The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

Abstract

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

Interrogating systematic review recommendations for effective chemical restraint

“…This provides little guidance to frontline clinicians who have to make rapid, informed decisions when confronted with a mental health crisis. 2,15,90 The current body of synthesized RCT evidence reports on the effects of different drugs, delivered in different combinations, in different doses, and by different forms of delivery, using different outcome measures and timeframes of measurement. The subtlety here is that whilst all RCT samples reflect adults whose uncontrolled behaviours are related to mental health conditions, subjects differ in their capacity to consent (or not) to receiving drug interventions.…”

“…There is a large and rapidly increasing body of evidence in the use of drugs for this situation; however, the current evidence synthesis provides little clarity on the safest and most effective drug interventions for emergency circumstances. This provides little guidance to frontline clinicians who have to make rapid, informed decisions when confronted with a mental health crisis 2,15,90 …”

Putting Restraint on Chemical Restraint: Exploring the Complexity of Acute Inpatient Mental Health Nurses' Experience of Chemical Restraint Interventions

“…Restraint use has been a common nursing practice in acute inpatient mental health care settings (Chieze et al, 2019;Garriga et al, 2016;Landeweer et al, 2010). For decades, the common practice on acute inpatient mental health units was guided by guidelines and educational material for mental health staff that highlighted the coercive use of psychotropic Pro Re Nata (PRN) medication to subdue patients who pose a safety risk, most notably violence risk (Emmanuel et al, 2013;National Consumer and Carer Forum, 2009;Registered Nurses' Association of Ontario, 2012), despite little published formal research on the use of chemical restraint interventions until recent years (Hu et al, 2019;Muir-Cochrane, 2020;Muir-Cochrane et al, 2019;Muir-Cochrane, Oster, Gerace, et al, 2020). Direct care nurses are most often the health care providers who initiate and administer the coercive interventions of restraints on mental health inpatient units (Bigwood & Crowe, 2008;Cunha et al, 2016).…”

A wicked problem: Chemical restraint: towards a definition

“…2019; Muir‐Cochrane et al . 2020a). This editorial discusses the complexities of issues surrounding the definition of chemical restraint in an attempt to provide clarity for clinicians, consumers and to assist researchers investigating this less researched subject.…”