Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study

Prediction of Disruptive Behavior over Time from Changes in Patients' Global Functioning in Acute Psychiatric Care

Disruptive behavior of patients in acute psychiatric care is a problem for both patients and staff. Preventing a patient's impending disruption requires recognizing and understanding early signals. There are indications that a change in a patient's global functioning may be such a signal. The global functioning of patients is a multidimensional view on their functioning. It captures a patient's psychological symptoms, social skills, symptoms of violence, and activities in daily living. The aim of this study was to gain insight into the predictive value of global functioning on the risk of disruptive behavior of patients in acute psychiatric care. Also assessed was the time elapsed between the change in global functioning and a patient's disruptive behavior, which is necessary to know for purposes of early intervention. In a longitudinal retrospective study, we used daily measurements with the Brøset Violence Checklist (BVC) and the Kennedy Axis V (K-As) of each patient admitted to two acute psychiatric units over a period of six years. Data from 931 patients for the first 28 days after their admission were used for survival analysis and cox regression analysis. Disruptive behavior was mostly observed during the first days of hospitalization. Global functioning predicted disruptive behavior from the very first day of hospitalization. A cut-off score of 48 or lower on the K-As on the first admission day predicted a higher risk of disruptive behavior. If functioning remained poor or deteriorated substantially over three days, this was an additional signal of increased risk of disruptive behavior. Improvement in global functioning was associated with a decreased risk of disruptive behavior. More attention is needed for early interventions on global functioning to prevent disruptive behavior.

Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward

Violence and aggression (V&A) are identified as an issue on mental health wards that negatively affect staff, patients, care delivery and safety. This project took place on a male acute mental health ward where V&A are known to be an issue with an average of 21.3 incidences per month in the 6 months preceding the project.The aim was to use QI (Quality Improvement) methodology to reduce incidences of V&A by 20% over a 4-month period. A root cause analysis was completed with staff, previous QI projects and literature on interventions for V&A were reviewed. Two changes were introduced via PDSA (plan, do, study, act) cycles; first was a safewards bundle including a training package, weekly emails and noticeboard displays, the second was safety crosses displayed on the ward.There was a reduction in incidences of V&A across the project, mean weekly incidences reduced from 2.5 at baseline audit to 2.0 at the end of the project. This equates to a 20% reduction in V&A. The project did result in an increase of safewards interventions recorded and staff ratings of ward safety improved. There was a statistically significant correlation found between incidences of V&A and rates of restrictive practices.Further analysis of the 20% reduction did not find a special cause variation, so results may be due to a common cause variation rather than the QI interventions. Safety crosses were not found to have an impact on rates of V&A, it is likely these need to be more embedded into communication about V&A on the ward. Potential confounding patient variables such as illicit drug use and history of V&A as well as staffing should be recorded and monitored in future projects. Recommendations to enhance further change should include regular meetings with both staff and patients to support open communication about the topic.

Nurses' and Patients' Perceptions about Psychiatric Intensive Care-An Integrative Literature Review

This integrative literature review describes nurses's and patients' perceptions of care in psychiatric intensive care units (PICU). The database search was conducted in April 2020. PRISMA checklist and Mixed Method Appraisal Tool guided the identification and evaluation of the studies (n = 21). Data was analyzed with qualitative content analysis. Nurses perceived PICU as a challenging work environment where their primary task was to ensure the unit's safety. Patients views on their treatment varied from positive to negative. Patients wished to have more privacy and supportive interaction. Findings can be used as a basis in developing care practices and staff's further education in PICUs.

Medication Use and Physical Assaults in the Psychiatric Emergency Department

Objective: To evaluate the relationship between medications used to treat acute agitation (antipsychotics, mood stabilizers, and benzodiazepines) and subsequent assault incidence in the psychiatric emergency department. Methods: Medication orders and assault incident reports were obtained from electronic health records for 17,056 visits to an urban psychiatric emergency department from 2014 to 2019. Assault risk was modeled longitudinally using Poisson mixed-effects regression. Results: Assaults were reported during 0.5% of visits. Intramuscular (IM) medications were ordered in 23.3% of visits overall and predominantly were ordered within the first 4 hours of a visit. IM medication orders were correlated with assault (incident rate ratio [IRR] = 24.2; 95% CI, 5.33-110.0), often because IM medications were ordered immediately subsequent to reported assaults. Interacted with time, IM medications were not significantly associated with reduction in subsequent assaults (IRR = 0.700; 95% CI, 0.467-1.04). Neither benzodiazepines nor mood stabilizers were associated with subsequent changes to the risk of reported assault. By contrast, antipsychotic medications were associated with decreased assault risk across time (IRR = 0.583; 95% CI, 0.360-0.942). Conclusions: Although assault prevention is not the sole reason for ordering IM medications, IM medication order rates are high relative to overall assault incident risk. Of the 3 major categories of medications ordered commonly in the psychiatric emergency setting, only antipsychotic medications were associated with measurable decreases in subsequent assault risk. As antipsychotic medication can have a significant side effect burden, careful weighing of the risks and benefits of medications is encouraged.

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.

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.

Risk Factors and Triggers That May Result in Patient-Initiated Violence on Inpatient Psychiatric Units: An Integrative Review

The aim of the present integrative review is to identify and describe risk factors and triggers that may result in patient-initiated violence on inpatient psychiatric units. Original studies were searched for in PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. From the 826 identified publications, 18 were included for a synthesis. The results are presented in three themes, which demonstrate that patient characteristics, staff approach, and the ward environment are influencers that may trigger the emergence of violent incidents. Incidents are discussed from the theoretical framework of complexity science as dynamic, highly variable in manifestation, and adaptive, in that the forthcoming process and outcomes are highly dependent on how the surrounding environment responds. Our recommendation is that staff on inpatient wards recognize the myriad influencers that may trigger inpatient violence in a context of highly complex interactions.

