Prevalence and risk factors of agitation in newly hospitalized schizophrenia patients in China: An observational survey

An Exploration of Depression and Aggression Among Patients with Schizophrenia in China Rural Community

Purpose

In schizophrenia, aggressive conduct is frequent. And depressed mood can also contribute to the occurrence of aggressive behaviors. The aim of this study was to investigate the risk factors for the occurrence of aggression in stable schizophrenia patients in rural China, mainly to investigate the role of depressed mood in the occurrence of aggression in schizophrenia patients.

Patients and Methods

This is a cross-sectional study conducted in the townships surrounding Chaohu City, Anhui Province, China. Patients' depressive mood was evaluated using the PHQ-9 (The 9-item Patient Health Questionnaire). Patients' aggressiveness was evaluated using the Modified Overt Aggression Scale (MOAS). A score of ≥4 was used as a threshold and divided into aggressive and non-aggressive groups.

Results

This study comprised a total of 821 schizophrenia patients. Among them, the prevalence of having aggressive behavior was 18.8%. After correcting for confounders, logistic regression analysis showed that low education level (OR=0.470, 95% CI 0.254-0.870; p=0.016), living with family (OR=0.383, 95% CI 0.174-0.845; p=0.017) depressed mood (OR=1.147, 95% CI 1.112-1.184; p<0.001) was significantly associated with the risk of aggressive behavior in patients with schizophrenia. Multivariate linear regression indicated that higher levels of aggression were linked with lower levels of education and higher depressive mood.

Conclusion

This study suggests that aggression is more common in patients with stable schizophrenia, and lower levels of education and higher levels of depression are associated risk factors for its occurrence. Living alone may be helpful in reducing the likelihood of aggression.

The safety and efficacy of sequential intramuscular/oral ziprasidone treatment of acute episode in patients with schizophrenia: a multicenter, open-labeled study

BACKGROUND

Ziprasidone mesylate injection is an atypical antipsychotic drug which is recently approved in China. In combination with its oral formulation, sequential therapy with ziprasidone brings new interventions to patients with agitation in the acute phase of schizophrenia. The purpose of this 7-day multicenter study conducted in China was to evaluate the efficacy and safety of ziprasidone sequential treatment through intramuscular/oral routes in agitated patients with schizophrenia.

METHODS

A total of 95 patients were enrolled from three centers in this study. The study duration was 7 days. In the first 3 days, subjects were administered an intramuscular injection of ziprasidone 10-40 mg daily and started sequentially with oral ziprasidone 40-80 mg at dinner (or lunch) from the day of the last intramuscular injection. In the following 4 days, according to the severity of the symptoms and the drug response, 120-160 mg of ziprasidone was orally administered daily. In total, six visits were scheduled to assess the Positive and Negative Syndrome Scale (PANSS), the Behavioral Activity Rating Scale (BARS), the Clinical Global Impression of Severity (CGI-S), and Improvement (CGI-I) scores throughout the procedure. Lastly, adverse events were recorded during treatment.

RESULTS

Out of the 95 patients that were enrolled, 83 cases were effectively completed. Visits 3, 4, 6, PANSS, and PANSS-excited component (PANSS-EC) subscale points, and Visit 2-Visit 6 viewpoints, BARS scale points, and baseline scores denote a progressive downward trend (P < 0.001). In this study, 62 adverse events were reported. The most common adverse events were extrapyramidal symptoms (EPS) (23 cases) and excessive sedation(10 cases), and 13 cases of prolonged QTc interval were reported.

CONCLUSIONS

Ziprasidone IM demonstrated significant and rapid reduction in agitation, and sequential oral formulation keep stability and continuation of the treatment can further ensure efficacy. Ziprasidone sequential therapy may provide a new approach to acute agitation in schizophrenic patients.

TRIAL REGISTRATION

The Chinese Clinical Trials Registry; URL: https://www.chictr.org.cn : ChiCTR-OIC-16007970.

Offenders and non-offenders with schizophrenia spectrum disorders: Do they really differ in known risk factors for aggression?

