Racial Disparities in Seclusion and Restraint Interventions


Racial Disparities in Seclusion and Restraint Interventions
June 30, 2023 MHO

Restrictive interventions of seclusion or restraints are controversial practices in psychiatric care from the legal and clinical point of view, and their therapeutic benefits are debated.[1]  Nonetheless, most experts agree they play an important role in the acute care setting, specifically for the prevention of patient harm to self, other patients, or staff. Indeed, accrediting bodies and professional organizations have long recommended using these interventions only in behavioral emergencies or as a last resort. Additionally, these interventions have become an area of focus in behavioral health racial disparities research.

Examining the Relationship between Race, Ethnicity, and Events

Inpatient stays over the past 4 years with at least one seclusion or restraint incident (referred to as having an event) were identified in the MHO database to investigate race and ethnicity trends in restrictive interventions. Overall, events are generally a low frequency occurrence, with only 3.0% of inpatient stays associated with at least one event.


Figure 1. Percent of inpatient stays with events by race/ethnicity (2019 – 2022)

Over the last few years, a small but significant decline (3.0% to 2.7%) in stays with an event has occurred (Figure 2). Importantly, Black and Hispanic patients benefitted from this significant downward trend as much as their White, non-Hispanic peers. However, significant differences still exist between racial and ethnic groups, where white patients are the least likely to experience an event.

 Figure 2. Trends in percent of inpatient stays with at least one seclusion and/or restraint by race/ethnicity

Are there moderators for racial and ethnic disparities?

After controlling for patient characteristics (gender, age, and primary diagnosis), race and ethnicity remained associated with increased likelihood of at least one event. Being Black rather than White was associated with a 50% increase in likelihood of any event type while being Asian was associated with a 10% increase in likelihood of any event.  And although being Hispanic is generally associated with higher rates of events, after adjusting for modifiers their risk compared to White peers was not meaningfully different. Being male, younger, and having a psychotic disorder (versus a mood disorder) were also associated with higher risk.

This is consistent with research that shows race is associated with increased risk for events regardless of other clinical or demographic factors.  For example, a higher use of restraints is seen in the emergency department setting for Black and Hispanic patients[2],[3]. For children and adolescents in acute and residential psychiatric care, demographic factors including race explain more variance in the risk for seclusion or restraint than clinical factors, where Black children are more likely to experience restrictive events[4],[5].

What can facilities do?

Progress has been made in reducing both events and disparities, but racial and ethnic disparities in events remain1,6. In fact, there is significant variation from facility to facility, where facility characteristics (location, resources, institutional factors) may influence both events and observed racial disparities 6,7. Therefore, each facility should develop its own policies and procedures to reduce event disparities. This starts with a data strategy to identify and track areas of racial and ethnic disparity. Stratify reliable and valid data collected by racial and ethnic characteristics to track trends over time. Differences could be based on clinician factors, patient symptoms and behaviors, or facility locations and resources [6],[7],[8].

Behavioral emergencies requiring events put both patients and staff at risk, and there is no denying that addressing all risk factors improves the chance of success. All patients (and staff) deserve a safe and supportive environment for care. Our understanding of how patient characteristics are associated with events can be used in combination with knowledge of non-patient risk factors (staff, case-mix, and environmental) to create targeted strategies to reduce risk, reduce disparity, and improve associated patient outcomes.

[1] Chieze, M., Hurst, S., Kaiser, S., Sentissi, O. (2019). Effects of seclusion and restraint in adult psychiatry: A systematic review. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00491

[2] Vidal C, Reynolds EK, Praglowski N, Grados M. Risk Factors for Seclusion in Children and Adolescents Inpatient Psychiatry: The Role of Demographic Characteristics, Clinical Severity, Life Experiences and Diagnoses. Child Psychiatry Hum Dev. 2020 Aug;51(4):648-655. doi: 10.1007/s10578-020-00963-0. PMID: 32026261.

[3] Martin A, Krieg H, Esposito F, Stubbe D, Cardona L. Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study. Psychiatr Serv. 2008 Dec;59(12):1406-12. doi: 10.1176/ps.2008.59.12.1406. PMID: 19033167.

[4] Carreras Tartak JA, Brisbon N, Wilkie S, Sequist TD, Aisiku IP, Raja A, Macias-Konstantopoulos WL. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med. 2021 Sep;28(9):957-965. doi: 10.1111/acem.14327. PMID: 34533261.

[5] Schnitzer, K., Merideth, F., Macias‐Konstantopoulos, W., Hayden, D., Shtasel, D., & Bird, S. (2020). Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Academic Emergency Medicine, 27(10), 943–950. https://doi.org/10.1111/acem.14092

[6] Shields MC. Patient Characteristics Associated With Admission to Low-Safety Inpatient Psychiatric Facilities: Evidence for Racial Inequities. Psychiatr Serv. 2021 Oct 1;72(10):1151-1159. doi: 10.1176/appi.ps.202000657. Epub 2021 May 17. PMID: 33993716.

[7] Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903

[8] Staggs VS. Variability in Psychiatric Facility Seclusion and Restraint Rates as Reported on Hospital Compare Site. Psychiatr Serv. 2020 Sep 1;71(9):893-898. doi: 10.1176/appi.ps.202000011. Epub 2020 Jun 3. PMID: 32487008.