Aggressive incidents on a psychiatric intensive care unit

Aims and Method

This study looked at patient aggressive behaviour on an Irish psychiatric intensive care unit, and whether it was related to diagnosis, patient's insight and symptomatology. Each aggressive incident was recorded throughout the patient's stay using the Staff-Observed Aggression Scale.

Results

Ninety-nine individuals were admitted to the unit during the study. We recorded 82 aggressive incidents, with most occurring during the daytime and on weekdays. There was no statistical difference in BPRS scores between the aggressive and non-aggressive groups. the aggressive patient group had a lower insight score than the non-aggressive group (P < 0.05) as measured on the Schedule of the Assessment of Insight. However, when gender and verbal aggression only were included in the analysis, the difference in insight was less significant (P=0.07).

Clinical Implications

Aggression is common on a psychiatric intensive care unit. Low levels of insight in patients may increase the risk of aggression.

Characteristics of aggression among psychiatric inpatients by ward type in Japan: Using the Staff Observation Aggression Scale - Revised (SOAS-R)

Aggressive behaviour by psychiatric patients is a serious issue in clinical practice, and adequate management of such behaviour is required, with careful evaluation of the factors causing the aggression. To examine the characteristics of aggressive incidents by ward type, a cross-sectional descriptive study was conducted for 6 months between April 2012 and June 2013 using the Staff Observation Aggression Scale - Revised, Japanese version (SOAS-R) in 30 wards across 20 Japanese psychiatric hospitals. Participating wards were categorized into three types based on the Japanese medical reimbursement system: emergency psychiatric, acute psychiatric, and standard wards (common in Japan, mostly treating non-acute patients). On analyzing the 443 incidents reported, results showed significant differences in SOAS-R responses by ward type. In acute and emergency psychiatric wards, staff members were the most common target of aggression. In acute psychiatric wards, staff requiring patients to take medication was the most common provocation, and verbal aggression was the most commonly used means. In emergency psychiatric wards, victims felt threatened. In contrast, in standard wards, both the target and provocation of aggression were most commonly other patients, hands were used, victims reported experiencing physical pain, and seclusion was applied to stop their behaviour. These findings suggest that ward environment was an important factor influencing aggressive behaviour. Ensuring the quality and safety of psychiatric care requires understanding the characteristics of incidents that staff are likely to encounter in each ward type, as well as implementing efforts to deal with the incidents adequately and improve the treatment environment.

[Association between the violence in the community and the aggressive behaviors of psychotics during their hospitalizations]

BACKGROUND

Violence is a common issue in psychiatry and has multiple determiners. The aim of this study is to assess the psychotic inpatients' violence in association with the violence of the neighborhood from which the patients are drawn and to estimate the impact of this environmental factor with regard to other factors.

METHOD

A prospective multicenter study was led in nine French cities. Eligible patients were psychotic involuntary patients hospitalized in the cities' psychiatric wards. During their treatments, any kind of aggressive behavior by the patients has been reported by the Overt Aggression Scale (OAS).

RESULTS

From June 2010 to May 2011, 95 patients have been included. Seventy-nine per cent of the patients were violent during their hospitalizations. In a bivariate analysis, inpatient violence was significantly associated with different factors: male gender, patient violence history, substance abuse, manic or mixed disorder, the symptoms severity measured by the BPRS, the insight degree and the city crime rate. In a multivariate analysis, the only significant factors associated with the patients' violence were substance abuse, the symptoms severity and the crime rates from the different patients' cities.

CONCLUSION

These results suggest that violence within the psychotic patients' neighborhood could represent a risk of violence during their treatments.

Workplace Violence Toward Mental Healthcare Workers Employed in Psychiatric Wards

Background

Workplace violence (WPV) against healthcare workers (HCWs) employed in psychiatric inpatient wards is a serious occupational issue that involves both staff and patients; the consequences of WPV may include increased service costs and lower standards of care. The purpose of this review was to evaluate which topics have been focused on in the literature and which are new in approaching the concern of patient violence against HCWs employed in psychiatric inpatient wards, in the past 20 years.

Methods

We searched for publications in PubMed and Web of Science using selected keywords. Each article was reviewed and categorized into one or more of the following four categories based on its subject matter: risk assessment, risk management, occurrence rates, and physical/nonphysical consequences.

Results

Our search resulted in a total of 64 publications that matched our inclusion criteria. The topics discussed, in order of frequency (from highest to lowest), were as follows: “risk assessment,” “risk management,” “occurrence rates,” and “physical/nonphysical consequences.” Schizophrenia, young age, alcohol use, drug misuse, a history of violence, and hostile-dominant interpersonal styles were found to be the predictors of patients’ violence.

Conclusion

Risk assessment of violence by patients appeared the way to effectively minimize the occurrence of WPV and, consequently, to better protect mental HCWs. We found paucity of data regarding psychologic sequelae of WPV. According to these findings, we suggest the need to better investigate the psychologic consequences of WPV, with the aim of checking the effective interventions to assist HCW victims of violence and to prevent psychologic illness.

Inpatient Violence

Inpatient violence constitutes a major concern for staff, patients, and administrators. Violence can cause physical injury and psychological trauma. Although violence presents a challenge to inpatient clinicians, it should not be viewed as inevitable. By looking at history of violence, in addition to clinical and other historical factors, clinicians can identify which patients present the most risk of exhibiting violent behavior and whether the violence would most likely flow from psychosis, impulsivity, or predatory characteristics. With that information, clinicians can provide environmental and treatment modifications to lessen the likelihood of violence.

