De-escalation for Minimizing Coercion in Acute Psychosis: Evidence and Challenges

De-escalation is recommended as the first-line, least restrictive response to agitation and aggression in acute psychosis, yet randomized evidence for the technique itself remains scarce. This review argues that the gap reflects the level at which evidence lies rather than its absence and examines four converging lines of support. Seclusion and restraint can cause physical and psychological harm, and their use must therefore be clearly justified rather than adopted as a default practice. Inpatient aggression arises largely from modifiable staff and environmental factors, and structured short-term risk assessment reduces aggressive incidents and coercive measures. Evaluated as complex organizational rather than isolated interventions, programs such as Six Core Strategies and Safewards have reduced containment. Least restrictive principles impose a normative obligation. A 2024 survey of 388 Korean institutions documented marked interinstitutional variation, suggesting that progress depends less on efficacy trials than on standardized metrics, adequate staffing, and implementation research.