Psychiatr Q (2014) 85:405416

DOI 10.1007/s11126-014-9299-1

ORIGINAL PAPER

Opinions of Forensic Schizophrenia Patients on the use

of Restraints: Controversial Legislative Issues

Branimir Margetic Branka Aukst Margetic Dragutin Ivanec

Published online: 6 June 2014

Springer Science+Business Media New York 2014

Abstract The use of restraints is a controversial issue even though legal regulations may
seem straightforward. Our aims were to evaluate the forensic patients opinions on certain
aspects of restraining and to compare these opinions with the current legal norms. Inpa-
tients with schizophrenia or schizoaffective disorder at the Department of Forensic Psy-
chiatry in Popovaca, Croatia, were asked the following questions about the use of
mechanical restraints: (a) Should the patients family be informed about the use of
restraints? (b) Should the physician ask the patient whether to inform the family about the
use of restraints? (c) Can the use of restraints be a kind of punishment for intentionally
aggressive behavior toward people in their environment? and (d) Should restraints be used
if the patient requests to be restrained? The patients were assessed according to the
Temperament and character inventory and Positive and Negative Symptom Scale. Fifty-
four forensic patients with a history of serious offences were included in the study. Their
average age was 44.7 ( 8.39) years and the mean duration of their treatment was 6.6
( 5.08) years. There was no predominant opinion on sharing the information with the
family, but there was a relationship between the opinions and psychopathology and per-
sonality. Regardless of the patients mental state and personality, the opinions on the
voluntary use of restraints and the use of restraints as punishment for intentionally
aggressive behavior were mainly positive. The patients opinions suggest a need for the
implementation of more specific guidelines in the area of forensic psychiatry.

Keywords Schizophrenia
Mechanical restraints
Patients opinions
Legislation

B. Margetic (&)
Neuropsychiatric Hospital Dr. Ivan Barbot, Jelengradska 1, 44317 Popovaca, Croatia
e-mail: branimir.margetic@zg.t-com.hr

B. Aukst Margetic
Department of Psychiatry, University Hospital Center Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia

D. Ivanec
Department of Psychology, Faculty of Humanities and Social Sciences, Zagreb, Croatia

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Introduction

The use of mechanical restraints is a controversial issue. Sometimes they are regarded as a
necessary measure used in treatment of agitated, aggressive or otherwise disturbed patients
when they need to be protected from self-harm or to prevent them from causing harm to
others. However, they are also seen as an essentially punitive intervention and a violation
of an individuals basic human rights [1]. The act of putting somebody in restraints may be
dramatic, accompanied by negative feelings, physical resistance and even spitting or biting.
Therefore, this is a risky procedure allowed in most Western countries, but regulated by the
relevant mental health legislation [2].
Although the issue has not been addressed in more detail in Croatia, our impression
based on our clinical experience is that restraints are used less frequently than a few
decades ago. Probable reasons are more staff, better education and medication, fewer
inpatients, new legislation, and other changes that have occurred over time. Since the aim
of psychiatric practice in general is to reduce the use of restraints, Croatian legislation has
incorporated the World Health Organization (WHO) recommendations [3] on the use of
this measure and has stipulated that restraints may be used as procedures of last resort,
which should only be utilized in exceptional cases to prevent imminent harm to self or
others. This measure must not be used as a form of punishment, and family members/
guardians and personal representatives must be immediately informed when the patient has
been restrained. The use of restraints is considered the most extreme measure in psychiatric
settings and documentation explicitly explaining the reasons why the patient has been
restrained is required. According to abundant literature on the use of mechanical restraints,
we may claim that WHO recommendations are implemented not only in Croatia but in
many jurisdictions worldwide.
As we have described previously [4] in Croatia forensic patients are not legally
responsible for their acts, and after a criminal trial, their placement in forensic institutions
is not in the domain of criminal but civil law. The majority of patients are those with
schizophrenia, others have other types of psychotic disorders or severe intellectual dis-
abilities, while those with personality disorders without co-morbidity with psychotic dis-
orders are not treated in forensic departments. As they are not legally responsible, these
patients may not be imprisoned, but have to be treated in forensic departments within state
hospitals. This issue is regulated by a separate mental health law, which regulates not only
the involuntary treatment of all patients, but also the protection of rights of psychiatric
patients. This means that the legislators intention was that all patients should be in
practically the same position. It is noteworthy that according to the patients opinions, the
length of placement in an institution should depend on the seriousness of the offence [4].
Although the acceptance of forensic patient treatment is often clearly motivated by
increasing the possibility for discharge, coercive measures, such as the use of restraints or
forced medication, are primarily applied to control agitated and/or aggressive behavior. It
should be noted that seclusion is a rather rare practice in Croatia, and patients usually have
no such experience. Since forensic patients are usually institutionalized for prolonged
periods of time, they are also able to witness the use of coercive measures on different
occasions. Our clinical experience shows that patients have very different opinions on the
use of mechanical restraints and consequently on the legal regulations that should protect
the patients interests. Yet, these issues remain under-researched. This fact makes certain
legal regulations, which have been adopted from the existing international WHO recom-
mendations, highly controversial.

