Characteristics of Patients Involved in Physical Assault in an Acute Inpatient Psychiatric Setting

Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2017-2022

Since the 1960s, empirical research has focused on a better understanding of the characteristics of assaultive psychiatric patients. International research from 1960 to 2017 indicated that male and female patients with schizophrenia and substance use disorder presented the greatest risk for assault with nursing personnel being at higher risk. This present review of studies sought to assess the latest research findings on assaultive patients for the most recent five-year period, 2017-2022. It was hypothesized that patients with schizophrenia and substance use disorders would present the greatest assault risk for nursing personnel. The studies in this review supported this hypothesis. Assaults by patients with schizophrenia and substance abuse has been a consistent finding worldwide for 62 years of published research. Explanations for these findings, the possible role of posttraumatic stress disorder (PTSD) in assaultive patients, and an updated methodological review are presented.

Physical Assault in the Psychiatry Emergency Room

Previous studies of physical assaults in hospitals focused primarily on inpatient psychiatric units, leaving unanswered questions about the extent to which findings generalize to psychiatric emergency rooms. Assault incident reports and electronic medical records from one psychiatric emergency room and two inpatient psychiatric units were reviewed. Qualitative methods were used to identify precipitants. Quantitative methods were used to describe characteristics of each event, as well as demographic and symptom profiles associated with incidents. During the five-year study period, there were 60 incidents in the psychiatric emergency room and 124 incidents on the inpatient units. Precipitating factors, incident severity, means of assault, and interventions were similar in both settings. Among patients in the psychiatric emergency room, a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with manic symptoms (Adjusted Odds Ratio (AOR) 27.86) and presenting with thoughts to harm others (AOR 10.94) were associated with an increased likelihood of having an assault incident report. Similarities between assaults in the psychiatric emergency room and inpatient psychiatric units suggest that the broader literature from inpatient psychiatry can be generalized to the psychiatric emergency room setting, although some differences exist. Reprinted from J Am Acad Psychiatry Law 2020; 48:484-495, with permission from The American Academy of Psychiatry and the Law. Copyright © 2020.

Determinants and Characteristics of the Violent Incidents in a Tertiary-Level Mental Health Care Center

Background  The Mental Health Care Act of India, 2017 has for the first time focused on violence management interventions, especially restraint and seclusion in psychiatric settings, and recommended important guidelines in this aspect.

Objective  This situation has created a strong need to review the prevalence of violence in inpatient settings, associated clinical and social correlates keeping a preventive model in context. Hence, this study was undertaken to fulfill this need. Methods: A retrospective matched case–control chart review design was employed. All patients who exhibited at least one violent incident during their ward stay were included. For each case, the control was selected by individual matching based on age ± 2 years and gender from patients who were admitted during the study period but did not exhibit any violent incident. The information about the characteristics of violent incidents and management was also collected.

Results  8.80% of patients exhibited at least one incident of violence and a total of 186 violent incidents were recorded during the study period. Variables including involuntary admission, history of the previous admission, history of violence, impulsivity, lack of insight, and irritability at the time of admission significantly predicted the likelihood of violent incidents. The use of chemical restraining was the most common method of management of violent incidents.

Conclusion  Violent incidents in psychiatric inpatient settings are still common. Efforts should be made to understand the risk as well as antecedent factors well in time. Verbal de-escalation should be employed and chemical and physical restraint should be used only as a last resort after exhausting the least restrictive interventions.

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.

Young age and the risk of violent behaviour in people with severe mental disorders: prospective, multicentre study

Background

During adolescence and young adulthood people appear to be more prone to violent behaviour. A greater tendency to violent behaviour appears to be associated with hyperactivity, impulsivity and low tolerance for frustration and provocation in social settings.

Aims

This prospective cohort study aimed to evaluate rates of violent behaviour among young people with mental disorders, compared with older age groups.

Method

A total of 340 individuals with severe mental disorders (125 living in residential facilities and 215 out-patients) were evaluated at baseline with the SCID-I and II, Brief Psychiatric Rating Scale, Specific Level of Functioning scale, Brown–Goodwin Lifetime History of Aggression scale, Buss–Durkee Hostility Inventory, Barratt Impulsiveness Scale and State–Trait Anger Expression Inventory-2. Aggressive behaviour was rated every 15 days with the Modified Overt Aggression Scale (MOAS).

Results

The sample comprised 28 individuals aged 18–29 years, 202 aged 30–49 and 110 aged 50 and over. Younger age was associated with a personality disorder diagnosis, substance use disorder, being single and employed. These results were confirmed even controlling for the gender effect. The patterns of the cumulative MOAS mean scores showed that younger (18–29 years old) individuals were significantly more aggressive than older (≥50) ones (P < 0.001).

Conclusions

This study highlights how young age in people with severe mental disorders is correlated with higher levels of impulsivity, anger and hostility, confirming previous analyses. Our results may assist clinicians in implementing early interventions to improve anger and impulsivity control to reduce the risk of future aggressive behaviours.

[Individual and contextual factors associated with violent behaviours during psychiatric hospitalizations]

BACKGROUND

The prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community.

OBJECTIVES

This study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations.

METHOD

The study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n=4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale - Revised (SOAS - R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi² independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs.

