Brøset Violence Checklist Research Articles

Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study

Health care providers, particularly nursing staff, are at risk of physical or emotional abuse from patients. This abuse has been associated with increased use of physical and pharmacological restraints on patients, poor patient outcomes, high staff turnover, and reduced job satisfaction. In this study, a multidisciplinary team at Tufts Medical Center implemented the Brøset Violence Checklist (BVC), a screening tool administered by nurses to identify patients displaying agitated behavior. Patients who scored high on the BVC received a psychiatry consultation, followed by assessments and recommendations. This tool was implemented in an inpatient medical setting in conjunction with a one-hour de-escalation training led by nursing and Public Safety. The intervention design was executed through a series of three distinct Plan-Do-Study-Act cycles. This study measured the number of BVCs completed and their scores, the number of psychiatric consults placed, the number of calls to Public Safety, the number of staff assaults, nursing restraint use, and staff satisfaction. During the study period, restraint use decreased 17.6% from baseline mean and calls to Public Safety decreased 60.0% from baseline mean. In the staff survey, nursing staff reported feeling safer at work and feeling better equipped to care for agitated patients. The BVC is an effective, low-cost tool to proactively identify patients displaying agitated or aggressive behavior. Simple algorithms for next steps in interventions and training help to mitigate risk and increase feelings of safety among staff. Regular psychiatric rounding and the identification of champions were key components in a successful implementation.

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.

Violence Risk Assessment in the Emergency Department

IntroductionWorkplace violence is a prevalent problem in health care, with mental health and emergency departments being the most at-risk settings. The aim of this evidence-based practice project was to pilot use of a violence risk assessment tool, the Broset Violence Checklist, to assess for risk of type II violence and record the interventions that nurses chose to implement to mitigate the situation. Additionally, reports made to the hospital reporting system were tracked and compared to previous reporting frequency. MethodsFollowing staff education, nurses were instructed to complete checklists for all patients who have a score of 1 or higher, which indicates the presence of at least 1 high-risk behavior, and continue hourly scoring until the score returned to 0 or the patient was dispositioned. The number of incidents recorded, time of day, scores, interventions applied to mitigate violence, and change in scores after interventions were evaluated. The number of Broset Violence Checklist scoring sheets submitted and reports made via the hospital reporting system were compared. ResultsIncidents were most frequent from 11 am until 3 am. The highest scores occurred in the late evening and early morning hours. There were significantly more incidents captured with the use of the Broset Violence Checklist as compared to the hospital reporting system. Incidents significantly associated with higher scores included providing comfort measures, addressing concerns, and applying restraints. DiscussionThe Broset Violence Checklist was used successfully in the emergency department setting to identify behaviors associated with violence. Under-reporting to the hospital report system was identified in this project, consistent with reports in the literature. Specific interventions were not associated with a decrease in Broset Violence Checklist scores.

Short-term risk assessment in the long term: A scoping review and meta-analysis of the Brøset Violence Checklist.

INTRODUCTION: Existing literature on the Brøset Violence Checklist (BVC) is examined in the context of usability, implementation and validity to provide evidence-based recommendations on its application and identify opportunities for future development. To identify current knowledge on the BVC and guide clinicians and researchers toward the next steps in using this tool in clinical practice to prevent violence in healthcare settings. A scoping review approach with a meta-analysis supplement was adopted to broadly identify and map available evidence on the BVC and provide specific estimates of predictive validity in different contexts. Sixty-two studies conducted in 23 countries addressed the implementation of the BVC across various settings. Many studies adapted the original BVC, and the clinical utility was noted as an important feature. A meta-analysis of the original BVC format estimated a pooled area under the curve at 0.83 (95% CI 0.78-0.87) in a subset of 15 studies. The BVC combines high predictive validity and good clinical utility across a wide range of settings and cultures. It should continue to be incorporated into routine practice in mental health services focused on preventing violence and coercion. Development of collaborative approaches with service users involved in assessing their own risk of future violence.

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative.

