Post-incident debriefing for people with schizophrenia after coercive measures.

Abstract

Background: 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 methods: 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.