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However, if we assume that patients opinions vary, the question remains which
patients characteristics could be influencing their opinions.
As reviewed by Ohi et al. [5] patients with schizophrenia have rather specific person-
ality traits. A number of recent studies suggest that with patients with schizophrenia,
personality traits may predispose them toward violent [6] and suicidal behavior [7], or
predispose them to be restrained [8]. There are also reports that personality may influence
the individuals social functioning and quality of life [9], and the experience of self-stigma
[10]. Generally speaking, personality traits are associated with cognitive appraisals, stress
vulnerability, adjustment, and personal functioning [11]. A number of studies have shown
that a variety of special interests or attitudes may be associated with personality. For
example, personality may predispose a student of medicine to choose a certain special-
ization [12], predispose a person toward gambling [13], or a psychopath toward criminal
behavior [14]. Therefore, although the relationship between personality and opinions on
certain legislative or ethical norms has not been investigated yet, it seems logical that a
persons personality may predispose him or her toward specific needs and accordingly
toward forming certain opinions, including those related to ethical issues.
One of the most frequently used personality models among psychiatric research models
is the psychobiological model of personality developed by Cloninger and his colleagues
[15]. The model is based on four temperament dimensions which are considered to be
biologically based and highly heritable individual differences in habits and skills, and three
character dimensions considered as a developmental construct consisting of self-concepts
about values and goals that influence the significance of what has been or is being expe-
rienced. The temperament dimension Harm Avoidance (HA) is defined as pessimistic
worrying in anticipation of problems; Novelty Seeking (NS) describes the initiation of the
appetitive approach in response to novelty; Reward Dependence (RD) describes the
maintenance of behavior in expectation of social reward, and Persistence (P) is defined as
perseverance of behavior despite frustration. According to Cloningers psychobiological
model of personality, the four temperament dimensions are associated with basic emotions:
fear (Harm Avoidance), anger (Novelty Seeking), love (Reward Dependence), and tenacity
(Persistence) [16]. The character dimension of Self-directedness (SD) is defined as having
will-power and determination, Cooperativeness (C) describes individual differences with
regard to tolerance and empathy, and Self-transcendence (ST) characterizes individual
differences in spirituality. These character dimensions mature in response to learning and
life experiences and can influence the expressions of temperament [15]. The psychobio-
logical model might be particularly relevant for schizophrenia, since there is empirical
evidence that temperament dimensions, excluding persistence (P), reflect the regulation of
brain activity by distinct neurotransmitters [17].
The intensity of psychopathology may also be associated with patients perception of
the environment and patients behavior. For example, violent behavior [18] and perception
of stigma with positive symptoms [19] or apathy may be reflected in decreased goal-
directed behavior and goal-directed cognition [20]. Furthermore, social cognition, a
specific domain of cognitive functioning that refers to the mental operations that underlie
social interactions, including perceiving, interpreting, and generating responses to the
intentions, dispositions, and behaviors of others, has emerged as an important area of
psychopathology in schizophrenia [21]. Having certain opinions on an issue that involves
ethical decisions, such as the use of restraints, may be viewed as a complex social cognitive
task, possibly also shaped by psychopathology.
Generally speaking, it seems likely that not only could certain types of behavior be
associated with, and in fact motivated by, psychopathology, personality and previous

