Violence in treatment resistant psychotic inpatients

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.

What leads to high antipsychotic dosing in forensic patients with schizophrenia?

Earlier findings suggest that forensic schizophrenia patients are treated with higher doses of antipsychotics. This practice-based specificity is insufficiently studied, and clinicians' motives regarding this practice remain poorly understood. In this editorial, the authors provide their data on treatment of forensic schizophrenia patients and identify characteristics of psychopathology and previous types of behaviors, including suicidal attempts, as potential reasons for the practice. They also emphasize that "these previous acts" often took place years ago, and suggest that current or recent aggression is unlikely the main reason for dosing, but rather the clinicians' intention to maintain "must remain unaggressive" condition. Therefore, the authors suggest new ideas that may contribute to a better understanding of the specific prescribing patterns in the forensic population and hope that these ideas would be implemented in further well-designed prospective studies.

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

BACKGROUND

Although aggressive behavior in psychiatric settings is a major concern, very few studies have focused exclusively on physical assault in a general inpatient psychiatric population.

OBJECTIVES

This study had 3 main goals: (1) to evaluate the prevalence of assaultive behavior in an acute psychiatric hospital; (2) to identify the clinical and socio-demographic factors associated with assaultive behavior during hospitalization; and (3) to explore whether a diagnosis of schizophrenia spectrum disorder increases the risk of assaultive behavior.

METHODS

We conducted a retrospective chart review of patients admitted to acute units in a psychiatric hospital between 2009 and 2012. A subset of occurrence reports identified by a multidisciplinary team as "physical assault" was included in the analysis. Using logistic multivariate regression analysis, these patients were compared with a randomly selected nonassaultive control group, matched for length of stay to identify factors associated with assaultive behavior.

RESULTS

Of 757 occurrence reports, 613 met criteria for significant assault committed by 356 patients over 309,552 patient days. The assault incident density was 1.98 per 1000 patient days. In the logistic regression model of best fit, the factors significantly associated with assaultive behavior were age, legal status, and substance use. A diagnosis of schizophrenia spectrum disorder was not significantly associated with assaultive behavior.

CONCLUSIONS

Clinicians should take extra precautions for involuntarily admitted young patients with a history of substance use, as they are more likely to exhibit assaultive behavior. A diagnosis of schizophrenia spectrum disorder in itself is not significantly associated with assaultive behavior. Screening instruments such as the Dynamic Appraisal of Situational Aggression may be useful in assessing risk of assault.

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.

The Short-Term Assessment of Risk and Treatability (START)

A new assessment scheme-the Short-Term Assessment of Risk and Treatability (START)- presents a workable method for assessing risks to self and others encountered in mentally and personality disordered clients. This study aimed to demonstrate (a) prevalence and severity of risk behaviors measured by the START, (b) psychometric properties of START, (c) similarities and differences in START scores across different mental health professionals, and (d) concurrent validity of START with diverse negative outcomes. Treatment team members completed the 20-item, dynamically focused START for 137 forensic psychiatric inpatients. Prevalence and severity of START risk domains were measured for 51 patients detained in the hospital for 1 year. Results revealed high rates of generally low-level adverse events. With some exceptions, START scores were meaningfully associated with outcomes measured by a modified Overt Aggression Scale.

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).

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.

The Diagnostic Efficiency of the Extended German Brøset Violence Checklist to Assess the Risk of Violence

Background and Purpose: The prevention of aggression and violence of patients is part of the challenge for the psychiatric inpatient care. Resources needed are a systematic risk assessment and taking preventive measures according to the risk. The extended Brøset Violence Checklist (BVC-CH) is an assessment instrument for the short-term assessment of the risk of violence for physical attacks toward medical staff and other patients. Until now, the instrument was only validated in the context of the development phase of the instrument. The aim of this study was to investigate how valid the BVC-CH scale is for adult psychiatry in acute inpatient care facilities. Methods: In a prospective cohort study, 232 consecutively admitted patients were assessed using the BVC-CH. The calculation of the predictive values was based on a contingency table. The discriminatory power of the instrument and the determination of the cutoff point were done using the receiver operating characteristic (ROC) curve analysis. Physical attacks were registered with the Staff Observation of Aggression Scale–Revised (SOAS-R). Results: The sensitivity was 58.8% and the specificity was 96.8% by a cutoff point of ≥7. By choosing a cutoff point of ≥6, the sensitivity was 64.7% and the specificity was 95.1%. A value of .93 was determined for the area under the curve receiver operating characteristic (AUCROC). Conclusions: Overall, the BVC-CH is a valid instrument for the short-term prediction of physical attacks. Further research of the BVC-CH is recommended but in particular for the cutoff point.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 2

