Chemical restraint: Behind locked doors

Earlier this month, CCTV footage emerged showing Miriam Merten, naked and disoriented in an Australian hospital. Ms Merten falls backwards several times in a cell-like room, before walking to the door and banging on a small window. The video then shifts to the corridor outside the room. She shuffles, still naked, and falls again.

Ms Merten died from a brain injury in 2014 after she fell more than 20 times inside the Mental Health Unit of Lismore Base Hospital. While there has already been a coronial inquiry, the publicity surrounding this CCTV footage has led to a New South Wales parliamentary inquiry.

These appalling events raise many issues, one of which is the use of psychotropic or mind-altering drugs to control Ms Merten’s behaviour. An important question is whether the dosage of these drugs contributed to her falls, and ultimately, her death.

My research indicates that the use of medication to control behaviour in health care settings is poorly regulated across Australia. These findings form part of an Australian Research Council funded Discovery project which aims to provide health practitioners, and the individuals in their care, with a clear and consistent legal framework for reducing, and ideally eliminating, the use of interventions such as physical restraint, where bodily force is used to restrict movement; mechanical restraint, where devices such as belts and wrist cuffs are used; and medication to control behaviour.

Over-use and over-prescription

The ABC has been investigating reports of the over-prescription of psychotropic drugs to control the behaviour of people with disabilities. A study conducted in the United Kingdom in 2015 found that as many as 71 per cent of adults with a learning disability were prescribed antipsychotic medication when they had no record of a diagnosis of mental illness.

Here in Australia, the Victorian Office of the Senior Practitioner has reported that the use of medication to control behaviour, generally called ‘chemical restraint’, has been the most commonly used form of restraint in the aged care sector. The Australian Law Reform Commission has also raised concerns that chemical restraint is widely used on individuals diagnosed with dementia. In England, the over-prescription of anti-psychotic medications in aged care has been linked to 1800 deaths a year.

It is impossible to know the extent of this problem in Australia because there is no national database for recording the dosage or circumstances in which psychotropic medications are prescribed. This is of particular concern when they are prescribed without consent.

Lack of regulation

The use of chemical restraint is poorly regulated across health care sectors, partly because, as the South Australian guidelines state, there is “no agreed definition available”.

A strong starting point to defining what chemical restraint means is found in section 3 of Tasmania’s Mental Health Act 2013, which is echoed in some disability legislation, as “medication given primarily to control a person’s behaviour, not to treat a mental illness or physical condition”.

In recent years, there have been concerted efforts to reduce the use of seclusion, physical and bodily restraint in mental health facilities. Gains have been made in regulating and reducing the use of seclusion, although the 2015-2016 data suggest a worrying slight upward trend.

At a recent forum held in Perth on the issue, data concerning the rates of physical and mechanical restraint were released for the first time. Although drawing comparisons across jurisdictions is difficult because of inconsistent reporting requirements across the states and territories, at least getting the information together is a step in the right direction.

Chemical restraint should be the next practice that is defined and regulated. There may, of course, be difficulties in turning regulation into practice. For example, psychotropic medication given to treat a mental health condition may have strong sedative effects, thus affecting behaviour. In such circumstances, it may be impossible to prove an intention to control behaviour rather than to treat a medical condition.

There is also a fine line between chemical restraint and what is considered to be ‘emergency sedation’ or ‘rapid tranquillisation’, where the aim is to reduce specific symptoms of behavioural disturbance rather than treat an underlying cause.

There is also clearly a gap between how mental health service users and practitioners view chemical restraint. An interdisciplinary study conducted for the National Mental Health Commission surveyed mental health service users, their carers and practitioners about whether it was feasible to eliminate chemical restraint. Sixty-two per cent of mental health service users agreed it was feasible, but only 14 per cent of mental health practitioners agreed elimination is realistic. Why there is such a gap remains to be explored.

Some form of regulation, be it via legislation or national guidelines, is better than having none at all, as is the case in some Australian jurisdictions. Some form of data collection on the use of medication without consent in health care settings would provide information about the extent of the use of medication to control behaviour.

For example, in the Netherlands, the Dutch Health Care Inspectorate, which has extensive powers to investigate and assess the quality of health services, prevention measures and medical products, receives reports on all restrictive and coercive interventions, including the use of involuntary medication.

Global efforts

Internationally, the World Health Organization has launched a ‘Quality Rights Initiative’ aimed at improving care in mental health facilities. It is also in the process of developing training modules, including one on strategies to end the use of seclusion and all forms of restraint, including chemical restraint. These modules may provide a useful framework for other health care facilities.

While there are still many obstacles on the road towards eliminating restrictive practices, it is heartening to see that in Wales, a service-user designed facility is leading the way in focusing on recovery rather than coercion and control. Research conducted by the Melbourne Social Equity Institute, on behalf of the National Mental Health Commission, found that environmental changes are high on the list of factors that reduce the use of seclusion and restraint.

Ultimately, if people are given power over others behind locked doors, things will go wrong without clear regulations and constant monitoring. It’s time to add chemical restraint to the regulation of restrictive practices in order to work towards its elimination.

Professor McSherry is currently working on an Australian Research Council Discovery Grant entitled Model laws to Regulate the Use of Restraint in Health Care Settings.