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications. Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration. The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates. 377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124). In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Chronic wound care in psychiatric nursing practice. A case study

Individuals suffering from mental illnesses are characterized by poorer health and live shorter than the general population. Health problems, improper lifestyle, non-compliance with therapeutic recommendations, and the use of neuroleptics contribute to the occurrence of chronic wounds. The most common types of chronic wounds observed in the mentally ill include pressure ulcers, leg ulcers and the diabetic foot. The aim of the study was to present the specificity of the care provided for a patient with a chronic wound complicated by mental illness in the view of the diagnosis of nursing and caring problems. The study involved the use of a case study method. In planning patient care, data collected through interviews, direct observation, and documentation analysis were used, whereas the severity of symptoms was assessed with the VAS scale and Broset Violence Checklist. The ulceration was evaluated by means of the LUMT scale. Subsequently, the nursing issues were identified and interventions were implemented in line with the Evidence Based Practice. Following the implementation of topical and systemic therapy, the condition of the wounds improved by means of fibrin clearing, removal of dead epidermis from the wound edges, and gradual development of granulation tissue. The size of the wound on the left lower leg was reduced by about 20%, and on the right lower leg by about 30%. The improvement in the body hydration, nutritional status, biochemical parameters was achieved in the course of the systemic treatment and a proper diet. Not only did the patient’s mental condition improve, but also the willingness to cooperate with the staff. This allowed for the transfer to an open ward, where the wound treatment was continued. Another accomplishment was the positive impact on the patient’s awareness regarding wound care self-management. However, since the patient was discharged on his own request, complete wound healing was not achieved during hospitalisation. It is unknown whether he has undertaken further treatment at the indicated wound treatment clinics. Treatment of chronic wounds in patients with mental illnesses is a difficult process, since during the period of exacerbation of the disease, they tend to neglect their healthy needs. In the care of chronic wounds in patients with mental illnesses, treatment should be gradually introduced, adapting it to the patient’s needs, lifestyle and acceptance of the proposed treatment methods. Interventions against their will and expectations results in the loss of trust in the staff, non-compliance and even aggression. The multidimensional impact on the patient with a chronic wound increases the probability of complete healing of the wound. Care for a non-healing wound in patients with mental disorders should be comprehensive and include the treatment of both the wounds and mental disorders. Therefore, focusing solely on the wound is not enough, as only holistic measures will optimize wound care, leading to its healing.

Reducing levels of Violence in the Psychiatric Intensive Care Unit (PICU) - a multidisciplinary quality improvement project

AimsOur aim: To reduce the number of Level 1* violent incidents in Ward 4 by 30% by April 2020*Level 1 is defined as “Behaviour involving force, which causes or is intended to cause physical harm to others; but excludes assault on objects, threats or verbal abuse”Ward 4 is Belfast Health and Social Care Trust's only PICU, with a total of 6 beds. Our project took place on the background of a recent move to a new purpose-built inpatient unit, as well as a trust-wide initiative to address levels of violence across inpatient psychiatry services.MethodWe divided our project into 3 main areas:Patient factorsStaff factorsEnvironmental factorsWe identified and implemented a number of change ideas, using Plan-Do-Study- Act methodology, regularly meeting to review progress and plotting our data on a run chart.Key patient interventions included a “Mutual Respect” exercise and regular “Community Meetings”.Staff interventions included use of Safety Crosses, Daily Safety Briefings and the Broset Violence Checklist (BVC).Environmental factors were continually assessed and escalated as appropriate.We raised awareness of our project and gained feedback by creating a dedicated notice board, providing a staff information session and including it as an agenda item at ward meetings.Our project measures were identified as:Outcome: Number of level 1 violent incidents occurring per weekBalancing: Number of incidents in other categories; Patient satisfactionProcess: Staff safety rating; Engagement with interventionsResultUnfortunately, we were unable to meet our initial goal and there continued to be considerable variation in the number of weekly incidents.We believe this was attributable to several factors, including the level of acuity within the ward during the project timeframe. It was noted that a relatively small number of patients contributed to a large proportion of the total incidents. Our results, therefore, did not reflect the success of interventions with other patients on the ward.Despite this, we noted improvements in terms of patient and staff engagement with the project, including subjective reports of staff safety during shifts.ConclusionThe unpredictable and complex nature of the PICU setting cannot be under-estimated and this ultimately impacted on achieving our intended outcome.We do feel, however, that the project has had a positive impact and we hope we can build on this progress over the coming months.Further interventions are being explored, including personalised daily activity schedules and attempts to reduce levels of continuous observations.