Aggression on inpatient units: Clinical characteristics and consequences

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient-staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression-rule breaking, aggression-medication, and aggression-containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression-containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.

Prevalence of aggression in hospitalized patients with schizophrenia in China: A meta-analysis

INTRODUCTION

Aggression is a major concern in psychiatric inpatient care. Variations in study designs, settings, populations and data collection methods render comparisons of the prevalence of aggressive behavior in high-risk settings difficult. We proposed to estimate the pooled prevalence of aggression among inpatients with schizophrenia in China.

METHODS

Reports on aggressive behaviour involving physical contact or risks of interpersonal violence, in schizophrenia in Chinese general psychiatric wards were retrieved by using computer-assisted searches and manual searches of the reference lists of the relevant literature. Statistical analyses were conducted using the Comprehensive Meta-Analysis V2 software. Potential sources of heterogeneity were analyzed with Cochrane's Q analysis.

RESULTS

The search yielded 19 eligible studies involving a total of 3,941 schizophrenia patients. The prevalence of aggressive behavior in psychiatric wards ranged between 15.3% and 53.2%. The pooled prevalence of aggression was 35.4% (95% CI: 29.7%, 41.4%). The most commonly reported significant risk factors for aggression were positive psychotic symptoms: hostility or suspiciousness, 78.9% (15 studies); delusions, 63.2% (12 studies); disorganized behavior, 26.3% (5 studies); and auditory hallucinations, 10.5% (2 studies); together with: past history of aggression, 42.1% (8 studies); and involuntary admission, 10.5% (2 studies).

CONCLUSIONS

Aggressive behaviour is common in Chinese inpatients with schizophrenia. The prevalence figures indicate the need to identify reliable clinical and illness predictors for aggression in inpatient psychiatric wards and to test investigations aimed at reducing aggressive episodes and their adverse outcomes.

Students' Aggression and Its Relevance to Personal, Family, and Social Factors

Background:

Aggression is defined as behaviors intended to hurt, harm, or injure another person. Aggression is by no means a new concern in human society, especially in youth. Universities are among the institutions in which most of the members are young people and because of facing with various personal and social stressors, the students usually experience high level of stress.

Objectives:

This study aimed to determine aggression among university students and its association with their personal, family, and social characteristics.

Materials and Methods:

This cross-sectional, analytic study was conducted on a representative sample (n = 809) of university students (1 state university and 2 private universities) locating in Gonabad, Iran in 2012. Using proportional to size stratified sampling, we selected the respondents and gathered the required data using a valid and reliable questionnaire. The data were entered into SPSS (version 20) and analyzed through t test, ANOVA, and regression model.

Results:

A total of 381 (47.2%) male and 428 (52.8%) female students participated in the study. Mean (SD) age of the respondents was 21.79 (2.86) years. Overall mean aggression score (SD) in the students was 72.45 (15.49) and this score for in dorm and out of dorm students was 74.31 (15.59) and 70.93 (15.23), respectively. There were significant associations between the mean aggression score of dormitory students and sex (P = 0.004), age (P = 0.044), and type of the university (P = 0.039). On the other hand, there was no significant association between all independent factors and mean aggression score of students living out of dorm.

Conclusions:

Regarding the control of aggressive behaviors, paying attention to male, young students living in dormitory, especially in non-governmental universities has the highest priority.

Associations with violent and homicidal behaviour among men with schizophrenia

Objective We aimed to assess the risk factors associated with homicidal behaviour in male patients diagnosed with schizophrenia. Methods In a period of 1 year, male schizophrenia cases between 18-65 years of age (n = 210) were included. The clinical evaluation included the Positive and Negative Syndrome Scale (PANSS) and Overt Aggression Scale (OAS). The patients were divided into three groups in terms of violent behaviour history: (1) homicide group (n = 30), (2) a violent act resulting in serious injury (n = 71), (3) control group (patients without a history of a violent act) (n = 109). Results Lower level of education, rural residence, being unemployed and living alone were found to be significantly more common in patients who had committed a violent act compared to the schizophrenia patients in the control group. In order to explore the predictive value of several factors associated with violent behaviour, a logistic regression model was used, and variables (shorter duration of education, living alone, and lack of insight) significantly predicted the presence of violent behaviour (murder and/or injury) (χ(2)=31.78, df = 12, p = 0.001). Conclusions In order to be able to determine causality of homicidal acts in schizophrenia patients, our significant findings between homicidal violence, non-homicidal violence and the control group would merit further attention and exploration in further studies.

Violent typologies among women inpatients with severe mental illness

PURPOSE

Extant severe mental illness (SMI) and physical violence literature focus disproportionately on community-based men samples. To address this empirical imbalance, the current study explored violence towards others and oneself among women inpatients with SMI. As those with SMI are more likely to be victims than perpetrators of violence, victimisation was also an important factor assessed in this study.

METHODS

The study used a quantitative within-subject cross-sectional design. Data were extracted from 5675 inpatient women cases between 2009 and 2013.

RESULTS

Women with a manic disorder (without psychotic features) were 4.5 times, whilst those with psychotic disorders were 2 times, more likely to be physically violent to others compared to those with major mood disorders. Conversely, women with a major mood disorders were 4.8 times and 7.5 times more likely to engage in violence towards oneself (deliberate self-harm), compared to those with psychotic disorder and manic disorders, respectively. The past victimisation increased the likelihood of later physical violence.

