Use Of Seclusion Research Articles

2.126 Developing a Model Curriculum to Improve De-Escalation Skills of Child and Adolescent Psychiatry Physicians in Training

Many studies have examined the effectiveness of de-escalation training in reducing the use of seclusion and restraint in adult inpatient psychiatry settings, but few have published their training materials or adapted these techniques to child and adolescent populations. This project applies de-escalation techniques to child and adolescent patients and creates a model curriculum accessible to residency and fellowship programs across the nation.

83.4 Safe Use of Restraint and Seclusion

The process of restraining a patient suffering from extreme agitation/aggression is one of the dangerous and unsafe events a child and adolescent psychiatrist will encounter during their career, typically in the setting of an emergency department or in acute or residential hospitalization. The majority of our evidence base and research has appropriately focused on the importance of reducing these restraint and seclusion events. Unfortunately, less attention has been focused on the best practice for physically restraining patients.

Change over time: the use of seclusion in secure residential youth care in The Netherlands

ABSTRACT Seclusion can be harmful for children and adolescents. Hence, all locations for secure residential youth care in the Netherlands are committed to reduce its use by implementing monitoring and feedback as a seclusion reduction intervention. This study examined change over time in the use of seclusion in secure residential youth care in the Netherlands using a broad conceptualization of seclusion and by analyzing four variables (frequency, duration, room, reason). During two six months periods, seclusions were registered in 19 locations. Every month, all locations received feedback on the use of seclusion. Negative binomial mixed model analyses were used to investigate change over time in frequency and duration of seclusion. Logistic mixed model analyses were used to identify change over time in reason for use and type of room used for seclusion. Results showed that seclusion frequency significantly decreased (RR = 0.92, p < .001). Further, duration of placement in a seclusion room significantly increased (RR = 1.04, p < .001). This change was only significant in seclusion in response to aggression (RR = 1.06, p < .001). The results emphasize the need for future studies to examine reduction using a broad conceptualization of seclusion.

Understanding the influence of nursing staff characteristics on the use of seclusion and restraint in the adult forensic inpatient setting: a systematic literature review

Background/Aims Seclusion and restraint use in health care is controversial. Such practices occur more frequently in forensic mental health settings than in acute mental health settings. There is growing interest in staff factors and their influence on such practices. The aim of this review was to identify and appraise studies that explore whether nursing staff characteristics, including age, gender, ethnicity and physical stature, influenced the use of these practices in forensic mental health settings. Methods Eight electronic databases were searched to identify research studies published between 2010–2020. The search yielded 1085 articles, three of which fulfilled the inclusion criteria. Results There was no significant correlation between age, gender and experience and the tendency to use seclusion and restraint. No studies examined ethnicity, physical stature, seniority or role. Conclusions The results demonstrate a paucity of research on nursing staff characteristics and their influence on seclusion and restraint in this setting. Such research may inform violence prevention strategies.

Effects of Ending the Use of Seclusion and Mechanical Restraint in the Pennsylvania State Hospital System, 2011-2020.

The Pennsylvania State Hospital System's use of containment procedures has been studied for >30 years. This prospective study assessed the effects of ending the use of seclusion and mechanical restraint in the system's six civil hospitals and two forensic centers from 2011 to 2020. The study examined the effect of this change on key safety measures: physical restraint, assaults, aggression, and self-injurious behavior. In total, 68,153 incidents, including 9,518 episodes of physical restraint involving 1,811 individuals, were entered into a database along with patients' demographic and diagnostic information. All data were calculated per 1,000 days to control for census changes. During the study, mechanical restraint was used 128 times and seclusion four times. Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 2.02 in 2020. The average length of time a person was held in physical restraint was reduced by 64%, from 6.6 minutes in 2011 to 2.4 minutes in 2020 (p<0.001). All safety measures improved or were unchanged. Use of unscheduled medication did not change. The hospital system safely ended the use of mechanical restraint and seclusion by using a recovery approach and by following the six core strategies for seclusion and restraint reduction.

