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‘Consent rituals’ in evaluation of coercive care
  1. Marianna Purgato1,
  2. Maritta Välimäki2,
  3. Richard Whittington3,
  4. Andrew Clifton4,
  5. Evandro S F Coutinho5,
  6. Gisele Huf6,
  7. Prathap Tharyan7,
  8. Clive E Adams8
  1. 1Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy
  2. 2Department of Nursing Science, University of Turku and Southwest Hospital District, Turku, Finland
  3. 3Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
  4. 4Community & Education Studies, School of Health, Northumbria University, Newcastle, UK
  5. 5Department of Epidemiology, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
  6. 6National Institute of Quality Control in Health—Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
  7. 7Centre for Evidence-Informed Healthcare, Christian Medical College, Vellore, Tamil Nadu, India
  8. 8Division of Psychiatry, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Marianna Purgato, Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona 37134, Italy, marianna.purgato{at}

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Medical research is a pre-requisite for maintaining good clinical care and advancing our knowledge base. Before new interventions can be introduced into clinical practice, their effects have to be tested in research settings, often involving patients. Ethics committees, among other things, are concerned with protecting the interests of patients participating in research.1 This is particularly acute for evaluation of treatments and especially sensitive when participants have mental health issues.

In psychiatry emergency situations, the levels of patient violence are high. Violent behaviour occurs in up to 30% of those who attend or are brought to psychiatric services for the first time,2 and these acute violent situations represent a risk for the patients themselves, for other patients and for the staff.3 Guidelines recommend, first line, to calm the situation using words and reassurance, to acquire a diagnostic history and to complete physical and laboratory tests before starting drug treatment. Yet, if these techniques fail, effective and urgent alternative interventions are necessary to ensure the safety of everyone involved. To date, some of these interventions in psychiatric care remain coercive,4 ,5 but many of these approaches have not been subject to fair evaluation within trials despite calls from national bodies6 ,7 as well as grieving relatives.8

Where trials of treatments given under coercion have been undertaken, they have frequently necessitated informed consent from participants. These procedures generate a delay in the enrolment of participants and make results difficult to apply …

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