CONCLUSION

The data illuminate differential risk factors among women inpatients with SMI that may help predict violence occurring towards others and oneself and allow gender comparisons with the established literature.

Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR-20

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR-20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3-month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR-20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item-outcome analysis revealed that impulsivity, negative attitudes, and non-compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients.

Trajectory classes of violent behavior and their relationship to lipid levels in schizophrenia inpatients

OBJECTIVE

To characterize the trajectory patterns of violence in schizophrenia inpatients, examine the relationships between the violence trajectories and baseline clinical features and lipid levels, and generate a model to predict the more violent trajectories.

METHODS

In a sample of 107 consecutively admitted patients with schizophrenia spectrum disorders, violent behavior was weekly rated using the Violence Scale. The patients' blood levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were measured at admission. A trajectory analysis was used to classify the patients' longitudinal courses in violence, and the correlates of these trajectories were assessed using multinomial logistic regression analyses. A stepwise logistic regression was used to select the best predictor variables for the more violent trajectories.

RESULTS

Four violence trajectories of inpatients were obtained: class 1 (no violence, 37.4%), class 2 (low-leveling off, 39.2%), class 3 (high-falling sharply, 10.3%), and class 4 (high-falling slowly, 13.1%). Although the relationship between decreasing TC and TG levels and increased violence in the trajectory classes did not reach statistical significance, a decreasing trend in the proportion of high dichotomized-TG levels was significantly associated with more violence in the trajectory classes (p = 0.04). A five-variable model consisting of female gender, early onset, higher scores of positive symptoms, lower scores of negative symptoms, and low dichotomized-TC levels had a predictive accuracy of 0.85 (95% CI = 0.72-0.97).

CONCLUSIONS

Distinct violence trajectories exist in schizophrenia inpatients, and the more violent trajectories can be predicted using baseline clinical features and lipid levels.

Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: A Systematic Review and Meta-Analysis

Background

Violence in acute psychiatric wards affects the safety of other patients and the effectiveness of treatment. However, there is a wide variation in reported rates of violence in acute psychiatric wards.

Objectives

To use meta-analysis to estimate the pooled rate of violence in published studies, and examine the characteristics of the participants, and aspects of the studies themselves that might explain the variation in the reported rates of violence (moderators).

Method

Systematic meta-analysis of studies published between January 1995 and December 2014, which reported rates of violence in acute psychiatric wards of general or psychiatric hospitals in high-income countries.

Results

Of the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least one act of violence was 17% (95% confidence interval (CI) 14–20%). Studies with higher proportions of male patients, involuntary patients, patients with schizophrenia and patients with alcohol use disorder reported higher rates of inpatient violence.

Conclusion

The findings of this study suggest that almost 1 in 5 patients admitted to acute psychiatric units may commit an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors that are associated with violence among individual patients (male gender, diagnosis of schizophrenia, substance use and lifetime history of violence).

Psychosocial approaches to violence and aggression: contextually anchored and trauma-informed interventions

Psychosocial interventions are part of the complex understanding and treatment of violent behavior in our state mental health hospitals. A comprehensive assessment of violence and aggression includes attention to all 3 domains of prevention and assessment (primary-institutional, secondary-structural, and tertiary-direct). Trauma experiences and their consequences may include behavioral violence and aggression. The authors' premise is that trauma is a universal component in the individual assessment of violent behavior. Therapeutic interventions must include a trauma-informed formulation to be effective. Organizational commitment to trauma-informed, person-centered, recovery-oriented (TPR) care is crucial to the efficacy of any of the interventions discussed. Thus, the dynamic nature of the individual, interpersonal, environmental, and cultural factors associated with the daily operations of the inpatient unit need to be assessed through the lens of primary and secondary violence prevention, building on the recognition that the majority of persons served and staff have significant trauma histories. Once a compassionate, respectful, empathic, and empowering approach is embraced by leadership and staff, the work with individuals can proceed more effectively. Interventions used include a variety of cognitive-behavioral, interpersonal, and somatosensory therapies. These interventions, when effectively applied, result in more self-esteem, self-mastery, self-control for the person served, and diminished behavioral violence.

Characteristics of international assaultive psychiatric patients: review of published findings, 2000-2012

In international reviews of psychiatric inpatient violence, one study of all types of patient violence found hostility, involuntary admission, and longer hospital stays associated with violence. A second study of comparison-group papers of patient assaults found younger males with schizophrenia, past violence, and substance abuse assaultive. The present review of raw assault data studies assessed characteristics of assaultive patients worldwide. It was hypothesized that patients with schizophrenia would present greatest assault risk. There were three analyses: International/no American studies (reviewed earlier), European studies, and merged International/American studies. Results revealed that male and female patients with schizophrenia, affective disorders, personality disorders, and other diagnoses presented greatest worldwide risk. Results partially support earlier findings. Given that individual institutional studies in this review reported significant assailant characteristics, a second finding is the absence of most of these institutional characteristics in this international review. Possible explanations for findings and a detailed methodological review are presented.

Safewards: the empirical basis of the model and a critical appraisal

ACCESSIBLE SUMMARY

In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model.