Nigeria's mental health and substance abuse bill 2019: Analysis of its compliance with the United Nations convention on the rights of persons with disabilities

Countries are struggling with reconciling their national mental health legislation with the CRPD approach, which stresses equality as the focal point of legislation, policies, and practices that affect people with disabilities. Several failed attempts have been made over the last two decades to update Nigeria's obsolete mental health legislation. The most recent attempt is the Mental Health and Substance abuse Bill 2019, which aims to protect the rights of people with mental health needs. It addresses many areas neglected by previous bills, such as non-discrimination of people with mental and substance use problems in the exercise of their civil, political, economic, social, full employment, religious, educational, and cultural rights. It categorically prohibits the use of seclusion in the treatment of people with mental health problems, makes provision for service users to be members of the Mental health review tribunal and allows for the protection of privacy and confidentiality of information about people with mental health problems. While keeping to most of WHO's recommendations for mental health legislation, the bill diverges from the CRPD's recommendations by allowing forced admission and treatment based on mental capacity, substitute decision-making by legal representatives or closest relatives, and non-prohibition of coercive practices. The bill does not make provisions for advance directives and is silent on informed consent to participate in research. Despite the bill's deficiencies, it would be a significant step forward for the country, whose current mental health legislation is the Lunacy Act of 1958. Although the CRPD has left it unclear how countries, especially low resource countries, should go about creating a workable legal framework, it is clear that all countries are expected to join the current global effort to eliminate, or at least reduce to the barest minimum, the use of coercion in mental health care. We expect that future revisions of this bill will examine its limitations in light of Nigeria's socio-cultural context.

La Palette des émotions : une médiation graphique pour améliorer les pratiques d’isolement et de contention

Background and objectivesThe use of seclusion and restraint within mental health settings has long been considered controversial. According to the literature, patient experiences of seclusion and restraint are mainly negative, harmful or traumatic. Patients express a need to discuss the seclusion or restraint event and their feelings afterwards. This paper describes the Emotional Palette, a graphical tool for enhancing patients’ expression of emotional experience after seclusion or restraint. Materials and methodsOn the basis of a focused review of literature, demonstrating the relevance of investigating patients’ experiences after seclusion or restraint, this article presents the Emotional Palette, a graphic tool created in a psychiatric ward for helping patients express their emotional experience. This graphical tool (figure 1) consists of a coloured checkerboard which presents terms typically used to express emotions relating to seclusion or restraint's experience. Each term is associated with a colour, ranging from red (negative feeling) to white (intermediate feeling) and green (positive feeling). Patients are interviewed a few days after seclusion. Firstly, they are asked to complete three Emotional Palettes, which refer to three moments of their experience : the time when they were put inside the seclusion room, the time spent during the seclusion process, and the time after the seclusion. For each moment, patients identify the predominant emotions on the corresponding Palette. After completing the Palettes, they are interviewed. The aim is to promote a relationship of confidence to make the persons feel free to say what they like. They are also encouraged to express their own proposals for alternative methods and suggestions for improving seclusion practice. In this article, the usefulness of the approach based on this tool is discussed within three clinical case studies. For each patient the result of the Emotional Palette was transcribed and a thematic analysis was used to analyse the verbatim. ResultsThe seclusion-related negative emotions mainly identified by patients were fear, anger, boredom, helplessness, resignation, loneliness and humiliation. Negative feelings were linked to perceived lack of interaction with the staff before and during seclusion. Patients reported that they were not given enough information about the reason for their seclusion and what would happen next. After the seclusion process, they mentioned positive experiences such as finding calm, gratitude and confidence in the nursing staff. Some patients’ suggestions regarding the improvement of seclusion practices were related to a need for more interaction with nurses and doctors. These emotions and views expressed by patients echo the findings of previous studies and surveys. Beyond these results, the main benefit lies in the fact that, by giving the opportunity to have a debrief, the Emotional Palette tends to strengthen the patient's position and involvement. All of them expressed a satisfaction to be able to discuss the seclusion event and their feelings afterwards. They suggested alternatives to seclusion that could expressly work for them (one-to-one intervention, specific activities..). They stressed the importance of interaction with the nurses and the doctors, through empathetic listening, attention and understanding, active communication and for more staff presence in the ward. Thanks to the Emotional Palette, patients experienced that their views and emotions had been heard and recognized. Finally, by giving every patient an opportunity to discuss his/her experience with the staff, the Emotional Palette helps to develop a personal prevention strategy that could offer alternative methods for seclusion in case of crisis. Future research is needed to provide generalizable data and validate the usefulness of the Emotional Palette. ConclusionsBy helping patients to express their emotions after a seclusion process, the Emotional Palette offers a framework and a therapeutic approach which prove useful in regaining a positive interpersonal relationship with a patient. By allowing the patient to give their views and suggestions for improvement and alternatives, this tool could also constitute a means to reduce seclusion practices.

