Psychtropic Drugs - Restrictive and coercive practices in mental health care

Running head: PSYCHTROPIC DRUGS
Restrictive and coercive practices in mental health care
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Introduction
According to Muir-Cochrane & Gerace (2017), psychotropic drugs such as sedatives to
control the behavioral symptoms is a subject of debate and has been argued as a coercive
approach with severe ill-effects on the patient. Sedatives are one of the five groups of
psychotropic drugs that reduce the functioning of the brain and make the person feel relaxed.
They are widely prescribed by healthcare professionals for anxiety disorders. These
tranquilizers suppress the central nervous system (CNS) and are also termed as CNS
depressants (Allison & Moncrieff, 2014). At significant doses, these drugs may be associated
with adverse effects such as slow reflexes, slurred speech and staggering gait. Moreover, the
administration of these drugs for prolonged periods has demonstrated the dependency of the
patients on these medications. However, sedatives and tranquilizers are critical medications
for the treatment of maximum mental disorders (Innes & Sethi, 2013). Due to these reasons,
the use of sedatives for mental health treatment faces worldwide controversy. This essay
critically argues the use of sedatives to control behaviors with relevant evidence, its impact
and the challenges faced by registered nurses to administer these medications to the
consumers with mental health disorders posing significant self-harm and to others as well.
Discussion
Sedatives in pharmacological management
Psychotropic medications are known to be useful options for the management of behavioral
symptoms, specifically, if the observed behavior is of a psychiatric origin such as psychosis
or in cases where the behavior puts the patient or others around them at high immediate risk.
According to the guidelines of NICE, patients or their caregivers may have the right to make
informed decisions related to their care. However, if someone lacks the minimum capacity to

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make proper decisions, the safeguards stated in the Mental Capacity Act 2005 have to be
followed. Irrespective of the route chosen, the medication should have a rapid onset of action,
exhibiting an effect that lasts for only a few hours. The term ‘rapid tranquillization’ is used
by NICE to define medicines used parenterally to decrease the risk of harm and for
minimizing aggression and violence (Nice.org.uk, 2020). These medications are commonly
called the sedatives and are administered intramuscularly. The most prescribed drugs include
benzodiazepine lorazepam and the usual antipsychotic haloperidol, and both of these drugs
have clear evidence demonstrating efficacy. Theoretically, Benzodiazepines can cause
significant sedation and may result in respiratory depression, which may be reversed by
intravenous flumazenil (Calver et al., 2010). Lorazepam, on the other hand, is short-acting
with extremely unlikely respiratory depression on prescribed doses. Thus, Lorazepam is
considered a safer first-line drug in comparison to the other, longer-acting, benzodiazepines,
such as diazepam (Rahimi et al., 2016). It is expected that the use of psychotropic sedative
medication reduces the adverse behavioral symptoms such as agitation and will considerably
decrease after the patients move into the community.
Impact of sedative medications
The clinical consequences of patients acutely intoxicated with sedatives are similar to those
of alcohol intoxication. Psychiatric features involve disturbed attention, labile mood,
inappropriate behavior, and impaired judgment. Physical symptoms are decreased reflexes,
nystagmus, and unsteady gait. As the dosage increases, specifically beyond the developed
tolerance of the patient, progressively more dysfunctions can be observed in judgment and
brain functioning (Schumacher et al., 2017). It is also stated that the prolonged use of
sedatives like benzodiazepines may worsen underlying depression and anxiety. Another study
demonstrated that benzodiazepines accounted for about 30% of deaths caused by
pharmaceutical agents, and 75% of overdose-induced deaths were unintentional. A common

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adverse effect associated with sedatives is the dependency on the drug, followed by
withdrawal symptoms. It is argued that the unconsented/consented use sedatives to manage
agitation can lead to addiction to the drug wherein the individual fails to function normally
without the drug. This addiction or dependency is believed to end with withdrawal
symptoms, which forms a significant point of the controversy along with the coercive nature
of the practice (Ries et al., 2014).
There is a growing public concern regarding the use of sedatives and psychotropic drugs in
patients for the management of problem behavior. Some of the probable reasons for this
increasing concern include poly-pharmacy and the use of higher doses than recommended of
antipsychotics, prolonged use without regular reviews, associated ill-effects which could
cause severe harm, and inappropriate concomitant intake of drugs to counter ill-effects and
the practices of administering these drugs as highly coercive (Iaboni et al., 2016; Cross et al.,
2016. The proposed benefits along with the associated side-effects and coercive nature of
these practices, are the fundamental basis of the controversy regarding the use of sedative
medications.
Government regulations
The government regulates the systematic and safe method of administering acute sedation
when de-escalation of behavioral symptoms has been unsuccessful. This ct indicates that
acute sedation can be a clinically appropriate treatment approach when consumers exhibit
extreme agitation, threaten violence, are violent in reality and pose considerable danger to
themselves or others. Acute sedatives must only be prescribed after attempting to manage the
behavioral disturbances with de-escalation methods and oral medication has been
unsuccessful (Health.nsw.gov.au, 2020). The objectives of the managing acute behavioral,
psychiatric emergencies include to calm the person and thereby managing extreme aggression