This is the second of a two part paper which seeks to explore a wide range of phenomena that have been found to have an association with aggression and violence (A/V) in inpatient mental health care, synthesize these propositions according to fit or congruence into a systemic model of A/V, explore the empirical evidence pertaining to these propositions, and begin to consider application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The systemic model is comprised of four thematic categories with part two of the paper focusing on the final two categories: mental health-care system-related phenomena and clinician-related phenomena. The paper then discusses a number of implications arising out of embracing a more systemic model of A/V in mental health care. In broadening our understanding to include all the phenomena that contribute increased risk of A/V incidents, we are able to move away from inaccurate views that disproportionately assign 'responsibility' to clients for causing A/V when the evidence indicates that the client-related phenomena may only account for a small portion of these incidents.

Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services

BACKGROUND

The START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. The DUNDRUM-3 and DUNDRUM-4 also measure positive factors, programme completion and recovery in forensic settings.

METHODS

We compared these instruments with other validated risk instruments (HCR-20, S-RAMM), a measure of psychopathology (PANSS) and global function (GAF). We prospectively tested whether any of these instruments predict violence or self harm in a secure hospital setting (n = 98) and whether they had true protective effects, interacting with and off-setting risk measures.

RESULTS

SAPROF and START-strengths had strong inverse (negative) correlations with the HCR-20 and S-RAMM. SAPROF correlated strongly with GAF (r = 0.745). In the prospective in-patient study, SAPROF predicted absence of violence, AUC = 0.847 and absence of self-harm AUC = 0.766. START-strengths predicted absence of violence AUC = 0.776, but did not predict absence of self-harm AUC = 0.644. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales also predicted in-patient violence (AUC 0.832 and 0.728 respectively), and both predicted in-patient self-harm (AUC 0.750 and 0.713 respectively). When adjusted for the HCR-20 total score however, SAPROF, START-S, DUNDRUM-3 and DUNDRUM-4 scores were not significantly different for those who were violent or for those who self harmed. The SAPROF had a significant interactive effect with the HCR-dynamic score. Item to outcome studies often showed a range of strengths of association with outcomes, which may be specific to the in-patient setting and patient group studied.

CONCLUSIONS

The START and SAPROF, DUNDRUM-3 and DUNDRUM-4 can be used to assess both reduced and increased risk of violence and self-harm in mentally ill in-patients in a secure setting. They were not consistently better than the GAF, HCR-20, S-RAMM, or PANSS when predicting adverse events. Only the SAPROF had an interactive effect with the HCR-20 risk assessment indicating a true protective effect but as structured professional judgement instruments all have additional content (items) complementary to existing risk assessments, useful for planning treatment and risk management.

Mental health-related risk factors for violence: using the evidence to guide mental health triage decision making

Mental health clinicians working in emergency crisis assessment teams or mental health triage roles are required to make rapid and accurate risk assessments. The assessment of violence risk at triage is particularly pertinent to the early identification and prevention of patient violence, and to enhancing the safety of clinical staff and the general public. To date, the evidence base for mental health triage violence risk assessment has been minimal. This study aimed to address this evidence gap by identifying best available evidence for mental health-related risk factors for patient-initiated violence. We conducted a systematic review based on the National Health and Medical Research Council of Australia's methodology for systematic reviews. A total of 6847 studies were retrieved, of which 326 studies met the study inclusion criteria. Of these studies, 277 met inclusion criteria but failed the quality appraisal process, thus a total of 49 studies were included in the final review. The risk factors that achieved the highest evidence grading were predominantly related to dynamic clinical factors immediately observable in the patient's general appearance, behaviour and speech. These factors included hostility/anger, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability.

Self-harm and attempted suicide within inpatient psychiatric services: a review of the literature

Self harm is a major public health concern, yet there are considerable challenges in providing support for those who self harm within psychiatric inpatient services. This paper presents the first review of research into self harm within inpatient settings. Searches of the main electronic databases were conducted using key words for self harm and inpatient care. There was substantial variation in the rates of self-harm and attempted suicide between studies, but rates were highest on forensic wards. There was no evidence of differences in prevalence of self-harm between men and women; women, however, were at increased risk of attempting suicide. People were more likely to self-harm in private areas of the ward and in the evening hours, and often self-harmed in response to psychological distress, or elements of nursing care that restricted their freedom. Wards used a variety of strategies to prevent self-harm; however, there is little research into their effectiveness.

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.