Safety hazards in clinical practice of seclusion in psychiatric care

IntroductionSeclusion is part of the clinical practice in European psychiatric hospital care with the aim to maintain the safety of patients and staff. Adverse events and harm have been reported for patients and staff resulting from seclusion. Safety hazards, which are the prerequisite of adverse events, can be identified using video observation methods. Identifying safety hazards can be used to prevent adverse events and improve the quality of psychiatric care.ObjectivesTo identify safety hazards during seclusion in psychiatric hospital care.MethodsDescriptive design with non-participant video-observation of seclusion care practice. Data consisted of video recordings (n = 36) from six wards of one psychiatric hospital in Finland. The data were analysed with inductive thematic analysis.ResultsClinical practice of seclusion included safety hazards stemming from the actions of patients and staff. Patients’ actions were as follows: aggressive behaviour, attempting to escape, precarious movements, preventing the visibility of staff, exposing themselves to contamination, and falls during seclusion. Staff actions included: leaving dangerous items to seclusion, issues in the administration of medication, performing physical and mechanical restraints in unsecure way, and precarious movements and postures.ConclusionsAccording to our results, the use of seclusion has safety hazards that can result in harm for patients and staff. To improve the quality and safety of seclusion in clinical practice, the guidelines, practices, and staff training need to consider the various safety hazards. While the work in Europe to abolish the use of seclusion is still in progress, this topic requires attention in clinical practice, education, and policymaking.DisclosureNo significant relationships.

Audit Cycle on Medical Reviews of Seclusion in Medium and Low Secure Learning Disability Units

AimsSeclusion is defined as “the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others”. Patients in seclusion require reviews at the frequency set out in the Mersey Care NHS Foundation Trust policy, “The use of seclusion and long-term segregation” (SD28). This is based on the requirements set out in the Chapter 26 of the Mental Health Act 1983 Code of Practice (2015).This audit will look at whether medical reviews for secluded patients in the secure learning disability wards meet with the expectations set out in the Trust Policy. In doing so, the audit will establish whether medical reviews of seclusion meet and uphold the guiding principles of the Mental Health Act Code of Practice as highlighted in Chapter 26.110.MethodsRetrospective audit that collected data from inpatients on secure learning disability wards in Mersey Care. After reviewing data, we actioned plans which involved educating colleagues working in secure services. This was re audited after three months. One month of seclusion reviews was audited in each cycle, which equated to 39 reviews in the first cycle and 100 reviews in the second.ResultsThe re-audit data showed an improvement in most parameters.Re-audit showed that 66% (34%) of the seclusion reviews had an initial medical review within the first hour. The on call consultant was informed in 60% (50%) of the situations and 4 hourly reviews took place in 66% (50%) of scenarios. All MDT reviews took place within 24 hours, Responsible Clinician was present in 100% (67%) of reviews.34% (33%) of MDT reviews had only 2 MDT members.There was 100% compliance with reviewing physical health in both audits. 100% (90%) of the reviews commented on mental health, 72% (20%) commented on medications used, 51% (39%) of reviews commented on level of observations and 89% (48%) included risk assessment. 95% (92%) of reviews assessed need for continuing seclusion. 84% (59%) of reviews commented on reducing restriction in seclusion.ConclusionThis audit cycle has focused on the quality of medical reviews and not just the frequency. The improvement in practice will strengthen the safeguard provided by these reviews.