Introduction

Individuals with schizophrenia spectrum disorders (SSD) have an elevated risk for aggressive behavior, and several factors contributing to this risk have been identified, e. g. comorbid substance use disorders. From this knowledge, it could be inferred that offender patients show a higher expression of said risk factors than non-offender patients. Yet, there is a lack of comparative studies between those two groups, and findings gathered from one of the two are not directly applicable to the other due to numerous structural differences. The aim of this study therefore was to identify key differences in offender patients and non-offender patients regarding aggressive behavior through application of supervised machine learning, and to quantify the performance of the model.

Methods

For this purpose, we applied seven different (ML) algorithms on a dataset comprising 370 offender patients and a comparison group of 370 non-offender patients, both with a schizophrenia spectrum disorder.

Results

With a balanced accuracy of 79.9%, an AUC of 0.87, a sensitivity of 77.3% and a specificity of 82.5%, gradient boosting emerged as best performing model and was able to correctly identify offender patients in over 4/5 the cases. Out of 69 possible predictor variables, the following emerged as the ones with the most indicative power in distinguishing between the two groups: olanzapine equivalent dose at the time of discharge from the referenced hospitalization, failures during temporary leave, being born outside of Switzerland, lack of compulsory school graduation, out- and inpatient treatment(s) prior to the referenced hospitalization, physical or neurological illness as well as medication compliance.

Discussion

Interestingly, both factors related to psychopathology and to the frequency and expression of aggression itself did not yield a high indicative power in the interplay of variables, thus suggesting that while they individually contribute to aggression as a negative outcome, they are compensable through certain interventions. The findings contribute to our understanding of differences between offenders and non-offenders with SSD, showing that previously described risk factors of aggression may be counteracted through sufficient treatment and integration in the mental health care system.

Status and clinical influencing factors of involuntary admission in chinese patients with schizophrenia

BACKGROUND

Though controversial for its various disadvantages, involuntary admission (IA) is necessary in providing mental health care for patients suffering from schizophrenia in China. This article examines the IA rate in a representative sample, and under which circumstances are these patients more likely to be admitted involuntarily.

METHODS

Adult patients consecutively admitted to two typical hospitals in Shanghai between 2013 and 2014 with a diagnosis of ICD-10 schizophrenia were included. 2167 patients were included in this study. Sociodemographic and clinical data, as well as personal information of psychiatrists who made risk assessment, were collected. The whole sample was divided into voluntary and involuntary admission groups. Group comparisons were performed with SPSS 17.0, using one-way ANOVA, Wilcoxon rank sum test, Chi-squares and Logistic regression.

RESULTS

Among 2167 inpatients, the majority (2003, 92.4%) were involuntarily admitted. Clinical features, including age of patients (p < 0.001, OR = 1.037), lacking of insight (p < 0.001, OR = 3.691), were statistically significant for IA. Psychiatrist's age (p < 0.001, OR = 1.042) was independently associated with IA. However, risk behaviors had dramatically affected patients' admission status, of which the strongest predictor of IA was noncompliance with treatment (p < 0.001, OR = 3.597). The areas under the curve of the ROC and accuracy for the regression model were 0.815 and 0.927, respectively.

CONCLUSION

IA patients account for a major proportion of all those hospitalized with schizophrenia in China. Insights and risk behaviors contributed the most reasons for admission status of patients. This research shed light on necessity of further qualitative studies learning detailed evaluation processes of IA and high-quality interventional studies aiming to limit the performance of IA among patients with schizophrenia.

Fifty years of experience with loxapine for the rapid non-coercive tranquilization of acute behavioral disturbances in schizophrenia patients, and beyond

INTRODUCTION

Acute behavioral disturbances in psychosis, including agitation, comprise a heterogeneous group of manifestations varying in intensity and duration they last for. They require rapid, non-coercive treatments ranging from verbal de-escalation to the calming effect of pharmacological agents. The treatment goals are reduction of patient suffering and prevention of disease deterioration. Stabilizing rather than sedating is preferred to ensure improved compliance and a stronger therapeutic alliance. Furthermore, animal pharmacology and clinical studies on agitation reveal the robust calming and anxiolytic properties of loxapine.

AREAS COVERED

This review covers the pharmacological and clinical history of loxapine along with research developments. It emphasizes the advantages of its multiple formulations ranging from injectable forms and tablets to orally inhaled forms to attain rapid and fine-tuned tranquilization.

