Course and predictors of physical aggressive behaviour after discharge from a psychiatric inpatient unit: 1 year follow-up

Substance Abuse Associated with Aggressive/Violent Behaviors in Psychiatric Outpatients and Related Psychotropic Prescription

Psychiatric disorders with substance abuse are considered the leading causes of most violent and aggressive behaviors in the general population. This study was aimed to assess the impact of substance abuse and the therapeutic approaches adopted by psychiatrists in aggressive vs non-aggressive outpatients (n = 400) attending community-based psychiatric services and recruited over a 3-year period. Clinical and therapeutic variables were collected from medical records and the Modified Overt Aggression Scale (MOAS) was used to assess any aggressive/violent behavior. Violent behaviors were significantly higher in alcohol and substance abusers compared to non-abusers (p < 0.01), except for heroin abusers. Mean weighted MOAS score was significantly higher in patients taking antipsychotics (p < 0.005). The administration of Haloperidol, Zuclopenthixol, and Clozapine was more frequent in aggressive than in non-aggressive patients. The most frequently administered drug in these patients was Haloperidol (23.91%), with a higher mean daily dosage in violent vs non-violent patients. Our results confirm the well-established relationship between substance abuse and violent behaviors in psychiatric inpatients also within outpatient community services. Observed rates of most frequently prescribed antipsychotics to aggressive patients did not show any preference for newer generation compounds, with clinicians operating in the community setting likely being in need for further evidence and specific training to support their treatment choice.

Aggressiveness and violence in psychiatric patients: a clinical or social paradigm?

OBJECTIVE

Psychiatric disorders are often considered the leading cause of violence. This may be due to a stereotype created by media and general opinion.

METHOD

The Modified Overt Aggression Scale (MOAS) was used to evaluate the severity of aggressive and violent behaviors in 400 patients who attended a post-acute psychiatric service in Milan from 2014 to 2016 and suffered from different psychiatric disorders. The psychopathological clinical picture was evaluated by Clinical Global Impression (CGI). The study also assessed the possible correlation between epidemiologic and sociodemographic factors, clinical variables, and aggression and violence.

RESULTS

Of the total number of subjects, 21.50% showed a MOAS score >0, 11.50% presented mild aggression (0-10 MOAS weighted score), 9% moderate aggression (11-20), and 1% severe aggression (MOAS >20). With respect to violent behaviors, 16% of patients showed a score >0 in one MOAS subscale other than verbal aggression according to violence definition. The severity of clinical picture seemed to be related to higher weighted MOAS score. Multivariate testing of different sociodemographic and clinical variables showed that violence was related to unemployment status, and significantly correlated to compulsory admission (TSO), suicide attempts (TS), and personality disorders, while the severity of clinical psychiatric picture seemed to play a secondary role.

CONCLUSION

Results have shown that personality disorders and sociodemographic factors, including economic factors, seem to be major determinants of violence among patients diagnosed with mental disorders.

Violence risk and mental disorders (VIORMED-2): A prospective multicenter study in Italy

Background

The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.

Aim

The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders.

Method

This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment.

Results

The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls.

Conclusions

Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.

Informal Caregiving Relationships in Psychosis: Reviewing the Impact of Patient Violence on Caregivers

A modest association can be found between people with a schizophrenia spectrum diagnosis (psychosis) and perpetrating acts of violence. When a person with psychosis does engage in violence, it is their informal carers, when compared to those from the general population, who are more likely to be the targets, and violence will often occur within the family home. Despite the importance of carer support for improving patient outcomes, our understanding of how carers are impacted by patient initiated violence in psychosis remains limited. This paper reviews literature documenting the effects of patient-initiated violence in psychosis on carer functioning. The review comprised searches of Medline, PsychInfo, Embase, and Web of Science databases and the hand searches of reference lists from relevant published papers. The review was limited to English language publications from inception to 11th September 2017, and where carer experiences following reports of violence from patients with psychosis were specifically recorded. Data from 20 papers using mixed methodologies were reviewed. Patient violence in psychosis was linked to poorer carer outcomes, including carer reports of burden, trauma, fear, and helplessness. There is, however, a significant need for further studies to systematically quantify the impact and correlates of patient initiated violence on psychosis caregivers, and improve prevention.

