Key messages
• Due to a lack of evidence, the benefits of post-incident debriefing after coercive measures (seclusion: locking someone in a separate room, or restraint: preventing them from moving) for people with schizophrenia or schizophrenia-type psychosis are unclear.
• Future research is needed into the effects of post-incident debriefing after coercive measures to find out whether it has benefits for people with schizophrenia and whether it has unwanted effects and costs.
What is schizophrenia, and what are seclusion and restraint?
Schizophrenia is a severe mental health condition that affects how people think, feel and behave. Schizophrenia and related psychotic disorders significantly impact millions of people globally, and pose challenges due to their diverse symptoms, economic burden and the risk of a person being locked in a secure room (seclusion) or prevented from moving (restraint), particularly if their behaviour is violent. Post-incident debriefing is suggested as a way to reduce the use and duration of these measures, and aims to ensure safety while acknowledging the ethical concerns and potential psychological harm that such measures may cause.
Seclusion is a coercive measure, which means locking a person into a separate room in a psychiatric ward. Restraint means preventing a person from moving, manually by staff members, or with different equipment, such as belts. These measures should be used as a last resort to prevent a person from hurting themselves or others. Post-incident debriefing can be used after these coercive measures and is a form of talking therapy. It aims to allow staff and people who have experienced coercion to learn from the event and so prevent future episodes of coercion.
What did we want to find out?
We wanted to find out the benefits and harms of post-incident debriefing after coercive measures for people with schizophrenia or schizophrenia-type psychosis.
What did we do?
We carried out a comprehensive search in specialised databases to identify studies in which people with schizophrenia were randomly assigned to two or more treatment groups to assess post-incident debriefing in adult psychiatric care.
What did we find?
We found one relevant study with data for 109 people. This study involved standardised post-incident debriefing until the person left hospital. People who received post-incident debriefing after coercive measures may be more likely to be secluded again compared to those receiving standard treatment, but this is very uncertain. The evidence supporting this result is based on one study, and we have very limited confidence in this finding. There was no evidence to suggest that people are less distressed during or immediately after the event or that they are more satisfied with their care compared to standard treatment. Again, we have very limited confidence in this finding. There was not enough information to determine changes in patient behaviour or unwanted or harmful effects.
What are the limitations of the evidence?
We have very little confidence in these findings because we only found one small study, and there were problems with how it was designed and reported. Although post-incident debriefing is common practice in clinical settings, the evidence is currently not available to support it in current forms. The findings of this review therefore suggest caution in its use. The review highlights the need for further high-quality studies to thoroughly assess the effects of post-incident debriefing in psychiatric inpatient care. Any post-incidence debriefing measures should be clearly defined and described so that people know how and why to use them in daily practice.
How up to date is this evidence?
This evidence is current to February 2023.
Read the full abstract
Schizophrenia and schizophrenia-type psychosis, severe mental illnesses globally impacting millions, present a dual challenge with their characteristic positive and negative symptoms, economic burdens, and heightened susceptibility to coercive measures. These measures, including seclusion and restraint, raise ethical concerns despite their intent to ensure safety, particularly during acute stages marked by violent behaviour. Addressing this backdrop, the significance of post-incident debriefing as an intervention to curtail the use and duration of coercive measures and alleviate the negative psychological effects of using these methods in managing individuals with schizophrenia is underscored. The employment of coercive measures, such as physical restraint and seclusion, to manage aggressive behaviour in psychiatric settings necessitates a thorough examination of their ethical implications and potential psychological harm. Although post-incident debriefing is recommended, the limited evidence supporting its efficacy and concerns about its impact on psychological well-being prompt a comprehensive analysis of existing literature.
Objectives
To investigate the effects of post-incident debriefing after coercive measures for people with schizophrenia or schizophrenia-type psychosis.
Search strategy
The Information Specialist conducted searches of the Cochrane Schizophrenia Specialised Register (compiled from searches of CENTRAL, MEDLINE, Embase, PubMed, CINAHL, PsycINFO, ClinicalTrials.gov, WHO ICTRP, ISRCTN, ProQuest Dissertations and Theses A&I) on 28 February 2023. We also inspected the references of all identified studies.
Selection criteria
We included all randomised controlled trials (RCTs) of post-incident debriefing after coercive measures in adult psychiatric care with participants diagnosed with schizophrenia or schizophrenia-type psychosis, encompassing various clinical states and stages. We considered studies if the post-incident debriefing was the only intervention randomised.
Data collection and analysis
At least two authors inspected the citations, selected studies, extracted data and conducted quality appraisal. We calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous outcomes. We assessed study risk of bias and used the GRADE approach to create a summary of findings table.
Main results
We included one study; the total number of participants randomised was 422, of which 109 participated. Participants were between 18 and 65 years old with psychotic disorder, at the acute stage of their illness, and had experienced at least one coercive measure during their hospital stay. The study included a standardised post-coercion review that was conducted until the discharge of the participant.
For the primary outcome, we found that there may be an increased risk of being secluded again for those receiving post-incident debriefing compared to treatment as usual, but the evidence is very uncertain (RR 1.32, 95% CI 0.74 to 2.33; 1 study, 109 participants; very low-certainty evidence).
No evidence was found that post-incident debriefing had an effect in reducing peritraumatic distress (MD -1.62, 95% CI -7.47 to 4.23; 1 study, 82 participants; very low-certainty evidence) or increasing satisfaction with care (perceived coercion: MD -0.37, 95% CI -1.59 to 0.85; 1 study, 109 participants; coercion experience: MD -1.61, 95% CI -13.36 to 10.14; 1 study, 109 participants; very low-certainty evidence) compared to treatment as usual. The evidence is very uncertain about the effect of post-incident debriefing on these outcomes.
No usable data were available for change in patient behaviour or adverse effects.
Authors' conclusions
Considering the available evidence, it is not possible to arrive at definitive conclusions that post-incident debriefing after coercive measures is effective for people with schizophrenia or schizophrenia-type psychosis. Further high-quality studies are warranted to evaluate the effects of post-incident debriefing in psychiatric inpatient care.