ABSTRACT

In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 1

Aggression and violence (A/V) in mental health care are all too frequent occurrences; they produce a wide range of deleterious impacts on the individual client, staff, organizations, and the broader community. A/V is a multifaceted and highly-complex problem, and is associated empirically with a wide range of phenomena. However, most attempts to reduce A/V in mental health care have invariably focused on one or two aspects of the problem at the expense of a more comprehensive, systemic approach; these have produced inconclusive results. As a result, this two-part paper seeks to: (i) recognize the wide range of phenomena that have been found to have an association with A/V in mental health care; (ii) synthesize these propositions according to fit or congruence into a systemic model of A/V; (iii) explore empirical evidence pertaining to these propositions; and (iv) begin to consider the application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The paper advances a systemic model of these phenomena comprised of four thematic categories, with Part 1 of this paper focusing on the first two categories: environmental and intrapersonal (client-related) phenomena.

Iranian nurses' experiences of aggression in psychiatric wards: a qualitative study

Aggression from psychiatric patients is a constant problem for care providers that causes major problems in the therapeutic environment, and may have negative effects on the quality of care. Since recognition of aggression with regard to cultural background leads to better control of aggression in the psychiatric wards, this study has been done to clarify Iranian nurses' experiences of aggression in psychiatric wards. A qualitative content analysis study was conducted to explore experiences of nurses. Data analysis revealed four themes: (1) Damage resulting from aggression, (2) Aggression catalysts, (3) Contagious nature of aggression, and (4) Various control strategies. There are various causes for in-patients' aggression, and nurses use various approaches to control it. These approaches are influenced by personnel, facilities, and ward environment. Identifying these factors and strategies can contribute to better management of aggression and, thus, better quality of care in psychiatric wards.

A review of violent incidents in a multilevel secure forensic psychiatric hospital: is there a seasonal variation?

There have been several attempts made to reduce the occurrence of violence in hospital settings, with most professional organizations taking a stance. The impact of violent incidence on the therapeutic environment and the cost in human terms led to the declaration by the World Health Organization that violence is a public health problem. There are strategies for reducing violence that flow out of known trends. We sought to examine the trends in institutional violence in a contextual sense. We reviewed the records of all incidents of violence, categorized by severity, victims and trends over five years in a multilevel secure forensic hospital in Canada. The rate of violence perpetrated by female patients was significantly higher than for male patients. Higher occurrence of violence was recorded in the winter months compared with any other season and was related to unstructured activities. There is a window of opportunity to develop some engaging programmes during the long winter months and improve supervision at all times of unstructured activity. The reasons for increased women perpetration and the winter peak of violence require further investigation.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression

OBJECTIVE

To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

METHOD

A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings.

RESULTS

Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse.

CONCLUSION

By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Conflict and containment events in inpatient psychiatric units

AIMS AND OBJECTIVES

To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns.

BACKGROUND

Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours.

DESIGN

A cross-sectional survey of conflict and containment events.

METHODS

Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively.

RESULTS

Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict.

CONCLUSIONS

This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours.

RELEVANCE TO CLINICAL PRACTICE

Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.

Shift climate profiles and correlates in acute psychiatric inpatient units

PURPOSE

Inpatient psychiatric units are dynamic in nature, potentially creating a different treatment experience for each person, which may be difficult to quantify. Among the goals of this multi-centre service evaluation project was an assessment of shift-to-shift changes in unit-level events and their impact on the social-emotional environment.

METHODS

Over 1 year, various nurse-completed logs were used within the 11 participating Australian psychiatric units (n = 5,546 admissions) to record patient- and unit-level events per shift, including ratings of the overall social-emotional climate using a novel shift climate ratings (SCR) scale (n = 8,176 shifts). These were combined with admission-level patient characteristics to investigate shift climate profiles and correlates.

RESULTS

Occupancy rates averaged 88% and two-thirds of admissions were involuntary. The psychometric performance of the SCR scale was considered to be satisfactory (e.g., high internal consistency, unidimensional factor structure, and evidence of discriminant and predictive validity). A series of hierarchical regressions revealed considerable variation in SCR total scores, with poorer climates being significantly associated with: day/afternoon shifts; higher occupancy levels; higher proportions of experienced staff, and male, older, or involuntary patients; higher rates of less serious aggressive incidents; reporting of additional staffing demands; and unit location in a stand-alone psychiatric hospital.

CONCLUSIONS

The day-to-day social-emotional climate can have important consequences for patient engagement and recovery. Improved understanding of the role played by unit, staff and patient characteristics, together with routine monitoring, should facilitate the development and evaluation of targeted interventions to reduce adverse incidents and improve the overall social-emotional climate.

The antecedents of violence and aggression within psychiatric in-patient settings

OBJECTIVE

To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings.

METHOD

Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data.

RESULTS

Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall.

CONCLUSION

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

Physical restraints in an Italian psychiatric ward: clinical reasons and staff organization problems

PURPOSE

To analyze physical restraint use in an Italian acute psychiatric ward, where mechanical restraint by belt is highly discouraged but allowed.

DESIGN AND METHODS

Data were retrospectively collected from medical and nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint rate and relationships between restraints and selected variables were statistically analyzed.

FINDINGS

Restraints were statistically significantly more frequent in compulsory or voluntary admissions of patients with an altered state of consciousness, at night, to control aggressive behavior, and in patients with "Schizophrenia and other Psychotic Disorders" during the first 72 hr of hospitalization.

PRACTICAL IMPLICATIONS

Analysis of clinical and organizational factors conditioning restraints may limit its use.

Aggression in psychiatry wards: a systematic review

Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal aggression, but the level of general health is significantly lower in nurses who report 'frequent' exposure to violent incidents, and there is disagreement between patients and staff concerning predictors of these episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words "aggress*" (aggression or aggressive) "violen*" (violence or violent) and "in-patient" or "psychiatric wards", and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.

Clinical manifestations of aggressive acts by schizophrenic inpatients: a prospective study

PURPOSE

The purpose of this study was to explore the clinical manifestations of aggressive acts by schizophrenic patients during hospitalization.