EXPERT OPINION

Rapid tranquillization is achieved within 2-6 hours using liquid orally-consumed loxapine, and within an hour or less with its IM or orally inhaled forms. Loxapine has been adopted in the management of a wide range of acute disturbances, such as agitation in psychosis. In the context of personalized medicine, key cellular and molecular elements of the schizophrenia phenotype were recently shown to be improved with loxapine.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Associations of C-Reactive Protein, Free Triiodothyronine, Thyroid Stimulating Hormone and Creatinine Levels with Agitation in Patients with Schizophrenia: A Comparative Cross-Sectional Study

PURPOSE

Agitation is prevalent among inpatients with schizophrenia. The aim of this study was to investigate whether biochemical parameters are associated with agitation in schizophrenia.

PATIENTS AND METHODS

Agitation was evaluated by the Positive and Negative Syndrome Scale-Excited Component questionnaire (PANSS-EC). Fasting serum levels of C-reactive protein (CRP), free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), uric acid (UA), creatinine, glucose and lipids were measured.

RESULTS

The analysis included 154 inpatients with schizophrenia (71 with agitation, 83 without agitation) and 75 healthy control subjects. Patients with schizophrenia and agitation had higher serum levels of CRP, FT3, FT4 and UA as well as lower levels of serum TSH and creatinine than patients without agitation (all P < 0.05). Multivariate logistic regression analysis indicated that serum CRP (odds ratio [OR] = 1.470, P = 0.001), FT3 (OR = 13.026, P < 0.001), TSH (OR = 0.758, P = 0.033) and creatinine (OR = 0.965, P = 0.004) were significantly associated with agitation in schizophrenia. CRP, FT3, TSH and creatinine achieved an area under the ROC curve of 0.626, 0.728, 0.620 and 0.663 respectively in discriminating schizophrenia with or without agitation.

CONCLUSION

Increased serum CRP and FT3 levels and decreased serum TSH and creatinine levels are independent risk factors for agitation in hospitalized patients with schizophrenia. Inflammation, thyroid hormones and renal function may be involved in the pathogenesis of agitation in schizophrenia.

Recognition and management of agitation in acute mental health services: a qualitative evaluation of staff perceptions

BACKGROUND

Agitation among patients is a common and distressing behaviour across a variety of health care settings, particularly inpatient mental health. Unless recognised early and effectively managed it can lead to aggression and personal injury. The aim of this paper is to explore the experiences of mental health nurses in recognising and managing agitation in an inpatient mental health setting and the alignment of these experiences with best practice and person-centred care.

METHODS

This study used a descriptive qualitative methodology. Semi-structured focus group interviews were conducted with 20 nurses working in a mental health unit in 2018. Nursing staff described their experiences of assessing and managing agitation. Descriptive and Thematic Analysis were undertaken of the transcribed focus group dialogue.

RESULTS

Nurses combined their clinical knowledge, assessment protocols and training with information from patients to make an individualised assessment of agitation. Nurses also adopted an individualised approach to management by engaging patients in decisions about their care. In keeping with best practice recommendations, de-escalation strategies were the first choice option for management, though nurses also described using both coercive restraint and medication under certain circumstances. From the perspective of patient-centred care, the care provided aligned with elements of person-centred care nursing care.

CONCLUSION

The findings suggest that clinical mental health nurses assess and manage agitation, with certain exceptions, in line with best practice and a person-centred care nursing framework.

Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis

AIMS

Voluntary admission rates of schizophrenia vary widely across studies. In order to make the topic be informed by evidence, it is important to have accurate estimates. This meta-analysis examined the worldwide prevalence of voluntary admissions for patients with schizophrenia.

METHOD

PubMed, EMBASE, PsycINFO, the Cochrane Library, Web of Science and Medline databases were systematically searched, from their commencement date until 19th November 2018. Meta-analysis of included studies was performed using the random-effects model.

RESULTS

Thirty-five studies with 134,100 schizophrenia patients were included. The overall voluntary admission rate of schizophrenia was 61.9 % (95 %CI: 52.3 %-70.7 %), while the involuntary rate was 43.0 % (95 %CI: 34.8 %-51.7 %). Subgroup analyses revealed that patients in Europe had significantly higher voluntary admission rates, while their North American counterparts were more likely admitted involuntarily. Papers published prior to 2008 reported higher involuntary admission rates. Meta-regression analyses showed that higher male percentage and higher study quality were significantly associated with higher voluntary admission rate.

