Prevalence of restraint use in psychiatric inpatient care facilities in India: A systematic review

Coercive interventions may be required during psychiatric in-patient care, but require careful monitoring to minimize inappropriate use.

In this article, we aimed to systematically review published literature on the frequency and patterns of selected coercive methods in mental health establishments (MHEs) in India.

From a systematic screening of four databases (MEDLINE, EMBASE, CINAHL and PSYCINFO) supplemented by searching relevant citations and selected journals, we retrieved studies of frequency and patterns of mechanical restraint, chemical restraint and seclusion at Indian MHEs.

Nine studies reported 1595 restraint events over 62699.86 in-patient days, i.e between 1.64 to 175.71 events per 1000 in-patient days or 16.38 to 195.22 events per 100 admissions. Chemical restraints using combinations of haloperidol with promethazine or lorazepam were preferred over physical restraints or combined physical/chemical restraint in most (8/9) studies. No clear patterns of acuity, setting or diagnostic break-up could be ascertained. No studies reported on the use of seclusion. From these results, we estimate that in a 30 bedded fully occupied psychiatric unit in India, a median of 43 admissions, 7 restrained patients and 26 monthly restraint events occur per month.

The varied rates suggest differences in clinical practice including practice culture (eg the involvement of caregivers), but might also reflect incomplete or inconsistent reporting. Determinants of restraint, which may operate at the level of the patient characteristics, staffing, or ward culture; needs further delineation. Finally, restraint reports are rare, and uniform reporting guidelines will help policy makers understand the phenomenon better.