Zero violence or zero seclusion. Which is more acceptable in our hospitals?

IntroductionThere is an established association between serious mental illness and violence. Secure forensic psychiatric services provide care and treatment to mentally disordered offenders. The majority of patients in forensic services suffer from severe mental illnesses such as schizophrenia, with co-morbid polysubstance abuse and maladaptive personality traits. Psychiatric services are under significant pressure to reduce the use of seclusion and restrictive practices, whilst mandated to provide safe environments for patients and staff.ObjectivesTo determine the number and characteristics of violent incidents in a secure forensic hospital in Ireland.MethodsA retrospective review of all incidents in Central Mental Hospital, Ireland between 1st March 2019 and 31st August 2021 was completed. Incidents were categorised into physical assaults and other violent incidents. Demographic measures and measures of violence risk (HCR-20), functioning (GAF), programme completion and recovery (DUNDRUM tool) were collated.ResultsA total of 321 incidents took place during the period examined, of which 47 (14.6%) involved physical assaults perpetrated by patients. Between March 2020 and August 2021, numbers of assaults increased by 50% and 78% compared to the preceding six-month period respectively. The majority of assaults were committed by a relatively small group of patients. Victims of assaults were more likely to be patients (n=27, 57.4%) and more likely to be males (n=43, 91.9%).ConclusionsPhysical assaults and other violent incidents happen in forensic and general psychiatric units. Restrictive practices, used in accordance with the law, are necessary at times to prevent serious harm to patients and staff in psychiatric hospitals.DisclosureNo significant relationships.

Individual and Environmental Characteristics of Residential Workers Using Restraint and Seclusion in Youth Treatment Centers

ABSTRACT The use of restraint and seclusion (R&S) in residential youth treatment centers has been a controversial topic over the past years. This study explored the differences between R&S super users and normal users for residential workers in terms of individual and environmental characteristics over eight weeks. One hundred ninety-eight residential workers completed the questionnaires, and Bayesian independent samples t-tests were conducted to verify the differences between the two groups. The results showed very strong evidence that super users have a greater fear of violence (B10 = 65.57), indeed strong evidence that they perceive more verbal aggression (B10 = 18.264), very strong evidence that they witness more aggression against themselves (B10 = 87.35), and extremely strong evidence that they perceive themselves to be more often victims of physical aggression (B10 = 398.55) than normal users. Moderate evidence also revealed that super users experienced a higher level of traumatic stress and perceived a better work climate than normal user (B10 = 3.751 and B10 = 5.116). Perceived stress, chronic fatigue, acute fatigue, recovery, self-efficacy, compassion fatigue, burnout, and social climate order, and organization (work team’s orientation and sense of cohesion) were not statistically associated with R&S (B10 = 0.166 to 0.415).

The mental health safety improvement programme: a national quality improvement collaborative to reduce restrictive practice in England

In 2018, 38 mental health inpatient wards belonging to NHS trusts across England took part in the national reducing restrictive practice collaborative project, which aimed to reduce the use of rapid tranquillisation, restraint and seclusion of patients by 33%. Teams were supported to use quality improvement tools by skilled coaches as part of a national collaborative learning system. At the end of the programme, the overall use of restrictive practice had reduced by 15%. Of the teams that achieved improvements, the average reduction in restrictive practice was 61%. Across the collaborative there were improvements in the mean monthly use of restraints and rapid tranquillisation, and in the total use of all three measures of restrictive practice combined. Support from quality improvement coaches allowed ideas to be tested across the collaborative, enabling the creation of a theory of change for reducing restrictive practice based on areas with a high degree of belief to inform future improvement work in this area.