CONCLUSION

Although the worldwide prevalence of voluntary admissions was higher than that of involuntary admissions, the latter was common for schizophrenia. With the continuing liberalization of mental health laws broadening community-based psychiatric services, the rate of voluntary psychiatric admissions is expected to further increase over time.

Prevalence of aggression in patients with schizophrenia: A systematic review and meta-analysis of observational studies

OBJECTIVE

Aggression is common in patients with schizophrenia and is clinically significant, but its prevalence is inconsistent across studies. This is a meta-analysis of the prevalence of aggression and its associated factors in patients with schizophrenia.

METHODS

PubMed, EMBASE, PsycINFO, the Cochrane Library, Medline and Web of Science databases were systematically searched. Studies that reported the prevalence of aggression in patients with schizophrenia using the Modified Overt Aggression Scale (MOAS) were included and analyzed using the random-effects model.

RESULTS

Fifteen studies with 4855 patients were initially included; of these, 13 studies with 3929 patients were pooled in the final meta-analysis. The pooled prevalence of aggression was 33.3% (95%CI: 21.5%-47.7%); specifically, the estimated prevalence of verbal, property-oriented, auto and physical aggression were 42.6% (95%CI: 17.0%-72.9%), 23.8% (95%CI: 10.1%-46.4%), 23.5% (95%CI: 6.5%-57.7%), and 23.7% (95%CI: 10.4%-45.3%), respectively. Subgroup analyses revealed that different MOAS cut-off values (P < 0.001) and source of patients (inpatients vs. community-dwelling patients) significantly moderated the results (P < 0.001). Meta-regression analyses found that studies published recently reported higher aggression rate, while higher quality assessment score was associated with lower aggression rate (both P < 0.01).

CONCLUSIONS

This meta-analysis confirmed that aggression is common in schizophrenia patients. Considering the significant clinical risk issues, appropriate treatments and effective management of aggression in this population need to be developed.

Prescription practices in the treatment of agitation in newly hospitalized Chinese schizophrenia patients: data from a non-interventional naturalistic study

BACKGROUND

Data on the pharmacological management of acute agitation in schizophrenia are scarce. The aim of this study is to investigate the prescription practices in the treatment of agitation in Chinese patients with schizophrenia.

METHODS

We conducted a large, multicenter, observational study in 14 psychiatry hospitals in China. Newly hospitalized schizophrenia patients with the PANSS-EC total score ≥ 14 and a value ≥4 on at least one of its five items were included in the study. Their drug treatments of the first 2 weeks in hospital were recorded by the researchers.

RESULTS

Eight hundred and 53 patients enrolled in and 847 (99.30%) completed the study. All participants were prescribed antipsychotics, 40 (4.72%) were prescribed benzodiazepine in conjunction with antipsychotics and 81 were treated with modified electric convulsive therapy (MECT). Four hundred and 12 (48.64%) patients were prescribed only one antipsychotic, in the order of olanzapine (120 patients, 29.13%), followed by risperidone (101 patients, 24.51%) and clozapine (41 patients, 9.95%). About 435 (51.36%) participants received antipsychotic polypharmacy, mostly haloperidol + risperidone (23.45%), haloperidol+ olanzapine (17.01%), olanzapine+ ziprasidone (5.30%), haloperidol + clozapine (4.37%) and haloperidol + quetiapine (3.90%). Binary logistic regression analysis suggests that a high BARS score (OR 2.091, 95%CI 1.140-3.124), severe agitation (OR 1.846, 95%CL 1.266-2.693), unemployment or retirement (OR 1.614, 95%CL 1.189-2.190) and aggressiveness on baseline (OR 1.469, 95%CL 1.032-2.091) were related to an increased antipsychotic polypharmacy odds. Male sex (OR 0.592, 95%CL 0.436-0.803) and schizophrenia in older persons (age ≥ 55 years, OR 0.466, 95%CL 0.240-0.902) were less likely to be associated with antipsychotic polypharmacy.

CONCLUSION

The present study demonstrates that monotherapy and polypharmacy display equally common patterns of antipsychotic usage in managing agitation associated with schizophrenia in China. The extent and behavioral activities of agitation and several other factors were associated with polypharmacy.