An examination of the stability of interpersonal hostile-dominance and its relationship with psychiatric symptomatology and post-discharge aggression

The relevance of interpersonal hostile-dominance (HD) to post-discharge aggression in mental health patients is unclear. This study assessed whether (1) HD is stable over time; (2) the relationship between HD and positive, negative, disorganized, and excited symptoms is consistent over time; and (3) HD is related to aggression post-discharge. Two hundred psychiatric inpatients were recruited on admission to hospital; 41 were available for follow-up at 6 months post-discharge, including 29 men and 12 women, with an age range of 19-63 (M = 39.63 years, SD = 12.69 years). Psychiatric symptomatology and interpersonal style were assessed at recruitment and follow-up; aggression in the community post-discharge was measured at follow-up. Results showed that (1) HD was stable over time despite an overall reduction in psychiatric symptoms, (2) HD was positively correlated with symptom severity at both time points, and (3) higher HD, excited symptoms, and positive symptoms measured in the community, and more severe positive symptoms measured in hospital, were associated with aggressive behavior post-discharge. These results suggest that HD is a risk factor for more severe psychopathology. Furthermore, HD, positive symptoms, and excited symptoms measured in the community act as risk factors for aggressive behavior post-discharge. As such, treatment planning and risk assessment should consider HD. Aggr. Behav. 42:324-332, 2016. © 2015 Wiley Periodicals, Inc.

Effects of nurse-led child- and parent-focused violence intervention on mentally ill adult patients and victimized parents: A randomized controlled trial

BACKGROUND

Child-to-parent violence is an often hidden serious problem for parental caregivers of mentally ill adult children who experience violence toward them. To date, the comprehensive dyadic parent-adult child intervention to manage child-to-parent violence is scarce.

OBJECTIVE

To evaluate the effect of Child- and Parent-focused Violence Program, an adjunctive intervention involved with both violent adult children with mental illness and their victimized biological parent (parent-adult child dyads) on violence management.

DESIGN

Open-label randomized controlled trial.

SETTING

A psychiatric ward in a teaching hospital and two mental hospitals in Southern Taiwan.

PARTICIPANTS

Sixty-nine patients aged ≥20 years, with thought or mood disorders, having violent behavior in the past 6 months toward their biological parent of either gender were recruited. The violent patients' victimized biological parents who had a major and ongoing role in provision of care to these patients, living together with and being assaulted by their violent children were also recruited. The parent-adult child dyads were selected.

METHODS

The intervention was carried out from 2011 to 2013. The parent-adult child dyads were randomly assigned to either the experimental group (36 dyads), which received Child- and Parent-focused Violence Intervention Program, or to the control group (33 dyads), which received only routine psychiatric care. The intervention included two individualized sessions for each patient and parent, separately, and 2 conjoint sessions for each parental-child dyad for a total of 6 sessions. Each session lasted for at least 60-min. Data collection was conducted at 3 different time frames: pre-treatment, post-treatment, and treatment follow-up (one month after the completion of the intervention).

RESULTS

Occurrence of violence prior to intervention was comparable between two groups: 88.9% (n=32) parents in the experimental group versus 93.9% (n=31) in the control group experienced verbal attack, and 50% (n=18) versus 48.5% (n=16) received body attack and were injured. The intervention significantly reduced violence, improved impulsivity, changed patients' and parents' violence attributions, and fostering active coping processes in the experimental group as compared to the control group (p<0.05). No significant reductions were found in verbal aggression, cognitive and social reactions in the parent's reactions to assault, attentional subscale of impulsivity and wishful thinking (p>0.05).

CONCLUSIONS

Child- and Parent-focused Violence Intervention Program is effective on child-to-parent violence management in parent-adult child dyads. Thus, the intervention can be helpful for patients who have just been diagnosed with mental illness and had an episode of violence toward their parents within a narrow time frame.