Letter

Coercive physical measures are often perceived by patients as traumatic and harmful experiences ( 1 ) and contribute to consumers' negative attitudes toward psychiatric treatment. As part of our study on the use of restraint and seclusion in the psychiatric unit of the University General Hospital of Ioannina in Greece, we documented the attitudes of patients and their relatives toward coercive measures.

The study setting and procedures have been described elsewhere ( 2 ). Data were collected retrospectively by chart review. Among 282 patients admitted to the hospital's psychiatric ward in a six-month period (December 2006 to May 2007), there were 31 cases of restraint (defined as the use of belts to secure a patient to a bed) and seclusion (defined at placing a patient in a locked room). After the episodes of restraint or seclusion, while the patients were still hospitalized, all were asked directly whether they considered the coercive measures justified and whether they perceived the experience as harmful. At the same time they were asked about their preferences in case of a future crisis, as in an advance directive. All answers were recorded in the patients' charts.

Of the 25 patients, 20 (80%) believed that their coercion was unjustified and perceived it to be a traumatic experience. The other five patients stated that the coercion was needed; two of these patients considered their experience harmful. Records indicated that only seven of the 25 patients (28%) had the decision-making capacity to state an advance directive. Of the seven patients, four preferred the use of an alternative to seclusion or restraint for managing a future crisis; however, conclusions cannot be drawn because of the small subgroup size.

The attitudes of 28 relatives were documented. Twenty-five (89%) believed that the decision to restrain or seclude the patient was justified. They agreed that coercion in these cases was the last resort for the prevention of potentially dangerous behavior and stated that the coercion had not been used for medical or punitive reasons.

Our study indicates that patients tend to perceive coercion as unjustified and harmful. This finding is in accord with those of other ( 3 ), but not all ( 4 ), previous studies of patients' views of coercive measures. The differences may be attributable to variations in methodology and patient samples. Nevertheless, clinicians and administrators need to recognize and respect the views of patients about these coercive procedures and engage in ongoing efforts to limit their use.

It is important for care planning to record and evaluate the attitudes of patients and their families toward use of coercive measures and to integrate these findings in mental health policy making. Careful documentation of these attitudes will enhance research on alternatives to coercion for containing patients' potentially dangerous behavior.

Dr. Bilanakis is affiliated with the Department of Psychiatry, General Hospital of Arta, Arta, Greece. Dr. Peritogiannis is with the University of Ioannina Medical School, Ioannina, Greece.