DESIGN AND METHODS

This prospective study followed 107 schizophrenic patients admitted to an acute psychiatric ward in Taiwan. The Chinese version of the Violence Scale was used to count and rate aggressive acts. The categories of the trend of aggressive acts were analyzed.

FINDINGS

The highest incidence rate of aggressive acts (58.9%) occurred during the initial week of hospitalization and decreased through the fourth week (16.9%). Most were disturbing but not severe. The incidence and decrease patterns of aggressive acts were found.

PRACTICE IMPLICATIONS

Aggressive acts can be prevented and managed.

Factors related to admission of psychiatric patients to medical wards from the general hospital emergency department: a 3-year study of urgent psychiatric consultations

OBJECTIVE

Emergency Rooms (ER) of Emergency Departments (ED) in General Hospitals (GH) have a role in providing for psychiatric evaluation. The aims of the present study were to examine the decision-making process of consultation psychiatry at the GH-ER and to analyze the differences between psychiatric patients admitted to a medical ward with those admitted to the psychiatry unit and those who are discharged from the ER.

METHOD

Over a period of 3 years, psychiatric consultations requested by ER of ED physicians to the GH Psychiatric service were recorded by using a form to describe epidemiological and clinical data on the consultation process.

RESULTS

Of 1,962 psychiatric consultations, most regarded subjects who had had previous psychiatric contacts (76.2%) and at least one psychiatric admission (53.6%), and were currently cared for by the Mental Health Services (51.1%). Neurotic/stress-related syndromes (27.98%), schizophrenia (27.67%), and personality disorders (21.81%) were the most frequent ICD-10 diagnoses. The psychiatrist's disposal was to discharge the patient in 49.9% cases, to admit him/her to medical wards of the GH (MGH; 26.9%) or to the acute inpatient psychiatric ward (AIP; 23.1%). MGH group statistically differed from AIP group for being female (p < 0.01), older (p < 0.01), more likely having an ICD-10 diagnosis of neurosis/stress-related syndromes (p < 0.01) or organic mental disorder (p < 0.01), and less likely having a diagnosis of schizophrenia (p < 0.01), being in charge of the Mental Health Services (p < 0.01), and having had previous psychiatric admissions (p < 0.01). These results were confirmed by logistic regression analysis.

CONCLUSIONS

The study shows that the medical wards of the General Hospital are a significant entry-point for providing psychiatric care of patients with ICD-10 neurotic and stress-related syndromes, even if without specific medical problems.

Identifying key factors associated with aggression on acute inpatient psychiatric wards

Aggressive behaviour is a critical issue for modern acute psychiatric services, not just because of the adverse impact it has on patients and staff, but also because it puts a financial strain on service providers. The aim of this study was to assess the relationship of patient violence to other variables: patient characteristics, features of the service and physical environment, patient routines, staff factors, the use of containment methods, and other patient behaviours. A multivariate cross sectional design was utilised. Data were collected for a six month period on 136 acute psychiatric wards in 26 NHS Trusts in England. Multilevel modelling was conducted to ascertain those factors most strongly associated with verbal aggression, aggression toward objects, and physical aggression against others. High levels of aggression were associated with a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Insufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.

A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements

This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.

Measuring observed mental state in acute psychiatric inpatients

BACKGROUND

Relationships within acute psychiatric units between patient-level experiences and events and fluctuations in mental state have rarely been examined.

AIM

Data from a multi-centre service evaluation (11 units, 5,546 admissions) were used to examine mental state patterns and associations with clinical characteristics, events and adverse incidents.

METHOD

During the 12-month evaluation period, nursing staff completed shift-level ratings using a new rating scale, the observed mental state (OMS) scale, which assessed active psychopathology (emotional distress, disinhibition, psychosis, cognitive impairment) and withdrawal (45,885 sets of day/afternoon shift ratings).

RESULTS

The OMS scale performed satisfactorily and is worth considering elsewhere (e.g., active psychopathology: internal consistency, alpha=0.72; short-term stability, r=0.72; sensitivity to change, adjusted standardised difference, ASD=0.71). Levels of active psychopathology were much higher on shifts in which reportable (ASD=1.47) and less serious aggression occurred (ASD=1.44), compared with other shifts in which pro re nata medications were also administered (ASD=0.76), suggesting that medication usage often followed these events, and possibly that agitation and distress levels either rose rapidly or went initially unnoticed on these shifts. Although mental state improved steadily across the admission, one-fifth of the patients with schizophrenia received OMS psychosis ratings in the moderate to severe range during the days prior to discharge.

CONCLUSIONS

Observed mental state ratings were strongly linked with diagnosis and reflected key events and incidents. Routine recording using the OMS scale may assist clinical decision-making and evaluation in acute psychiatric units.

Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures

OBJECTIVE

This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services.

METHOD

Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients).

RESULTS

The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25-30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8 days (mean=14.59 days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization.

CONCLUSIONS

By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Incidence, types and characteristics of aggressive behaviour in treatment facilities for adults with mild intellectual disability and severe challenging behaviour

BACKGROUND

Inpatient aggression in treatment facilities for persons with intellectual disability (ID) can have aversive consequences, for co-clients and staff, but also for the aggressors themselves. To manage and eventually prevent inpatient aggressive incidents, more knowledge about their types and characteristics is necessary.

METHOD

In four facilities, totalling 150 beds, specialized in the treatment of adults with mild ID or severe challenging behaviour, aggressive incidents were registered during 20 weeks using the Staff Observation Aggression Scale-Revised. Characteristics of auto-aggressive and outwardly directed incidents and differences in their incidence in male and female clients in these facilities were compared.

