Re: Venous thromboembolism after mechanical restraint in psychiatric hospitals: population based cohort and self-controlled case series study

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Agreement: I Agree Body: Dear Editor, 'Mechanical restraint outside hospitals deserves attention too' Viuff and colleagues demonstrate that mechanical restraint in psychiatric hospitals is associated with an increased short-term risk of venous thromboembolism. 1 The accompanying editorial rightly discusses risk assessment, thromboprophylaxis, and strategies to reduce restraint in psychiatric facilities. 2 An equally important question, however, lies beyond the hospital. In India, as in many low- and middle-income countries, most people with severe mental illness are cared for by their families. The Mental Healthcare Act 2017 appropriately regulates the use of restraint within mental health establishments and emphasizes access to community-based mental healthcare. 3 Yet during acute behavioral emergencies, many families have no realistic access to immediate psychiatric assessment, emergency medication, or community crisis services. Under these circumstances, physical restraint may become a temporary measure of last resort until professional help can be obtained. Unlike hospital-based restraint, these episodes occur without clinical supervision. Patients are therefore unlikely to be assessed for complications related to prolonged immobility, including venous thromboembolism, dehydration, pressure injury, or rhabdomyolysis. The Danish findings should therefore prompt a broader research agenda. If restraint is associated with measurable physical harm in well-resourced psychiatric hospitals, the burden may be greater—but largely invisible—in community settings where episodes are undocumented and medical surveillance is absent. Reducing restraint requires more than legislative safeguards. It also depends on making timely crisis assessment, emergency treatment, outreach services, and practical support available to families. Without these alternatives, restraint may remain an unintended consequence of inadequate access to care rather than a clinical decision. The physical consequences of community-based restraint represent an important evidence gap in global mental health and deserve systematic investigation. References: 1. Viuff JH, Pedersen L, Petersen I, Vandenbroucke JP, Østergaard SD, Sørensen HT. Venous thromboembolism after mechanical restraint in psychiatric hospitals: population based cohort and self-controlled case series study. BMJ. 2026;394:e100016. 2. Mueller C, Pozuelo Moyano B, Speed V. Restraint and venous thromboembolism in psychiatric hospitals: understanding risk and prevention. BMJ. 2026;394:e100056. 3. Government of India. The Mental Healthcare Act, 2017 (Act No. 10 of 2017). New Delhi: Ministry of Law and Justice; 2017. 4. Gill N, Drew N, Rodrigues M, Muhsen H, Morales Cano G, Savage M, et al. Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action. BJPsych Open. 2024;10(1):e23. doi:10.1192/bjo.2023.622. No competing Interests: Yes The following competing Interests: Electronic Publication Date: Sunday, July 5, 2026 - 17:23 AI use: No, I have not used AI Highwire Comment Subject: Venous thromboembolism after mechanical restraint in psychiatric hospitals: population based cohort and self-controlled case series study Workflow State: Released Full Title: Re: Venous thromboembolism after mechanical restraint in psychiatric hospitals: population based cohort and self-controlled case series study Highwire Comment Response to: Venous thromboembolism after mechanical restraint in psychiatric hospitals: population based cohort and self-controlled case series study Check this box if you would like your letter to appear anonymously:: Last Name: Prakash First name and middle initial: Om Email: [email protected] Address: Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, New Delhi INDIA 110095 Occupation: Professor of Psychiatry & Head, Department of Geriatric Mental Health Affiliation: Institute of Human Behaviour and Allied Sciences (IHBAS) BMJ: Additional Article Info: Rapid response Twitter: @ompsychiatrist