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experiences of each individual, but also opinions on various social interactions. Our
hypothesis was that certain characteristics of the patients, such as their current psycho-
pathology, personality traits and a history of being restrained, may be associated with
differences in their opinions.

Aims

In order to increase the quality of treatment and improve safety on psychiatric wards,
clinicians should learn more about the patients needs. Consequently, the aim of this study
was to determine the views of psychotic offender-patients on the use of mechanical
restraints as a kind of punishment, and on voluntary use and sharing of the information
about the use of restraints with the family, as well as to assess whether there is a connection
between the patients personality, psychopathology and the experience of being mechan-
ically restrained and the differences in their views.

Method

The Participants

The participants were inpatients recruited at the Department of Forensic Psychiatry in

Popovaca, the largest forensic department in Croatia with 200 beds (out of a total of 320
forensic beds in Croatia). The inclusion criterion for the study was a diagnosis of
schizophrenia or schizoaffective disorder based upon the DSM IV criteria established
before admission, and confirmed by at least two independent psychiatrists. The exclusion
criterion was intellectual disability due to conditions associated with the inability to
understand the purpose of the study (e.g. an acute psychotic decompensation, mental
retardation or dementia). Since offenders with schizophrenia and high levels of psycho-
pathic traits or alcohol/substance dependence typically exhibit rather different personality
profiles compared to patients with schizophrenia, [22, 23] those with co-morbidity with
antisocial personality disorder, and co-morbidity with alcohol or substance dependence
were also excluded.
Sixty-four male patients were approached after the initial selection by attending psy-
chiatrists in the period between October 2011 and August 2012. Seven patients refused to
participate and an additional three could not participate because of poor psychiatric con-
ditions. As the results are part of a larger study assessing different psychosocial factors in
the population, the reasons why these patients were unwilling to participate may be
associated with other parts of the study and/or with the length of the study. Data were
collected from 54 patients with a history of serious offences (21 or 38.9 % of the patients
had committed or attempted homicide). Fifteen (27.7 %) patients had a history of
attempted suicide.
All the patients selected were on medications (antipsychotic, with or without antide-
pressants, anxiolytics and mood stabilizers), and were in a stable phase of their illnesses,
meaning that the doses of their medications had not been changed in the last month. All
participants gave their informed consent after receiving a comprehensive explanation of
the nature of the study. The patients were told that their decision on participation would
have no bearing on their treatment and that all information they gave would be confi-
dential. The ethics committee approved the study.

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Instruments

The respondents views on mechanical restraints as a kind of punishment, voluntary use