RESULTS

During the observation period of 20 weeks, 639 aggressive incidents were documented. Most of these (71%) were outwardly directed, predominantly towards staff, while most of the remaining incidents were of an auto-aggressive nature. Of the 185 clients present during the observation period, 44% were involved in outwardly directed incidents (range per client 1-34), and 12% in auto-aggressive incidents (range per client 1-92). Auto-aggressive and outwardly directed incidents differed regarding source of provocation, means used during the incident, consequences of the incident and measures taken to stop the incident. The proportion of men and women involved in each type of incident was comparable, as well as the majority of the characteristics of outwardly directed incidents caused by men and women.

CONCLUSIONS

Although approximately half of all clients were involved in aggressive incidents, a small minority of clients were responsible for the majority of incidents. Therefore, better management and prevention of aggressive incidents for only a small group of clients could result in a considerable overall reduction of aggressive incidents in treatment facilities. Comparability of aggressive behaviour in these facilities shown by men and women and differences in characteristics of auto-aggressive and outwardly directed incidents are discussed.

Frequency and severity of aggressive incidents in acute psychiatric wards in Switzerland

Background

Aggression and violence and negative consequences thereof are a major concern in acute psychiatric inpatient care globally. Variations in study designs, settings, populations, and data collection methods render comparisons of the incidence of aggressive behaviour in high risk settings difficult.

Objective

To describe the frequency and severity of aggressive incidents in acute psychiatric wards in the German speaking part of Switzerland.

Methods

We conducted a prospective multicentre study on 24 acute admission wards in 12 psychiatric hospitals in the German speaking part of Switzerland. Aggressive incidents were recorded by the revised Staff Observation Aggression Scale (SOAS-R) and we checked the data collection for underreporting. Our sample comprised 2344 treatment episodes of 2017 patients and a total of 41'560 treatment days.

Results

A total of 760 aggressive incidents were registered. We found incidence rates per 100 treatment days between 0.60 (95% CI 0.10–1.78) for physical attacks and 1.83 (1.70–1.97) for all aggressive incidents (including purely verbal aggression). The mean severity was 8.80 ± 4.88 points on the 22-point SOAS-R-severity measure; 46% of the purely verbally aggression was classified as severe (≥ 9 pts.). 53% of the aggressive incidents were followed by a coercive measure, mostly seclusion or seclusion accompanied by medication. In 13% of the patients, one ore more incidents were registered, and 6.9% of the patients were involved in one ore more physical attack. Involuntary admission (OR 2.2; 1.6–2.9), longer length of stay (OR 2.7; 2.0–3.8), and a diagnosis of schizophrenia (ICH-10 F2) (OR 2.1; 1.5–2.9) was associated with a higher risk for aggressive incidents, but no such association was found for age and gender. 38% of the incidents were registered within the first 7 days after admission.

Conclusion

Aggressive incidents in acute admission wards are a frequent and serious problem. Due to the study design we consider the incidence rates as robust and representative for acute wards in German speaking Switzerland, and thus useful as reference for comparative and interventional research. Implications for clinical practice include the recommendation to extend the systematic risk assessment beyond the first days after admission. The study confirms the necessity to differentiate between types of aggressive behaviour when reporting and comparing incidence-data.

Clinical features and therapeutic management of patients admitted to Italian acute hospital psychiatric units: the PERSEO (psychiatric emergency study and epidemiology) survey

BACKGROUND

The PERSEO study (psychiatric emergency study and epidemiology) is a naturalistic, observational clinical survey in Italian acute hospital psychiatric units, called SPDCs (Servizio Psichiatrico Diagnosi e Cura; in English, the psychiatric service for diagnosis and management). The aims of this paper are: (i) to describe the epidemiological and clinical characteristics of patients, including sociodemographic features, risk factors, life habits and psychiatric diagnoses; and (ii) to assess the clinical management, subjective wellbeing and attitudes toward medications.

METHODS

A total of 62 SPDCs distributed throughout Italy participated in the study and 2521 patients were enrolled over the 5-month study period.

RESULTS

Almost half of patients (46%) showed an aggressive behaviour at admission to ward, but they engaged more commonly in verbal aggression (38%), than in aggression toward other people (20%). A total of 78% of patients had a psychiatric diagnosis at admission, most frequently schizophrenia (36%), followed by depression (16%) and personality disorders (14%), and no relevant changes in the diagnoses pattern were observed during hospital stay. Benzodiazepines were the most commonly prescribed drugs, regardless of diagnosis, at all time points. Overall, up to 83% of patients were treated with neuroleptic drugs and up to 27% received more than one neuroleptic either during hospital stay or at discharge. Atypical and conventional antipsychotics were equally prescribed for schizophrenia (59 vs 65% during stay and 59 vs 60% at discharge), while atypical drugs were preferred in schizoaffective psychoses (72 vs 49% during stay and 70 vs 46% at discharge) and depression (41 vs 32% during stay and 44 vs 25% at discharge). Atypical neuroleptics were slightly preferred to conventional ones at hospital discharge (52 vs 44%). Polypharmacy was in general widely used. Patient attitudes toward medications were on average positive and self-reported compliance increased during hospital stay.

