The End of Chemical Restraints: Expert Opinion

It is still not uncommon to hear psychiatrists, hospitalists, and emergency medicine physicians refer to using “chemical restraints” in agitated patients, despite the concept itself being in disfavor for close to 20 years. It’s now time to completely stop, once and for all, referring to — or using medications as — “chemical restraints.”

Fear not; this does not mean that we are in any way suggesting there is no role for medications in the care of agitated patients. It may not even entail a substantial difference in most doctors’ overall psychopharmacologic approach. But it may make a world of difference in what it means to your patients and treatment philosophy.

A frequent criticism of contemporary healthcare’s approach to mental illness has been the excessive degree of “stigma” or “discrimination” created in psychiatric patients. This may often be innocent or unintentional, but can be detrimental to patients and their recovery nonetheless. Something as simple as putting psychiatric patients in gowns colored differently from those of the other patients in emergency departments (a surprisingly common practice), ostensibly for safety reasons. This practice can identify people seeking mental health assistance as “different,” “one of those,”’ or even “shameful,” and is quickly recognized by everyone present, including other patients and families. Other examples can be as overt as staff members rolling their eyes or making sarcastic remarks when interacting with these patients, questioning the veracity of a mental health patient’s honestly-expressed history.

Beside the obvious effects such as embarrassment, these types of discrimination can lead to patient reluctance to go to emergency departments for help, perhaps leading to delays in seeking care, and thus to much worse outcomes than if interventions been started sooner.

And no persistent rubric may be more emblematic of psychiatric patient discrimination in hospitals than the concept of “chemical restraints.”

The terminology itself is stigmatizing. In no other medical condition are drugs referred to as “chemicals.” One would never hear of “chemically treating the diabetic” or “chemically relieving the asthmatic,” but it is still possible to hear about “chemically restraining the schizophrenic.” Calling psychiatric medications “chemicals” implies that they are somehow different from other drugs, perhaps even insinuating that psychiatric symptoms are not as genuine as medical or surgical concerns, or that agitation deserves punishment or subjugation rather than healing.

Beyond semantics, the actual definition of “chemical restraints” implies a practice that clinicians should not want to endorse. The Joint Commission, the hospital accreditation organization, defines chemical restraint as “a drug or medication, or a combination, when it is used as a restriction to manage the patient’s behavior, restrict the patient’s freedom of movement, or to impair the patient’s ability to appropriately interact with their surroundings – and is not standard treatment or dosage for the patient’s condition.”¹

“Restricting freedom of movement?” “Impair the ability to appropriately interact?” These sound more like a judge’s sentence on a guilty criminal than an act from an ostensibly therapeutic profession. And indeed, we have found that when most physicians learn of this definition, suddenly “chemical restraints” doesn’t sound like something they want associated with their good names.

Other published definitions refer to concepts around chemical restraint, including such nuggets as “staff convenience” or even medications “used for discipline” — neither of which sounds like part of proper medical care, or something a compassionate clinician would ever want to do.

In addition, if medication use is referred to as a chemical restraint, The Joint Commission then requires the same level of patient scrutiny, medical evaluation, and record-keeping as for the use of physical restraints. This means, at the very least, the same level of 1:1 observation, the same regular re-evaluation by a psychiatrist or other licensed independent professional, and the same lengthy documentation of reasoning behind the event, proof of multidisciplinary involvement, attempts taken to avoid the restraints, and why alternatives were not used instead.

Because of all this, many hospitals have come to include in their bylaws that they never utilize chemical restraints in their institutions; rather, they only prescribe appropriate medications indicated in specific clinical conditions. Note that one of the main parts of The Joint Commission’s definition of chemical restraints is that an agent is “not standard treatment or dosage for the patient’s condition.” But there are currently 4 different US Food and Drug Administration (FDA)-approved medicines specifically indicated in the treatment of agitation, each of which would clearly be an appropriate medication in the clinical condition of agitation. And certainly, any medication indicated in the particular cause of the agitation – for example, treating agitation originating from paranoid psychosis with an antipsychotic medication, or in medically addressing the source of a delirium – would also be a “standard treatment for a patient’s condition.”

Indeed, moving away from the historical concept of chemical restraints and toward an understanding that medications are instead used to treat the condition of agitation and its underlying causes fits in well with the evolving approach to agitation over the past 2 decades. This is best exemplified in the 2012 Project BETA guidelines (Best Practices in the Evaluation and Treatment of Agitation).²

It should only take a fairly modest change to the paradigm for providers, emergency settings, and hospitals: basically, just reframe perceptions to prescribe appropriate interventions in the treatment of agitation, rather than to give an order for chemical restraints. And clinicians may find that this simple move will result in many benefits, including better surveyor reviews, improved patient satisfaction, and easier family interactions. Perhaps, it could also lead to a bit more understanding and empathy for those suffering an agitation episode.

Scott Zeller, MD, is vice-president for psychiatry at CEP America, assistant clinical professor of psychiatry at UC-Riverside, and serves on the Editorial Board of Psychiatry Advisor. His new textbook, “The Diagnosis and Management of Agitation” (London: Cambridge University Press, 2017) is available at Amazon, Barnes & Noble and other booksellers.

References

1. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proceed. 2010;85:53-62.
2. Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26-34.