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and potentially violent behaviour that may result in physical harm, to reduce the mental
suffering of the patient, to decrease the physical distress experienced, to maintain a safe
surrounding for the consumer as well as the others, to ensure safe prescription of such
medications. For instance, the primary aim of administering these sedatives must be to calm
the patient and not to sedate the individual into unconsciousness (Www2.health.vic.gov.au,
2020).
The Act also provides guidelines to concerns regarding the consent while administering these
psychotropic sedatives. It states that the administration of acute sedatives must not preclude
the affected consumer from being provided consent to their treatment. The consumers must
be given the right to consent to the proposed treatment. In case the consumer lacks the
required capacity to provide or withhold their consent to the proposed treatment, involuntary
treatment can be given under the Mental Health Act 2016 (MHA) or the Guardianship and
Administration Act 2000 (GAA) after the required criteria stated within the legislation are
met. Besides, children below 16 years of age must not be sedated without the consent of the
parent(s) or legal guardian. Also, it is mandatory to confer with a consultant psychiatrist
before intake of such medications, except in emergency situations (Health.qld.gov.au, 2020).
Challenges faced by registered nurses to administer psychotropic medications
The registered nurses face significant challenges in administering psychotropic medications,
especially sedatives to patients susceptible to severe injuries to themselves and others around
them. Often, patients suffering from mental health disorders may exhibit challenging and
frequently violent behavior in a variety of healthcare settings (Baby, Glue & Carlyle, 2014).
Challenging behavior faced by the registered nurses may include any verbal, non-verbal or
physical action which causes difficulty in delivering quality care safely. It includes biting,
grabbing, punching, or self-injury as well. It may happen that the patient is unaware of their

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violent actions (Stokes, 2017). According to the NHS Business Services Authority, a total of
68,683 assaults against NHS staff were reported in 2013–2014, including 53,484 incidents
involving clinical factors where the perpetrator was unaware of their actions.
Some patients are restrained, which is observed as being coercive but most incidents require
such strict restraints of the patient, these commonly take place in acute medical wards (Muir‐
Cochrane, O'Kane & Oster, 2018). Nearly one-third of all sufferers admitted to an acute ward
demonstrate co-morbid mental conditions, elevating to nearly 45% in older patients, as
compared to about 5% of patients admitted in accident and emergency departments. The
majority of mental health diseases seen in acute hospitals include delirium, depression,
dementia, adjustment disorders and alcohol-associated conditions. Due to these reasons,
many registered nurses that provide mental health services, also known as mental health
nurses or psychiatric nurses, experience severe challenges and complexities in their work
duties accurately to administer sedatives that have been prescribed to the patients (Hagen,
Knizek & Hjelmeland, 2017). Among the challenges faced by the registered nurses is the
controversy surrounding the ethics and coercive practices involved in the administration of
acute sedation. Apart from the unprecedented trouble faced in dealing with mental health
patients, mental health nurses also experience oppositions in giving sedative medications to
needy patients from their family members. In cases where the functional capacity of the
person is not adequate, the family does not readily consent with the administration and
restrictive practices of giving these sedatives. They find these practices against the rights of
the individual and consider them harsh (Gemelli, Yockel & Hohmeier, 2016).
The fundamental challenge faced by registered nurses in delivering sedation and working
with these patients is the elevated amount of violence and extreme agitation in the behavior
of these patients: Their violence poses severe risks to self-harm and a danger to the others
too. This is why it is a severe challenge experienced by the nurses working in acute mental

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health departments as the patients may also lead to physical injuries. The violent actions may
take forms such as severe abuses, assaults, and risks to the environment. The nurses are the
most susceptible to this violence and frequently face physical and verbal assaults which leads
to extreme distress among nursing professionals (Wilson, Hutchinson & Hurley, 2017). It is
challenging to administer sedation to such patients but however, it necessary in almost all the
cases.
Moreover, the behavior of these patients are very unpredictable and often demonstrate
suicidal attempts. This is because the patients themselves are often not aware of their actions.
Such exposure to the uncertain actions and moods of patients with mental health diseases
exhibit strange actions. Even after administering sedatives, the functional activity of the brain
reduces further and if this continues for more extended periods, the patients get addicted to
these drugs and behave adversely in the absence of the medications. The challenge for the
nurses is to monitoring them at all times for suicidal attempts and often resulting in negative
experiences reported by the nurses. These behaviours are specifically adverse in acute care
settings (Hagen, Knizek & Hjelmeland, 2017). Also, the adversity in the behaviours of each
patient is unique based on distinct clinical conditions.
Besides, another challenge that registered nurses experience in dealing with the above-
described patients includes their tendency of direct self-harm or harm to others. Self-harm
may encompass various forms including self-hitting, cutting, burning, hair pulling,
strangulation, aggravating chronic wounds or inserting things into the body. Nurses report
that the most observed form of self-harm included breaking the skin. Also, they observed that
women frequently adopt queer techniques to restrict their breathing, while men are more
susceptible to outwardly aggressive forms. It is also observed that greater the patients hurt
themselves, they become more likely to be addicted to self-harm. These practices of self-

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harm is highly distressing and challenging for nursing professional while administering
sedation (Tofthagen, Talseth & Fagerström, 2014).
Conclusion
To conclude, the use of acute sedatives and psychotropic medications to control the behavior
of mental health patients and in managing their symptoms is a topic of high controversy. This
is attributed to its potential benefits in controlling the extreme agitation and violence of the
sufferers along with the adverse effects on its long-term usage and the coercive nature of
these practices is seen as unformidable by various people of the society. This presents their
applications as a debatable subject. However, many clinicians prescribe these medications
based on the behavioral symptoms displayed by the patients and the government policies
regulating their use, government interventions and regulations such as the Mental Health Act
rightly monitors the safe and systematic applications of these psychotropic medicines. The
adverse behaviours exhibited by these mental health patients pose massive challenges to the
registered nurses responsible to administer these sedatives and have been severely
undermined.

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