and sharing information with the family were evaluated by the following four statements:
(1) the physician should inform the patients family when the patient has been restrained;
(2) the physician should ask the patient for permission to inform the family that the patient
has been restrained; (3) the use of restraints is an adequate form of punishment if the
patient was intentionally/calculatingly aggressive toward the people in his or her envi-
ronment; (4) the physician should use restraints immediately if the patient asks to be
restrained. The patients rated their opinions using a five-point Likert scale (1 = strongly
disagree; 5 = strongly agree).
The patients personalities were assessed using the Croatian version of the Tempera-
ment and Character Inventory (TCI) [15] which is traditionally used in practice to measure
personality dimensions in patients with schizophrenia. This version was previously used in
a number of studies with Croatian schizophrenia patients [710]. The TCI is administered
through a self-report questionnaire based on 240 items requiring an answer of true or
false. Only the main scores of the four temperament dimensions and three character
dimensions of the TCI are reported in this study. The internal consistencies of the NS, HA,
RD, P, SD, C, and ST dimensions in this study were 0.65, 0.82, 0.45, 0.45, 0.80, 0.73, and
0.84, respectively. The questionnaire was distributed to the patients at the Department.
Each patient was given a few days to complete the questionnaire. The patients then
underwent clinical interviews (usually two or three days latter). The Positive and Negative
Syndrome Scale (PANSS) [24] was administered to all patients for the purpose of eval-
uating the severity of general psychopathology and positive and negative syndromes. The
instrument consists of 30 items, with each item rated on a 7-point severity scale. Items are
divided into three subscales: the positive syndrome scale (7 items), the negative syndrome
scale (7 items), and the general psychopathology scale (16 items). This is an interviewer-
administered scale scored on the basis of a clinical interview lasting 3045 min, and the
total score reflects the overall severity of psychiatric symptoms (range: 30210); the
interviews were performed by an experienced research psychiatrist, and they have
exhibited a high level of internal reliability in this sample with Cronbachs a of 0.91.

Statistical Analysis

The statistical analyses were conducted using the IBM SPSS Statistics 20 for Windows.
Data analysis included descriptive statistics and frequencies, while the comparison of the
groups was based on the MannWhitney U test (because of the skewed distributed data).
Bivariate correlations, Spearmans coefficients, were used to determine the relationship
between opinions, psychopathology and TCI dimensions. The internal reliability of each
dimension of the TCI in schizophrenic patients was determined by Cronbachs alpha. For
all analyses, the level of statistical significance was defined as P less than 0.05.

Results

The mean age was 44.7 (8.39) years, the PANSS score was 85.4 (15.66), and the
duration of institutionalized treatment 6.6 (5.08) years. Thirty-four (63 %) of the patients
had been mechanically restrained, and twenty (37 %) had never been mechanically

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35;64.8%

33;61.1%
20;37%

18;33.3%

strongly disagree
15;27.7%

disagree
nor disagree nor agree
12;22.2%
11;22.3%

11;20.3%
agree
strongly agree

9;16.6%
8;14.8%

7;12.9%
7;12.9%

6;11.1%

5;9.3%
4;7.4%

4;7.4%
3;5.5%

3;5.5%

3;5.5%
2;3.7%

should inform the should ask the patient for restraint is an adequate should use restraints
patients family permission kind of punishment immediately, if the
patients ask for it

Fig. 1 The frequency of the patients replies to the four statements about mechanical restraints

restrained but had witnessed this type of treatment. As the participants were relatively
stable, there were no patients with the experience of being restrained in the past 3 months.
The distribution of answers related to the four statements can be seen in Fig. 1.
The majority of the participants clearly opted to say that a patient who was intentionally
being aggressive should be punished by restraining, and that the patient who requested to
be placed in restraints should be restrained immediately. There were no predominant
answers for the two questions about sharing this information with their family members.
The magnitude of the opinions was associated with previous experience of being
restrained in only one case. Those who had previously been restrained more strongly
believed that a patient who requests to be placed in restraints, should be restrained
immediately; MannWhitney U = 239; P \ 0.05. As can be seen in Table 1, a number of
correlations suggest an association between opinions on sharing the information with the
family, the intensity of psychopathology and personality.

Discussion

The use of restraints is a controversial issue even though legal regulations may seem
straightforward. There is no doubt that patients must be protected, but the question of
forensic patients real needs remains unresolved. The problem is that positive intentions of
protecting the patients rights in some circumstances may produce opposite results, and are
sometimes clearly contrary to the patients will.