RESULTS

During the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.024), living in sheltered housing before admission (OR=2.46; CI: 1.61-3.75; P-value<0.000), schizophrenic disorders (OR=2.18; CI: 1.35-3.57; P-value=0.001), schizophrenic disorders with substance abuse comorbidity (OR=2.00; CI: 1.16-3.37; P-value=0.016), cognitive impairment (OR=3.41; CI: 1,21-8.25; P-value=0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR=4.38; CI: 3.20-6.08; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), number of previous hospitalizations (OR=1.06; CI: 1.00-1.12; P-value=0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.008), living in sheltered housing before admission (OR=2.46: CI: 1.61-3.75; P-value=0.034), cognitive impairment (OR=3.41; CI: 1.21-8.25; P-value=0.074), involuntary hospitalization (OR=3.46; CI: 2.48-4.87; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence.

CONCLUSION

The results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.

Factors associated with repetitive violent behavior of psychiatric inpatients

A small number of psychiatric inpatients displays a large proportion of Violent Behaviors (VB). These can have a major impact on both victims and patients themselves. This study explored personal, situational and institutional risk factors and their combined effects, which could lead to repetitive VB (three or more assaults). Data from 4518 patients, aged 18 to 65, admitted to an acute psychiatric care facility, were included in the analysis. VB, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale-Revised. 414 VB were reported during the study period, involving 199 patients. 0.75 % of all patients were repetitively violent and committed 43% of all VB. Factors that were linked to repetitive VB were living in sheltered housing before hospitalization, suffering from schizophrenia with substance abuse comorbidity, cumulating hospitalization days and some situational factors, like the fact of being in nursing offices and pharmacies. When all personal, situational and institutional factors were considered together, the combined effects of length of stay and living in sheltered housing increased the risk of repetitive VB. We have identified a small group of vulnerable patients for whom new modalities of inter-institutional networking should be developed to prevent repetitive VB.

Time from the Admission as the Predictor of Aggressive Behavior of Inpatients with Schizophrenia Spectrum Disorder

The aim was to assess the incidence of aggressive events (AE) committed by patients diagnosed with schizophrenia spectrum disorethder (SSD) after the first 7 days of hospitalization in psychiatric institution, in comparison to other psychiatric patients. This retrospective cohort study was performed at Psychiatric Hospital "Sveti Ivan", Zagreb, Croatia, using hospital safety records of all patients admitted between 2015 and 2017. Primary outcome was the proportion of patients who committed AE more than a week after the admission to the hospital. Secondary outcome was the time in days from admission to the first incident of AE. The primary analysis was performed using a multivariable binary logistic regression. SSD patients committed AE more often than other patients (incidence rate ratio 3.97 (95% CI 2.35-6.69; p < 0.001; FDR q = 0.002), but these occurred earlier in the course of hospitalization: median (IQR) 2 (1-10) days from admission compared to 11 (2-32) days in other patients. SSD patients had significantly and clinically relevantly lower odds for AE after the first week of hospitalization adjusted for the large number of pre-planned possible confounders (OR = 0.10; 95% CI 0.02-0.45; p = 0.003; FDR q = 0.002). SSD patients seem to express more aggression earlier in the course of hospitalization. Findings of this study indicate that hospitalization-inherent AE risk factors may play an important role in the etiology of AE and inpatients aggressive behavior. Their possible moderating effect should be included in risk-assessment instruments.

Inferior frontal gyrus gray matter volume is associated with aggressive behavior in schizophrenia spectrum disorders

We aimed to assess potential gray matter (GM) alterations for aggressive patterns of behavior in a sample of in- and outpatients with schizophrenia spectrum disorders. Eighty-four patients previously participating in brain volumetric studies were included. Aggression was assessed using the Modified Overt Aggression Scales (MOAS) based upon review of clinical records of the hospital register. Multiple regression analyses for total MOAS and each MOAS subscale separately were conducted correcting for age, sex, history of addiction, chlorpromazine equivalents, illness duration, and total intracranial volume. Significant effects were reported in two cases; the total MOAS scores and MOAS verbal aggression scores were associated with GM volume in left inferior frontal gyrus. From the demographic/clinical characteristics, only the number of episodes correlated with the subscales and the total MOAS scores. Our results highlight the role of GM volume in left inferior frontal gyri in patients with history of aggression. This evidence ties in well with previous data reporting involvement of these regions in response control and semantic networks.

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.

Moral mindfulness: The ethical concerns of healthcare professionals working in a psychiatric intensive care unit

Healthcare professionals working on inpatient wards face the externalizing or challenging behaviour of the patients who are admitted. Ethical values and principles in psychiatric nursing have been reported to be important when approaching patients during the most acute phase of deterioration in their mental health. Hence, the aim of this study was to discover and describe staff members' ethical and moral concerns about their work as healthcare professionals in a psychiatric intensive care unit. The study has a qualitative descriptive design and makes use of Framework Analysis. Registered nurses and psychiatric aides in a psychiatric intensive care unit in Sweden were observed during ethical reflection meetings. Four to six staff attended the 90-min meetings. The data comprise observations from six meetings, which provided 94 pages of text. The results demonstrate that the work was described as being both motivating and exhausting. The staff faced ethical concerns in their daily work, as patients often demonstrated challenging behaviours. Three themes were identified as follows: (i) concerns about the staff impacting on patients' experience of care, (ii) concerns about establishing a safe working environment, and (iii) concerns about becoming unprofessional due to expectations and a high workload. Ethical concerns included simultaneously taking into account both the patients' dignity and safety aspects, while also being exposed to high workloads. These elements of work are theorized as influencing complex psychiatric nursing. If we are to bring these influential factors to light in the workplace, advanced nursing practice must be grounded in moral mindfulness.