Restraints in Greek mental health services: Ethics, practice and costs

The use of physical and mechanical restraints in mental health services in Greece arise many ethical and practical issues. The justification of the use of such procedures is rather controversial and subjective to scientific debate. The practice of restraint puts both patients and staff at risk for injury and death. Moreover, restraints can be traumatic even when they do not result in any physical injury to the patient. The types of the physical adverse events include dehydration, suffocation, circulation disturbances, skin problems, loss of strength and mobility, incontinence, etc. Research studies regarding the use of restraints are limited, although individual, professional, and social impact is extensive. Worldwide many associations involving patients, care givers and patient rights authorities have disapproved such techniques as inhumane and against recent scientific evidence. Nevertheless, the methods are being used for highly agitated and violent patients in mental health hospitals in order to protect the patients and others towards physical harms. Verbal de-escalation strategies should be attempted prior to the use of any form of restraint. Although there are no strict guidelines in Greece for the use of the least restrictive and effective treatment for an agitated and/or violent patient there are certain occasions that restraints cannot be avoided. Physical, chemical and mechanical restraints should never be used for the sake of convenience or punishment. The healthcare professionals understand and follow proper procedures when restraining a patient to ensure safety and dignity of the person. Failure to follow guidelines is subjective to legal actions by the patient, the family and the independent mental health authorities. Restraining comes in many forms, like chemical, physical and mechanical. Clinical judgment must be applied to determine the necessity of any restrictive decision. Consultant psychiatrists, mental health nurses and ward staff are involved to the initial assessment, the level of restriction, the procedure of restraints, the follow-up and the reassessment of the level of safety, due to the guidelines and the wide range of complication concerns. Further to the clear public, medical and operational concerns for the restraints, these procedures are expensive for the mental health services. In our study we estimated the costs of the procedures per patient, excluding the medication costs. According to our data each mechanical restraint costs at least € 57.28 and each seclusion € 47.16 respectively for up to 2 hours of duration and increase according to the prolongation of the restraint procedures.