Informing the Family

Our results have shown that forensic patients with schizophrenia have very different
opinions regarding the need to inform the patients family whenever he/she has been

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Table 1 The correlations (Spearmans rank) of patients between the patients opinions on mechanical
restraints and personality dimension, psychopathology, age and duration of treatment
Should inform Should ask the Restraint is an Should use restraints
the patients patient for adequate kind immediately, if the
family permission of punishment patients ask for it

NS 0.02 -0.08 -0.06 -0.07

HA 0.37** 0.12 -0.14 -0.07
RD -0.23 0.13 0.27 -0.01
SD -0.27* -0.34* 0.16 0.03
C -0.34* -0.01 0.21 0.05
ST 0.18 0.10 -0.08 -0.01
P 0.14 -0.08 0.05 0.07
Positive subscale 0.37** 0.04 -0.01 0.06
Negative subscale 0.19 0.16 -0.01 0.17
General psychopathology 0.41** 0.21 -0.03 0.11
subscale
PANSS 0.44** 0.22 -0.03 0.13
Age 0.05 0.02 -0.08 -0.01
DT 0.01 -0.09 0.04 -0.04
NS Novelty Seeking, HA Harm Avoidance, RD Reward Dependence, SD Self-directedness, C Coopera-
tiveness, ST Self-transcendence, P Persistence, PANSS Positive and Negative Syndrome Scale, DT duration
of hospitalized treatment
* p \ 0.05, ** p \ 0.01

restrained. Although informing the family about the use of restraints may be helpful in
protecting a patient against unjustified use, this is also a controversial issue. It is a fact that
physical and verbal aggressions are among the most characteristic behavior leading to
restraining [25]. Aggressive inpatients were usually also aggressive before hospitalization,
often in their home environment. In cases of psychotic and especially forensic patients this
aggression was very often extremely severe and directed toward a family member.
Moreover, it is possible for the whole family to disintegrate after a mentally ill member
commits a serious offence [26]. It is therefore questionable whether the main message to
the family would be that the patient was restrained, or that he/she was aggressive and/or
agitated even in a protected environment and while on medication. The question here is not
whether legislation can influence and decrease the frequency of the use of restraints, but
rather what consequences such practice may have on the reintegration of patients. The
forensic patients had very different opinions on this issue. These were not influenced by
their previous experiences of being restrained, but more likely by their current psychop-
athologies and their personalities. Those with more intense symptoms (predominantly
positive symptoms and symptoms of general psychopathology) expressed more positive
opinions about the legal requirement that the physician should inform the patients family
when the patient has been restrained. Moreover, it has been reported that a great majority
of relatives of previously restrained or secluded patients approve of the use of such
measures [27]. Thus, it is possible that patients with less severe symptoms have a better
understanding of their condition and can better predict the responses of their relatives.
Individuals high in HA tend to be fearful, tense, timid, doubtful, inhibited and shy in
most social situations. The HA is a dimension of temperament, therefore a highly heritable

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characteristic, and persons with high HA are basically prone to fear [15]. Persons low in
SD are described as immature, weak, fragile, destructive, ineffective, irresponsible,
unreliable, and poorly integrated when they are not following a mature leader. In other
words, low SD in schizophrenic patients may reflect an immature personality [28]. Indi-
viduals with low C are socially intolerant, disinterested in other people, unhelpful,
revengeful and display destructive behavior; these characteristics are very important for
social adaptation [15]. It has been suggested that low C in schizophrenia is related to a lack
of insight into ones own illness [6]. On the whole, it seems likely that patients with more
intense symptoms who are prone to fear, immature, intolerant and less capable of social
adaptation would be more likely to assume that their family has to be informed. There was
no predominant answer for the following statement: The physician should ask the patient
for his/her permission to inform the family about his/her experience of being restrained.
The study did not aim at exploring the motivation for the given opinions in more detail, so
their motives may well vary. As we have shown, some patients were strictly against
sharing this information with their family. Some were so passive that they simply did not
care. Some believed that the physician should act according to the rules, some believed that
the physician always knows what is best for them. However, more than 40 % believed that
the patient should decide whether the family should be informed or not.
The problem is that, according to the law and/or WHO recommendations, families of all
patients should be informed, including families of those patients who are against such
practice. Here the basic question whether the strict use of regulations could jeopardize the
therapeutic process remains unanswered.