A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff

Workplace violence, including patient-perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty-nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries.

IMPLICATIONS

The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient-perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

[Medicolegal aspects of hospital treatment of violent mentally ill persons]

INTRODUCTION

This paper deals with medicolegal aspects of the hospital treatment of patients suffering from severe mental disorders and who are prone to violent behaviour, dangerous to self and others. Violent acts in this study were defined as deliberate and nonconsensual acts of actual, attempted or threatened harm to a person or persons, and classified into categories of any type of violence, physical violence and non-physical violence, which is in accordance with approaches used in other risk assessment researches,

OUTLINE OF CASES

The authors present four cases of mentally ill inpatients whose violent behaviour toward self or other persons resulted in self-destruction and physical aggression against other persons. The presented cases involved: 1) self-injury in a patient with acute organic mental disorder after jumping through a hospital window, 2) suicide by drowning of a patient with acute mental disorder after escaping from intensive care unit, 3) suicide in a depressive patient after escaping from a low-security psychiatry unit, 4) physical violence against body and life of other persons in a patient with chronic mental disorder.

CONCLUSION

The presented cases are considered to be rare in clinical practice and risk of violent behaviour and the consequent danger of mentally ill inpatients may be efficiently predicted and prevented with appropriate hospital management based on 1) repeated escalation of violent behaviour and 2) protection of the patient and others. Hence, if the physician in order to prevent harmful consequences, does not apply all the necessary measures, including appropriate diagnostic and therapeutic procedures, as well as treatment in an adequate setting, such act is against the Criminal Law of the Republic of Serbia which sanctions physician's negligence. Also, according to the Law on Obligations of the Republic of Serbia this presents a legal ground for damage claim and the requirement of liability for nonmaterial damage within a civil procedure.

Forensic psychiatric inpatients and aggression: an exploration of incidence, prevalence, severity, and interventions by gender

BACKGROUND

Previous investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.

OBJECTIVE

The goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.

METHOD

The population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.

RESULTS

Women were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.

DISCUSSION

Female forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.

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.

Traitement multimodal de l’agressivité et de la violence chez des personnes souffrant de psychose

Dans cet article, les auteurs décrivent les traitements non pharmacologiques qui ont fait preuve d’efficacité pour réduire l’agressivité et la violence chez les personnes souffrant de psychose. Ils présentent ensuite une approche de formulation/planification du traitement qui aborde les influences étiologiques complexes, et les facteurs multiples qui jouent sur le maintien du comportement agressif chez ces patients. Finalement, ils présentent en exemple un cas où l’on se sert de cette approche.

Predictors of aggression on the psychiatric inpatient service

Patients with severe mental illness are at increased risk to commit acts of aggression in the inpatient hospital setting. Aggressive behaviors have severe negative consequences for the patient, victims, clinical staff, and the therapeutic community as a whole. While risk factors of community and inpatient aggression overlap, many predictive factors diverge between the two settings. For example, while medication noncompliance has been a robust predictor of community aggression, this factor has little predictive value for inpatient settings where patients' pharmacotherapy is closely monitored. Relatively fewer investigators have examined a wide range of predictive factors associated with aggressive acts committed on the psychiatry inpatient service, often with conflicting results. The present study examined demographic, clinical, and neurocognitive performance predictors of self, other, object, and verbal aggressiveness in 118 acute inpatients. Results revealed that the arrival status at the hospital (voluntary vs involuntary), female gender, and substance abuse diagnosis were predictors of verbal aggression and aggression against others. Impaired memory functioning also predicted object aggression. Fewer symptoms, combined with higher cognition functioning, however, were significant predictors of self-aggressive acts committed on the inpatient service. The need for relating predictors of specific types of aggressiveness in schizophrenia is discussed.

Neuropsychological correlates of the PANSS Cognitive Factor

OBJECTIVE

Factor analytic studies of the Positive and Negative Syndrome Scale (PANSS) have consistently isolated a factor that is frequently labeled as 'cognitive'. The present study sought to further explore the factor by examining the relationships between 4 versions of the cognitive factor and a set of neuropsychological tests.

METHOD

Thirty-seven inpatients diagnosed with schizophrenia or schizoaffective disorder were assessed with the PANSS and neuropsychological measures.

RESULTS

Verbal intelligence and verbal memory were found to be most closely associated with cognitive factor scores. A global rating of illness severity showed greater relationships to cognitive variables than any cognitive factor.

CONCLUSIONS

The PANSS cognitive factor may reflect verbal ability and memory, but is not sufficiently comprehensive to be considered as a replacement for direct assessment of cognitive functioning.