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression.

ObjectiveIn the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it.MethodWe included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes.ResultsOf 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: “disruptive behavior” and “beneficial to patient.”ConclusionAwareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

What do we know about the experience of seclusion in a forensic setting? An integrative literature review.

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma‐related harm and re‐traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer‐reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex‐specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

A retrospective cohort study evaluating demographic and clinical characteristics associated with use of seclusion in a London psychiatric intensive care unit

Seclusion is generally regarded as an important tool for aggression management in those admitted to a psychiatric intensive care unit (PICU). Nevertheless, it remains controversial with concerns regarding the ambiguity of who meets the threshold for seclusion. This study provides a detailed analysis of those who met the threshold and were secluded, whilst admitted to a London PICU, identifying key demographic features and clinical characteristics associated with seclusion use. All PICU admissions were examined over a one-year period (10 January 2020 – 9 January 2021). Data were collected retrospectively from patient electronic records. 125 patients met inclusion criteria for analysis, of whom 49 (39.2%) had been secluded during their admission and 76 (60.8%) had not. Those secluded included a higher proportion of patients with Black ethnicity (p = 0.004). A higher proportion of those secluded had been in employment prior to admission with fewer reporting long-term sick leave (p = 0.048). Seclusion was associated with a longer mean admission time (p = 0.02). Those requiring seclusion received higher doses of benzodiazepines during their admission (p = 0.009). Illicit drug use and forensic history were not found to be factors associated with seclusion use, in contrast to previous studies. Findings indicate that, within this cohort, seclusion is mostly associated with patient demographics and severity of illness.

Ending seclusion and restraint use in Victoria’s mental health services: The implications for women of the Royal Commission’s recommendations

This article discusses the recommendations of the Royal Commission into Victoria’s Mental Health System relating to the reduction and elimination of the use of seclusion and restraint. The author focuses on the implications of these recommendations for women. She argues that the Royal Commission’s proposals stand to benefit all mental health consumers but did not address the full range of gender-specific experiences and needs of women. The Andrews government has committed to implementing the Royal Commission’s recommendations, and the author identifies a range of issues that must be attended to in order to ensure these matters are dealt with.

Under the law: The restraint and seclusion of students with disabilities

In recent decades, researchers have learned that the use of restraint and/or seclusion to discipline students is ineffectual at best, and sometimes fatal. The U.S. Department of Education agrees, advising schools that “every effort should be made to structure environments and provide supports so that restraint and seclusion are unnecessary.” Even so, more than 100,000 students are restrained or secluded in U.S. public schools every year. Most are students with special needs.

Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit

BackgroundIn inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions. MethodMulti-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions. ResultsThere was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July–September 2015, to 4.7 episodes in January–March 2016, reaching 0.0 episodes by April–June 2016. This reduction was maintained until April–June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant. LimitationsDue to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change. ConclusionsMultidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.

Does ending night-confinement reduce use of seclusion and prevalence of violence in a forensic psychiatric hospital? A retrospective observational study

Forensic psychiatry services strive to reduce the use of restrictive practices, and balance its occasionally necessary use with the creation of a therapeutic environment. There is limited research into the effects of least restrictive practice in forensic settings. The present retrospective observational study reviews the incidents of seclusion, restraint, and violence in a forensic psychiatric hospital one year before and one year after the introduction of a policy which ended night-confinement and allowed patients to exit their rooms overnight. The results show that there were fewer episodes of seclusion and fewer hours spent in seclusion post policy change, however this difference was not significant. There was no statistically significant difference in incidents of violence or in the use of physical restraint. While the research is of a small scale, it does suggest that policies ending night-confinement do not lead to increased seclusion episodes and encourages future research in this area.

The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment.

BackgroundOn January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients.MethodsWe studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events.ResultsThe mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (β = −1.867; Exp(β) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [β = 0.48; Exp(β) = 1.616, Wald = 2.33, p = 0.13].DiscussionThere was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future.ConclusionWe observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.