CONCLUSION

Results confirm the widespread use of antipsychotics and the increasing trend in atypical drugs prescription, in both psychiatric in- and outpatients.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk

This study investigated the aggressive behaviour of all mentally ill patients within a whole psychiatric hospital with a catchment area of 325 000 inhabitants over a 1-year period (i) to assess the 1-year prevalence and characteristics of aggressive episodes and index inpatients, and (ii) to identify predictors of patients at risk by a multivariate approach. Staff Observation of Aggression Scale was used to assess aggressive behaviour. Characteristics of index inpatients were compared with those of non-index inpatients. Logistic regression analysis was applied to identify risk factors. A total of 171 out of 2210 admitted patients (7.7%) exhibited 441 aggressive incidents (1.7 incidents per bed per year). Logistic regression analyses revealed as major risk factors of aggression: diagnoses (organic brain syndromes OR = 3.6, schizophrenia OR = 2.9), poor psychosocial living conditions (OR = 2.2), and critical behaviour leading to involuntary admission (OR = 3.3). Predictors of aggressive behaviour can be useful to identify inpatients at risk. Nevertheless, additional situational determinants have to be recognized. Training for professionals should include preventive and de-escalating strategies to reduce the incidence of aggressive behaviour in psychiatric hospitals. The application of de-escalating interventions prior to admission might be effective in preventing aggressive behaviour during inpatient treatment especially for patients with severe mental disorders.

An observational study in psychiatric acute patients admitted to General Hospital Psychiatric Wards in Italy

OBJECTIVES

this Italian observational study was aimed at collecting data of psychiatric patients with acute episodes entering General Hospital Psychiatric Wards (GHPWs). Information was focused on diagnosis (DSM-IV), reasons of hospitalisation, prescribed treatment, outcome of aggressive episodes, evolution of the acute episode.

METHODS

assessments were performed at admission and discharge. Used psychometric scales were the Brief Psychiatric Rating Scale (BPRS), the Modified Overt Aggression Scale (MOAS) and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE-30).

RESULTS

864 adult patients were enrolled in 15 GHPWs: 728 (320 M; mean age 43.6 yrs) completed both admission and discharge visits. A severe psychotic episode with (19.1%) or without (47.7%) aggressive behaviour was the main reason of admission. Schizophrenia (42.8% at admission and 40.1% at discharge) and depression (12.9% at admission and 14.7% at discharge) were the predominant diagnoses. The mean hospital stay was 12 days. The mean (+/- SD) total score of MOAS at admission, day 7 and discharge was, respectively, 2.53 +/- 5.1, 0.38 +/- 2.2, and 0.21 +/- 1.5. Forty-four (6.0%) patients had episodes of aggressiveness at admission and 8 (1.7%) at day 7. A progressive improvement in each domain/item vs. admission was observed for MOAS and BPRS, while NOSIE-30 did not change from day 4 onwards. The number of patients with al least one psychotic drug taken at admission, in the first 7 days of hospitalisation, and prescribed at discharge, was, respectively: 472 (64.8%), 686 (94.2%) and 676 (92.9%). The respective most frequently psychotic drugs were: BDZs (60.6%, 85.7%, 69.5%), typical anti-psychotics (48.3%, 57.0%, 49.6%), atypical anti-psychotics (35.6%, 41.8%, 39.8%) and antidepressants (40.9%, 48.8%, 43.2%). Rates of patients with one, two or > 2 psychotic drugs taken at admission and day 7, and prescribed at discharge, were, respectively: 24.8%, 8.2% and 13.5% in mono-therapy; 22.0%, 20.6% and 26.6% with two drugs, and 53.2%, 57.8% and 59.0% with > two drugs. Benzodiazepines were the most common drugs both at admission (60.0%) and during hospitalisation (85.7%), and 69.5% were prescribed at discharge.

CONCLUSION

patients with psychiatric diseases in acute phase experienced a satisfactory outcome following intensified therapeutic interventions during hospitalisation.

Main clinical features in patients at their first psychiatric admission to Italian acute hospital psychiatric wards. The PERSEO study

BACKGROUND

Few data are available on subjects presenting to acute wards for the first time with psychotic symptoms. The aims of this paper are (i) to describe the epidemiological and clinical characteristics of patients at their first psychiatric admission (FPA), including socio-demographic features, risk factors, life habits, modalities of onset, psychiatric diagnoses and treatments before admission; (ii) to assess the aggressive behavior and the clinical management of FPA patients in Italian acute hospital psychiatric wards, called SPDCs (Servizio Psichiatrico Diagnosi e Cura = psychiatric service for diagnosis and management).

METHOD

Cross-sectional observational multi-center study involving 62 Italian SPDCs (PERSEO--Psychiatric EmeRgency Study and EpidemiOlogy).

RESULTS

253 FPA aged < or = 40 were identified among 2521 patients admitted to Italian SPDCs over the 5-month study period. About half of FPA patients showed an aggressive behavior as defined by a Modified Overt Aggression Scale (MOAS) score greater than 0 Vs 46% of non-FPA patients (p = 0.3651). The most common was verbal aggression, while about 20% of FPA patients actually engaged in physical aggression against other people. 74% of FPA patients had no diagnosis at admission, while 40% had received a previous psychopharmacological treatment, mainly benzodiazepines and antidepressants. During SPDC stay, diagnosis was established in 96% of FPA patients and a pharmacological therapy was prescribed to 95% of them, mainly benzodiazepines, antipsychotics and mood stabilizers.

CONCLUSION

Subjects presenting at their first psychiatric ward admission have often not undergone previous adequate psychiatric assessment and diagnostic procedures. The first hospital admission allows diagnosis and psychopharmacological treatment to be established. In our population, aggressive behaviors were rather frequent, although most commonly verbal. Psychiatric symptoms, as evaluated by psychiatrists and patients, improved significantly from admission to discharge both for FPA and non-FPA patients.