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

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

Brøset Violence Checklist (BVC) versus Dynamic Appraisal of Situational Aggression-Inpatient Version (DASA-IV): their sensitivity, specificity and accuracy as a predictor of violence in 24 hours among schizophrenia patients

Background: Brøset Violence Checklist (BVC) and Dynamic Appraisal of Situational Aggression-Inpatient Version (DASA-IV) are risk assessment instruments of violence that nurses can use in psychiatric services, but their accuracy of the instruments in predicting violent behavior in 24 hours need to be tested.Objective: This study aims to examine the sensitivity and specificity of BVC and DASA-IV instruments in predicting violent behavior within 24 hours and which is more accurate.Method: This is a diagnostic study with a cross-sectional approach. The sample of this study was 112 patients. The respondents' behaviors were observed, based on parameters assessed by BVC and DASA-IV as well as recording incidents of violent behavior using AOS (Aggression Observation Short) as the gold standard. Sensitivity, specificity, and Receiver Operating Characteristic (ROC) tests were conducted to assess the accuracy of the two instruments in predicting violent behavior within 24 hours.Results: 23.2% of the respondents in this study experienced violent behavior in the first 24 hours. BVC has a sensitivity value of 65.4% and specificity of 94.5%. DASA-IV has a sensitivity value of 69.2% and a specificity of 95.5%. The level of accuracy of BVC is 87.9%, and of DASA-IV is 92.2%.Conclusion: DASA-IV is more sensitive, higher in its specificity, and is more accurate in predicting violent behavior within 24 hours in schizophrenic patients compared to BVC

Disaster psychiatry and homelessness: creating a mental health COVID-19 response

Homeless individuals across the globe live in a constant state of crisis Yet, during times of societal crisis such as COVID-19 that affect all populations, disaster planning has rarely included this high-risk group The high burden of co-occurring physical, mental, and substance use disorders, absence of reliable shelter, scant access to health information, and scarcity of financial, transportation, and nutritional resources all create unique vulnerabilities for this population These factors restrict the ability of people experiencing homelessness to respond and adapt to public health recommendations before and during a disaster In particular, the mental health needs of people who are homeless during disasters have received minimal attention (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Factors Affecting the Success of Psychiatric Nurses in Conducting Risk Assessment of Violence Behavior

Background: Patient violence behavior in psychiatric services is a challenge for health care providers.Violence behavior can affect patients themselves, other patients and staff including nurses and affect thequality of service. Psychriatic nurses can play roles in conducting risk assessment of violence behaviors toreduce impact and make appropriate decisions.Purpose: This systematic review aims to find out the factors that influence the success of psychiatric nursesin conducting risk assessment of violence behavior.Method: This systematic review begins with making questions by the PICO method, identification,eligibility, article inclusion criteria selection, screening and appraisal. Search articles through the databaseof Science Direct, Pubmed and Ebsco with a time span from 2009-2019. And continue with PRISMA flowdiagram and JBI critique tool up to get 13 articles that relevant to be analyzed be systematic review.Result and Discussion: Reviews are carried out on articles that fit the inclusion criteria. Factors thatinfluence the success of psychiatric nurses in conducting risk assessment of violence behavior are trainingand continuing education, self-confidence, understanding early warning signs/alert systems, understandingthe causes of violence and the use of violence risk assessment tools) such as the Brøset Violence Checklist(BVC) and Dynamic Appraisal of situational Aggression (DASA)Conclusion: Psychiatric nurses still need continuing education and training in understanding the early signsof a patient’s violence behavior and the use of assistive devices in the form of risk assessment of violencebehavior to increase the confidence of nurses and assist in making appropriate decisions.

Improving the Standard of Care in the Management of Agitation in the Acute Psychiatric Setting.

