In a groundbreaking national study conducted in France, researchers have unveiled stark disparities in the application of seclusion and mechanical restraint (MR) within adult mental healthcare facilities. This extensive analysis, covering 204 hospitals and nearly 100,000 involuntary psychiatric admissions in 2022, offers a rare, detailed glimpse into how restrictive practices vary widely across institutions and the complex factors influencing their use.
Mental healthcare systems worldwide grapple with ethical dilemmas related to seclusion and mechanical restraint—practices often employed to manage aggression or prevent harm but frequently criticized for their invasive and distressing nature. Despite global policy efforts to curb their use, empirical data exploring the nuances behind when and why these methods are applied remain surprisingly scarce. This French nationwide investigation steps into that void, presenting sophisticated multilevel statistical models to parse out patient, hospital, and environmental contributors.
The study taps into an unprecedented dataset, drawing on France’s comprehensive psychiatric hospital claims system, which meticulously documents the deployment of seclusion and mechanical restraint. Linking this registry with additional national databases encompassing somatic hospital care, community health services, annual hospital surveys, and census demographics, researchers acquired a multifaceted understanding of the landscape of involuntary psychiatric care and the institutional contexts in which these interventions occur.
Results from 2022 revealed that roughly one-third of involuntary psychiatric admissions (32%) involved seclusion, while nearly one in ten (9%) included mechanical restraint. However, this aggregated picture obscures dramatic variability—some hospitals reported no use of mechanical restraint, indicating highly divergent institutional cultures or protocols. Such variation signals that patient clinical needs alone do not dictate restrictive practice frequency, challenging assumptions about uniform standards of care.
Diving deeper into patient characteristics, the research identified primary diagnosis and prisoner status as among the most potent predictors of seclusion and MR use. This suggests that certain clinical conditions and legal statuses heighten vulnerability to these measures, but the overreliance on restrictive practices for specific groups raises important ethical and equity concerns. The interplay between diagnosis, incarceration, and restrictive interventions demands urgent scrutiny and tailored policy responses.
Hospital-level factors also emerged as influential. Admissions in public hospitals with teaching activities or multidisciplinary service provisions correlated with significantly lower odds of seclusion, implying that educational missions and integrated care models may foster less coercive environments. Conversely, hospitals boasting higher nurse-to-patient ratios and greater proportions of involuntary admissions showed reduced use of mechanical restraint, spotlighting the pivotal role of staffing and the patient mix in shaping care approaches.
Interestingly, the study found no robust associations between contextual variables—such as social or demographic characteristics of hospital catchment areas—and the employment of restrictive practices. This absence challenges assumptions that broader community factors are critical drivers of seclusion or MR, focusing attention instead on institutional policies and clinical decision-making processes as key intervention domains.
The methodological rigor in this research is noteworthy. Utilizing multilevel logistic regression analyses allowed for adjustment across nested data structures—patients within hospitals within regions—enhancing the validity of detected associations while accounting for potential confounders. This statistical strategy clarified how much variation arises from patient versus hospital factors, an essential distinction for targeted interventions.
The ethical implications of these findings are profound. With significant differences in restrictive practice use unexplained by patient needs, questions surface about fairness and consistency in mental health treatment. Facilities with disproportionately high rates may subject patients to unnecessary trauma, underlining the urgency of establishing stricter guidelines, standardized training, and oversight mechanisms to mitigate unwarranted use.
Moreover, the identification of hospital characteristics linked to reduced seclusion and restraint offers actionable pathways. Enhancing multidisciplinary collaboration, increasing nursing staff, and bolstering teaching and research components within psychiatric units could promote more humane, patient-centered care. These insights provide a blueprint for policymakers and healthcare leaders striving to uphold human rights and dignity in psychiatric settings.
This landmark analysis also lays a foundation for future international comparisons by demonstrating the value of comprehensive, routinely collected psychiatric data. Other nations may benefit from adopting similar registries to better understand and address their own institutional variations. Standardizing definitions and data capture techniques will be critical for cross-country benchmarking and knowledge exchange.
In conclusion, the French nationwide multilevel study delivers a compelling examination of seclusion and mechanical restraint within adult mental healthcare, revealing critical variations and determinants that transcend patient clinical profiles. As nations tighten regulations around restrictive practices, such data-driven research is indispensable for guiding ethical, equitable improvements in psychiatric care delivery—unveiling what truly happens behind closed doors.
Subject of Research: Variations in the use of seclusion and mechanical restraint in adult mental healthcare across hospitals in France.
Article Title: Behind closed doors: unlocking hospital variations in the use of seclusion and mechanical restraint – a nationwide multilevel analysis in adult mental healthcare in France.
Article References:
Touitou-Burckard, E., Coldefy, M., Bourin, C. et al. Behind closed doors: unlocking hospital variations in the use of seclusion and mechanical restraint – a nationwide multilevel analysis in adult mental healthcare in France. BMC Psychiatry 25, 1014 (2025). https://doi.org/10.1186/s12888-025-07404-z
Image Credits: AI Generated
DOI: https://doi.org/10.1186/s12888-025-07404-z