Punishment

According to the legislation, restraining must not be a type of punishment. There is no

doubt that this is sometimes perceived as such by patients. For example, a paranoid patient
who attacked another patient because he/she felt threatened by that patient would perceive
the use of restraints as punishment. However, aggression is among the most characteristic
types of behavior leading to the use of restraints [29]. Aggressive attacks on psychiatric
wards are not only psychotically motivated. The motives can also be psychopathic or
associated with a lack of impulse control [30]. After intentional psychopathically moti-
vated aggression especially, the use of restraints is perceived as a type of punishment rather
than treatment. In such situations the staff must react immediately, not only in order to
protect potential victims, but also because other patients may have very intense feelings of
insecurity. What should then be done in such situations? In forensic hospitals, where
patients are institutionalized for prolonged periods of time and after serious and in most
cases aggressive acts, the great majority of patients believe that the use of restraints as a
type of punishment may be an adequate response. The support for the use of restraints
appears to reflect a lack of alternative approaches to the management of unacceptable
behavior. These opinions are not influenced by the current psychopathology, age, or per-
sonality of the patients, and are therefore probably internalized social values. In the lit-
erature dealing with the use of mechanical restraints, it has been reported that nursing staff
(fortunately in a minority of cases) perceives the use of restraints as a form of punishment
[31]. Patients sometimes, though rarely, describe their personal experiences with coercive
measures as well-deserved punishment [32]. Moreover, it is questionable whether the use
of restraints as a form of punishment should be equated with unjustified humiliation that
may influence the treatment process in a negative way. One can reasonably assume that
such opinions should not be acceptable. If we accept that patients opinions on punishment

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are internalized values of the community, then we should accept that other patients most
typically strongly disagree with possible humiliation. Generally speaking, the communitys
goal is not humiliation but rather safety. Humiliation of a patient can have a devastating
effect on the therapeutic process on the whole psychiatric ward, and reasonable staff will
always avoid such situations. However, feelings of insecurity among psychotic, especially
forensic, patients can be dangerous. According to our clinical experience, psychotic de-
compensations in patients who were not directly involved are possible after psychopath-
ically motivated aggression in a ward. Indeed, the use of restraints may paradoxically
protect a restrained patient from other patients, the micro-community that demands
justice. Therefore, the dilemma whether restraining can be used as a kind of punishment
according to the opinions of forensic patients with schizophrenia basically does not exist.
Consequently, our finding that the majority of forensic patients would approve of the use of
restraints as punishment in certain situations seems logical (Fig. 1). However, what does
this finding actually mean? Should such unethical opinions of patients, as quoted from
WHO guidelines, be taken into account in the legislation? Should this kind of punishment
be legally established in (forensic) hospitals? On the other hand, is it possible that the
majority of the patients have unethical opinions?
The treatment of forensic patients is always accompanied by specific ethical dilemmas,
but the key question here is how the dignity and human rights of the majority of patients
and staff members in a forensic ward can be protected. Basically, there are only two
possible approaches. One may argue that the legislation is clear. In that case, patients
opinions should be irrelevant and the clinician who applied restraining as a kind of pun-
ishment in order to protect the dignity and rights of the majority of patients could be held
legally responsible. Another option is to argue that nothing can replace clinical research
and that in fact guidelines should be based on clinical research. Therefore, further research
on this and similar issues is more than necessary. It has been argued that justice, as a
principle, should be paramount in forensic psychiatry, and that there is a need for a more
specific code of ethics to cover specialized areas of medicine like forensic psychiatry. This
code should specify that in cases of conflict between different principles, justice should
gain precedence over the other principles [33]. The explanation for our finding is
therefore probably simple. Basically, in an organized community, there are ways of
punishing unacceptable behavior with the aim of preserving the dignity and safety of the
members of the community. For the forensic patients, the forensic ward is their organized
community, and their answers represent their need to be protected.