INTRODUCTION: In 2016-2017, assault and restraint rates on the involuntary inpatient psychiatric unit in an academic medical center in northeast United States were highest for the seven behavioral health hospital networks. Organizational assessment identified inconsistent implementation of Best Practices in Evaluating and Treating Agitation (BETA) guidelines, adopted in 2014. Contributing factors: 50% of nurses hired in 2016-2017 had 5 years or less nursing experience. Newer nurses might lack confidence managing escalating agitation until more restrictive containment is necessary. AIMS: The aims of this 8-week quality improvement project were (1) to determine if Brøset Violence Checklist (BVC) education improved documentation of BETA interventions from pre- to post-project, (2) to reduce restraint rates by 5% or greater, and (3) to improve registered nurses' attitudes regarding the use of violence risk assessment tools. METHODS: Retrospective restraint documentation was audited 8 weeks prior to project. Patients were assessed using the BVC twice daily for first 72 hours of admission. BVC checklists and electronic health record documentation were audited for BVC scores above 2. The author and nurses involved in each restraint reviewed documentation improvement opportunities. Pre- and post-BVC intervention surveys assessed nurse attitudes regarding violence risk tools. RESULTS: Outcome measurement included electronic health record documentation showed improvement reflecting BETA interventions; 6.5% reduction in restraint rates during the intervention; and improvement in attitudes regarding violence risk assessments. CONCLUSIONS: BVC agitation assessment in conjunction with BETA guidelines supports proactive management of violence risk, improving the standard of documentation and care.

Introduction of the Brøset Violence Checklist on a PICU

Background and aims: This survey pragmatically appraised the utility of the Brøset Violence Checklist (BVC) and its potential usefulness in guiding proactive management and interventions to help reduce episodes of violence and/or aggression within a psychiatric intensive care unit (PICU). Emphasis was placed on evaluating whether this instrument was completed prior to an episode of violence and/or aggression, and (through development of an appropriate action plan) the relationship it had on management plans.&lt;br/&gt; Method: Use of the BVC was introduced on a PICU. Incidents of disturbed patient behaviour were collated over a 13 week period using the DATIX incident reporting system. BVC records completed over the 24-hour period prior to any incident were examined. Usage of risk management plans developed after BVC completion was identified. Plans were coded as 'Use of medication', 'Environmental interventions' or 'Restrictive practice'. &lt;br/&gt; Results: 86 incidences were reported. Results suggested satisfactory completion of BVC score sheets for all patients. Management plans were noted as being present and robust for patients whose BVC scores were higher (≥3), as recommended by the tool. It was noted that implementation of restrictive interventions was less than use of either medication or environmental contingencies within proposed risk management plans. However, following an episode, management plans were not reviewed.&lt;br/&gt; Conclusion: An empirically-validated measure to predict potential risk of violence within a PICU was introduced and appropriate management strategy plans developed. Incorporating use of a structured short term risk assessment tool was therefore deemed to be a useful addition to standard procedures.

Risk assessment of imminent violence in acute psychiatry: a step towards an extended model

ABSTRACTAggression occurs frequently in mental health care settings, and studies have reported that 17% to 31% of patients admitted to acute psychiatric wards commit violence. Inpatients’ fluctuating mental states and behaviour patterns reinforce the need for an assessment instrument to predict potential violence in a timely manner. This naturalistic prospective inpatient study investigated whether an extended short-term risk assessment model that combines (a) short-term risk assessment with the Broset Violence Checklist (BVC), (b) patient’s own prediction of violence with the Self-Report Risk Scale (SRS) and (c) single items from the Violence Risk Screening 10 (V-RISK-10) provides better short-term predictive accuracy for violence than the BVC alone. All patients admitted to a psychiatric emergency hospital in Norway during one year were included (N = 508). Stepwise multivariate generalised linear mixed model analyses were conducted. When adjusting for repeated measurements, the results indicated that an extended model for short-term risk assessment, consisting of the BVC, SRS and Item 2 Previous and/or current threats from the V-RISK-10 explained more variance of imminent violence, compared to the BVC alone. Further studies are recommended to investigate whether the extended model provides a clinically better short-term risk prediction of imminent violence, compared to the BVC alone.

The Predictive Properties of Violence Risk Instruments May Increase by Adding Items Assessing Sleep.

