Inpatient aggression in community hospitals

Mapping Violent Behaviors and Psychiatric Symptoms Among Male Psychiatric Inpatients from a Network Perspective

Psychiatric symptoms are common risk factors of violent behaviors among psychiatric patients. This study explored the interrelationship between violence and psychiatric symptoms in male psychiatric inpatients. This is a cross-sectional survey conducted in 2019. All patients admitted to the Male Psychiatry Unit of the Second Xiangya Hospital were consecutively recruited. The presence of five violent behaviors and eleven psychiatric symptoms were collected by reviewing medical records and were included as categorical variable in the network analyses. A total of 673 participants were included. The most central symptoms were "flight of ideas", "property-oriented violence", "emotional high", "verbal violence", "physical violence attempt", and "physical violence" in the network of psychiatric symptoms and violent behaviors. The bridge symptoms connecting violence and psychiatric symptoms were "verbal violence", "property-oriented violence", "hyperbulia", and "emotional high" according to the indices of bridge expected influence. The directed acyclic graph analysis revealed that "emotional high" and "hyperbulia" were the key psychiatric symptoms triggering violence, while "verbal violence" and "property-oriented violence" were the most upstream violent behavior. Verbal and property-oriented violence should be addressed in the risk assessment among male psychiatric inpatients. In addition, emotional high and hyperbulia are the potential treatment targets for violent behaviors.

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.

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.

Short-term risk assessments in an acute psychiatric inpatient setting: A re-examination of the Brøset Violence Checklist using repeated measurements - Differentiating violence characteristics and gender

This study investigated the association between short-term risk assessment measured by the Brøset Violence Checklist (BVC) and imminent violence using repeated measurements and differentiating violence characteristics and gender. All patients admitted to an acute psychiatric ward during one year (N = 528) were included. Logistic regression and generalized linear mixed model (GLMM) analyses were conducted. Results confirmed BVC's suitability for both male and female inpatients throughout their hospitalization also when differentiating threats and physical violence, and adjusting for diagnostic subpopulations and circadian variability. Results point to modified interpretations of the BVC sum scores. Future research should adjust for repeated measurements.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

PURPOSE OF REVIEW

We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience.

RECENT FINDINGS

A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

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.

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.

The risk of assault against mental health professionals: a fatal case report and literature review

Assaults by patients against healthcare providers are an increasing phenomenon worldwide. Mental health professionals in acute facilities and rehabilitation wards have the highest risk of being attacked at work. Verbal abuse or intimidating behaviors represent the most common types of violence. Fatal assault by psychiatric patients has been rarely reported in the literature. We present a case of a female psychiatrist who was fatally stabbed in her office in a Mental Health Center. At autopsy seventy stab wounds were found: four wounds of the neck, fifty penetrating wounds of the thorax, three wounds of the abdomen, six wounds of the lumbar region, and seven wounds of the upper arms including defense injuries. The cause of death was massive blood loss due to multiple stab wounds. The perpetrator was a 44-year-old male patient who had been referred to the victim after a previous admission to hospital following experiences of suicidal ideation and confusion. The extreme and unmotivated violence in a non-acute setting were notable. A borderline-antisocial personality disorder was later diagnosed by forensic experts. This case emphasizes the significant occupational risk for mental healthcare staff to sustain life threatening injuries or death, with implications for training of clinicians, and strategies for preventing aggressive behaviors.

Exploration of Aggression/Violence Among Adult Patients Admitted for Short-term, Acute-care Mental Health Services

BACKGROUND/PURPOSE

The purpose of the study was to explore and describe: (a) the prevalence of incidents of aggression and violence among patients, including frequency, kinds and severity of incidents of among patients; target of the aggression; (b) situational factors including time of location and time of event; and (c) staff interventions. We describe the relationships among variables to answer the following research questions: (1) What factors are associated with incidents of aggression and violence, and (2) are factors modifiable?

METHODS

The exploratory descriptive study used data collected by retrospective chart review over a three-year period; the dates of January 1, 2011 to December 31, 2013. A medical record was included if it met the following criteria: 1) person ages 18-75years; 2) admitted to the psychiatric mental care unit (PMCU) during the designated time frame; 3) the length of stay was up to 7days; and 4) during this time the person made a verbal threat of violence or exhibited violent behavior towards property, self, another patient, or a member of the hospital staff. We examined data for a relationship among score on risk assessment items, sociodemographic factors, and outcome variables. We employed a variety of statistical analytic approaches to describe our data and uncover relationships among variables.