Asking to be Restrained

It is clear that a great majority of psychotic forensic patients believe that a patient who has
requested to be placed in restraints, should be restrained immediately (Fig. 1). Although
this practice is rather rare, few participants have never witnessed such measures, it seems
that the great majority of patients understand the need for such treatment. This measure is
usually used in obviously severely psychotic patients, who are not necessarily extremely
agitated or aggressive and are not necessarily able to talk about their conditions. The
process of restraining usually goes smoothly, and can be performed by one staff member.
According to our experience, the patients more often express two types of feelings,
sometimes after the fact: fear (e.g. that somebody was going to attack them) or they feel the
urge to do something unacceptable (e.g. to attack somebody). However, even though such
restraining may be voluntary, it should not be seen as a coercive measure. The problem is
that the legislation does not recognize such indications for the use of restraints even though

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according to the patients opinions it should. For the legislators, the use of restraints is
always a coercive measure. Moreover, the results suggest that patients with a history of
being restrained more strongly agree that a patient should be immediately restrained upon
his/her own request. Even though the literature on this issue is sparse, it has been reported
that patients with a history of seclusion had more positive feelings toward the measure than
those without such experience [34]. According to the legislation, the least restrictive
measure must be used. However, the best and the least restrictive measure for a
psychotic patient who is asking to be restrained is not defined.

Limitations

This study has several important limitations. The participants were only forensic male
patients, a great majority of whom had committed aggressive acts, and the sample was
rather small because of the number of available patients. These patients may have had
specific personality profiles. It is also questionable whether the thresholds for the use of
restraints were lower in that population. There is no doubt that the functioning of forensic
psychiatric services varies remarkably across the world. The methods of forensic psychi-
atric assessment and selection of patients, organization of forensic wards, different ethical
principles, and duration of treatment are not only different, but are all also highly con-
troversial issues that depend on legislation, political systems, economic development and
so on [35]. Therefore, our results are more or less specific to the Croatian health service
system. Finally, the study assessed the opinions of psychotic patients with relatively high
PANSS scores. Therefore, the validity of self-report measurement is questionable because
of the patients cognitive impairments [36].
Despite these limitations, we hope that our findings will contribute to a better under-
standing of the factors involved in the use of restraints and that the strength of the evidence
will inspire further studies. Having our patients in mind, we believe that respecting their
opinions and real needs is an acceptable approach.

Acknowledgments The authors would like to thank all the patients who participated in the study, and
Drs. Hrastic, Magerle, Petkovic and Zarkovic Palijan for their contributions to recruitment.

Conflict of interest The authors declared no conflict of interest in preparation of this manuscript.

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Branimir Margetic, MD is a clinical psychiatrist and researcher at the Department of Forensic Psychiatry,
Neuropsychiatric hospital Dr. Ivan Barbot Popovaca, Croatia. Dr. Margetic was involved in numerous
clinical studies. He is the author of over 40 original peer-reviewed publications in scientific journals. His
research interests include the relationship between personality and psychiatric patients behavior and side
effects of psychopharmacological medications.

Branka Aukst Margetic, MD, PhD is a clinical psychiatrist and researcher with extensive experience in
clinical practice at the Department of Psychiatry, University Hospital Center Zagreb, Croatia. She is the
author of over 50 original peer-reviewed publications. Her research interests include consultation-liaison
psychiatry and the relationship between psycho-social influences and health in patients diagnosed with
depression, schizophrenia and chronic somatic illnesses. She has worked as a reviewer for many highly
ranked international journals.

Dragutin Ivanec, PhD psychologist from the Department of Psychology, Faculty of Humanities and Social
Sciences, University of Zagreb, Croatia. The main fields of his research interest are psychological aspects of
pain perception, and the influence of the psychosocial context on behavior. He teaches the Methodology of
Experimental Psychology and Statistics for Psychologists.

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