Pratique de l’isolement chez des patients hospitalisés sous contrainte dans un service universitaire d’urgences psychiatriques. Revue de 266 dossiers

RésuméL’isolement thérapeutique est un outil de soin psychiatrique d’utilisation courante. Or, peu de travaux se sont intéressés à son utilisation dans le cadre des services d’urgences psychiatriques. Notre travail propose, à partir de l’étude de 266 dossiers de patients admis en hospitalisation sous contrainte et isolés pendant leur séjour dans un service d’urgences psychiatriques, de déterminer quels facteurs sociodémographiques et cliniques sont en lien avec le maintien de la mesure d’isolement ou sa levée pendant le séjour aux urgences. Deux profils de patients se dégagent de l’étude. Le premier correspond à des patients atteints de pathologies chroniques de type psychotique pour lesquels la mesure d’isolement est maintenue aux urgences. Le second correspond à des patients ayant un profil de crise, présentant des troubles de personnalité, des manifestations autoagressives ou des symptômes de la lignée dépressive et pour lesquels l’isolement est levé. Notre travail dresse un état des lieux de la question de l’isolement dans le soin psychiatrique d’urgence.

PurposeThe seclusion is a tool of psychiatric care of common use. Few works studied its use in emergency psychiatry unit. The purpose of our study is to determine what are factors bound to a levying of the seclusion in a service of psychiatric emergencies.MethodsOur study is retrospective, descriptive on 266 episodes of seclusion for patients hospitalized under constraint, in the service of Psychiatric Emergencies of the University hospital of Saint-Étienne (France).ResultsThe results show that the histories of psychosis (P = 0.0001), drug abuse (P = 0.0326), hospitalization in psychiatry (P = 0.0307), an age lower than 37 (P = 0.0113), a diagnosis of psychotic episode (P = 0.0023), symptoms of agitation (P = 0.0038), behavior disorders (P = 0.0012) and delusion (P < 0.0001) or maniac episode (P = 0.0006) at the beginning of the hospitalisation are connected with maintain of seclusion during the transfer in another psychiatric department. While the histories of alcohol abuse (P = 0.0001), mental pathology connected with alcohol abuse (P = 0.0326), suicide attempt (P = 0.0275), an age higher than 41 years (P = 0.0113), a diagnosis of disorders connected with a psychoactive substances abuse (P = 0.0023) or personality disorders (P = 0.0014), auto-aggressive behavior (P = 0.0013), behavior problems linked to drug abuse (P = 0.0014) and depressive symptoms (P = 0.0006) are bound to a levying of the seclusion in the psychiatric emergencies. The patients for whom the seclusion is maintained in the unit are more quickly transferred towards another unit and their average duration of stay is lower than those for which seclusion is raised in the psychiatric emergency unit (P = 0.0007). Our study highlights that seclusion was used within two different frameworks: on the one hand in management of mental chronic disease requiring care with long course (patient whose seclusion is maintained) and on the other hand for the care of the patients having a profile of “crisis” and for which seclusion is more easily raised.ConclusionsOur results thus allow the clinician to determine with more objectivity, at the beginning of the hospitalisation in the psychiatric emergencies unit, if the whole of the clinical situation could be managed in the unit, in a few days (“crisis” or “psychiatric emergencies”) or if an early orientation towards a general psychiatry unit must be done (“psychiatry in emergency”). It seems to be important to be able to carry on this type of studies so as to support a clinical reflexion on the rational and reasoned use of seclusion in the emergency care, and thus to decrease of it the use by reconsidering the care in particular around the problem of management of violence in practice psychiatric.