:.
  35. Sercan M, Bilici R. [Restraint variables in a regional mental health hospital in Turkey]. Turk Psikiyatr Derg. 2009;20(1):37–48.
  36. Kalisova L, Raboch J, Nawka A, Sampogna G, Cihal L, Kallert TW, et al. Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study. Soc Psychiatry Psychiatr Epidemiol. 2014;49(10):1619–29. doi:.
  37. Jarrett M, Bowers L, Simpson A. Coerced medication in psychiatric inpatient care: literature review. J Adv Nurs. 2008;64(6):538–48. doi:.
  38. Fiorillo A, Giacco D, De Rosa C, Kallert T, Katsakou C, Onchev G, et al. Patient characteristics and symptoms associated with perceived coercion during hospital treatment. Acta Psychiatr Scand. 2012;125(6):460–7. doi:.
  39. Whitehead PD, Liljeros F. Heavy-tailed distribution of seclusion and restraint episodes in a state psychiatric hospital. J Am Acad Psychiatry Law. 2011;39(1):93–9.
  40. Flammer E, Steinert T, Eisele F, Bergk J, Uhlmann C. Who is Subjected to Coercive Measures as a Psychiatric Inpatient? A Multi-Level Analysis. Clin Pract Epidemol Ment Health. 2013;9(1):110–9. doi:.
  41. Gassmann J. Wirksamkeit des Rechtsschutzes bei psychiatrischen Zwangseinweisungen in der Schweiz. 2011. p. 1-51. Available from:
  42. Patel MX, de Zoysa N, Bernadt M, Bindman J, David AS. Are depot antipsychotics more coercive than tablets? The patient’s perspective. J Psychopharmacol. 2010;24(10):1483–9. doi:.
  43. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 2013: American Psychiatric Pub.
  44. Raboch J, Kalisová L, Nawka A, Kitzlerová E, Onchev G, Karastergiou A, et al. Use of coercive measures during involuntary hospitalization: findings from ten European countries. Psychiatr Serv. 2010;61(10):1012–7. doi:.
  45. Hatta K, Shibata N, Ota T, Usui C, Ito M, Nakamura H, et al. Association between physical restraint and drug-induced liver injury. Neuropsychobiology. 2007;56(4):180–4. doi:.
  46. Strout TD. Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature. Int J Ment Health Nurs. 2010;19(6):416–27. doi:.
  47. Smith SB. Restraints: retraumatization for rape victims? J Psychosoc Nurs Ment Health Serv. 1995;33(7):23–8.
  48. Hottinen A, Välimäki M, Sailas E, Putkonen H, Joffe G, Noda T, et al. Underaged patients’ opinions toward different containment measures: a questionnaire survey in Finnish adolescent psychiatry. J Child Adolesc Psychiatr Nurs. 2012;25(4):219–23. doi:.
  49. Dack C, Ross J, Bowers L. The relationship between attitudes towards different containment measures and their usage in a national sample of psychiatric inpatients. J Psychiatr Ment Health Nurs. 2012;19(7):577–86. doi:.
  50. Steinert T, Schmid P. Effect of voluntariness of participation in treatment on short-term outcome of inpatients with schizophrenia. Psychiatr Serv. 2004;55(7):786–91. doi:.
  51. Gudjonsson GH, Rabe-Hesketh S, Szmukler G. Management of psychiatric in-patient violence: patient ethnicity and use of medication, restraint and seclusion. Br J Psychiatry. 2004;184(03):258–62. doi:.
  52. Fiorillo A, De Rosa C, Del Vecchio V, Jurjanz L, Schnall K, Onchev G, et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study. Eur Psychiatry. 2011;26(4):201–7. doi:.
  53. Hotzy F, Jaeger M. Clinical Relevance of Informal Coercion in Psychiatric Treatment-A Systematic Review. Front Psychiatry. 2016;7:197. doi:.
  54. Appelbaum PS, Le Melle S. Techniques used by assertive community treatment (ACT) teams to encourage adherence: patient and staff perceptions. Community Ment Health J. 2008;44(6):459–64. doi:.

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