RESULTS

There were 132 incidents of aggression/violence between January 1, 2011 and December 31, 2013Of the 93 patients, 68% (n=63) were male and 32% (n=30) were female. Their ages ranged from 20 to 57years with a mean age of 37 for females and 39 for males. Significant associations were found between type of intervention and patients' admitting diagnoses: Χ² (5, N=97)=11.603, p=0.004. Significant associations were also found with regard to drug history, Χ²(1, n=96)=4.673, p=0.03 and history of violence, Χ²(1, N=91)=7.618, p=0.006. Key variables were target (the staff) and location (the hallway). Multiple factor analysis yielded inconclusive results, as numerous factors were identified and variable loadings were weak possibly due to the small sample size and high number of relevant variables.

CONCLUSION

Findings from this study can be used to improve high quality care for hospitalized patients with acute mental health problems. All incidents of aggression/violence cannot realistically be prevented. Staff must stay vigilant for self-safety. The hallway may be modified to reduce visual and auditory stimuli.

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

This multi-center observational study investigated the prevalence of agitation in newly hospitalized schizophrenia patients in China and its potential risk factors. It was performed in 2014 and covered 14 hospitals. Newly hospitalized patients with schizophrenia or suspected schizophrenia who met the diagnostic criteria of the International Statistical Classification of Diseases and Related Health Problems, 10th revision, were recruited. Agitation and related risk factors were evaluated by a questionnaire designed for the survey. General demographic data, disease characteristics, scores on schizophrenia rating scales and agitation rating scales (e.g., Positive and Negative Syndrome Scale-Excited Component [PANSS-EC] and Behavioral Activity Rating Scale [BARS]) were collected. Among the 1512 patients screened in the study, 1400 (92.59%) were eligible. According to the PANSS-EC and BARS, the prevalence of agitation was 60.92% (853 of 1400) and 59.00% (826 of 1400), respectively. The overall prevalence of agitation was 47.50% (665 of 1400). The most important risk factor of agitation was being aggressive at baseline (Modified Overt Aggression Scale score ≥4, odds ratio=6.54; 95% confidence interval=4.93-8.69). Other risk factors included a history of aggressive behavior, northern region of residence, involuntary hospitalization, disease severity, low level of education, living alone, being unemployed or retired.

In-patient costs of agitation and containment in a mental health catchment area

BACKGROUND

There is a scarce number of studies on the cost of agitation and containment interventions and their results are still inconclusive. We aimed to calculate the economic consequences of agitation events in an in-patient psychiatric facility providing care for an urban catchment area.

METHODS

A mixed approach combining secondary analysis of clinical databases, surveys and expert knowledge was used to model the 2013 direct costs of agitation and containment events for adult inpatients with mental disorders in an area of 640,572 adult inhabitants in South Barcelona (Spain). To calculate costs, a seven-step methodology with novel definition of agitation was used along with a staff survey, a database of containment events, and data on aggressive incidents. A micro-costing analysis of specific containment interventions was used to estimate both prevalence and direct costs from the healthcare provider perspective, by means of a mixed approach with a probabilistic model evaluated on real data. Due to the complex interaction of the multivariate covariances, a sensitivity analysis was conducted to have empirical bounds of variability.

RESULTS

During 2013, 918 patients were admitted to the Acute Inpatient Unit. Of these, 52.8% were men, with a mean age of 44.6 years (SD = 15.5), 74.4% were compulsory admissions, 40.1% were diagnosed with schizophrenia or non-affective psychosis, with a mean length of stay of 24.6 days (SD = 16.9). The annual estimate of total agitation events was 508. The cost of containment interventions ranges from 282€ at the lowest level of agitation to 822€ when verbal containment plus seclusion and restraint have to be used. The annual total cost of agitation was 280,535€, representing 6.87% of the total costs of acute hospitalisation in the local area.

CONCLUSIONS

Agitation events are frequent and costly. Strategies to reduce their number and severity should be implemented to reduce costs to the Health System and alleviate patient suffering.

Psychopharmacology of Persistent Violence and Aggression

Persistent violence not due to acute psychosis or mania can be managed only after appropriate characterization of the aggressive episodes (psychotic, impulsive, or predatory/planned/instrumental). The type of violence combined with the psychiatric diagnosis dictates the evidence-based pharmacologic approaches for psychotically motivated and impulsive aggression, whereas instrumental violence mandates forensic/behavioral strategies. For nonacute inpatients, schizophrenia spectrum disorders, traumatic brain injury, and dementia comprise the majority of individuals who are persistently aggressive, with impulsive actions the most common form of violence across all diagnoses. Neurobiological considerations combined with empirical data provide a comprehensive framework for systematic medication trials to manage persistently aggressive patients.