Background: The psychometric instruments developed for short-term prediction of violence in psychiatric inpatients do not include variables assessing sleep. Disturbances in sleep may precede aggression in this setting. We investigated whether adding information on sleep improved the predictive properties of the Brøset Violence Checklist (BVC). Methods: The study population consists of all patients admitted to a psychiatric intensive care unit (PICU) over a 6-month period who were hospitalized for at least one night (n = 50). Sleep observed by staff (521 nights), behavior assessed with the BVC (433 days), and aggressive incidents recorded by the Staff Observation Scale-Revised (n = 14) were included in the analysis. Results: The ability of the BVC to predict aggressive incidents improved from AUCROC 0.757 to AUCROC 0.873 when a combined sleep variable including both sleep duration and night-to-night variations of sleep duration was added to the BVC recordings. The combined sleep variable did not significantly predict aggressive incidents (AUCROC 0.653, p = 0.051). Conclusions: A sleep disturbance variable improves the predictive properties of the BVC in PICUs. Further studies of sleep duration, night-to-night variations in duration of sleep, and aggression are needed.

Music Therapy and Physical Activity to Ease Anxiety, Restlessness, Irritability, and Aggression in Individuals With Dementia With Signs of Frontotemporal Lobe Degeneration.

The purpose of the current study was to evaluate whether a combined intervention of physical activity and music therapy could reduce anxiety, restlessness, irritability, and aggression among individuals with severe dementia. An exploratory design was used to evaluate a combined intervention of physical activity, music therapy, and daily walking. Interventions were systematically implemented for 8 weeks. Target groups were individuals with dementia with frontal lobe symptoms in institutional care. Primary outcome measure was the Brøset Violence Checklist (BVC). Four men and two women (mean age = 84.3 years) and their primary caretakers (n = 6) participated. The most prominent symptoms among participants at baseline were confusion, irritability, and verbal threats. The individual BVC total scores indicated significant improvements (p = 0.03). Implementation of individualized music therapy combined with increased physical activity for 8 weeks was a feasible intervention that reduced anxiety, restlessness, irritability, and aggression in the current study. [Journal of Psychosocial Nursing and Mental Health Services, 57(5), 29-37.].

Implementation of the Brøset Violence Checklist on an Acute Psychiatric Unit.

BACKGROUND: Violence on inpatient psychiatric settings has significant consequences for patients and staff. Research is needed to determine if Brøset Violence Checklist (BVC) is an accurate predictor of violence. AIMS: The study aims were to determine the relationship between BVC scores and incidence of violent behavior within 24 hours, to compare scores among those requiring high-level nursing interventions for violence, and to investigate the impact of scores on length of stay (LOS) and 30 day-readmission rates. METHOD: Retrospective cohort study. RESULTS: Logistic regression indicates 3.4 times greater risk of violence for every additional point on admission BVC (odds ratio = 3.4, 95% confidence interval = [2.29, 5.08], p < .0001). Patients requiring high-level interventions for violence had higher mean BVC scores on both Day 1 and 2 of admission. Pearson correlation was significant for positive association between BVC on admission and LOS (p < .001). Findings did not establish a link between BVC scores and violence with 30-day readmission rates. CONCLUSIONS: Efforts toward early identification and management of agitation and disruptive behavior is encouraged. Results showed increased risk of violence with every additional point on BVC on admission; further attention should be paid to these patients on admission when using violence screening tools.

Assessing the risk of violence in a psychiatric clinic: the Brøset Violence Checklist (BVC) Turkish version-validity and reliability study.

This study was conducted for the purpose of adapting the Brøset Violence Checklist (BVC) for Turkish patients and testing its validity and reliability in measuring and predicting the risk of violence psychiatric in patients. The BVC and the Overt Aggression Scale (OAS) were used in the study. The BVC was distributed to 126 patients at the psychiatric clinic. The receiver operating characteristic(ROC), the Mann-Whitney U test and χ 2 analysis were carried out. With a BVC total score cutoff of two points, 52% sensitivity and 100% specificity were found. A total of 47 violent episodes were observed in 25 patients. These results support the validity and reliability of the BVC. The Turkish version of the BVC was found to be a reliable and valid tool suitable for use in psychiatric inpatients.

14. VIOLENCE IN SCHIZOPHRENIA: PREVALENCE, MEASUREMENT, PREDICTION AND PREVENTION

Overall : Most patients with schizophrenia and bipolar disorders (severe mental illness, SMI) are not violent in their lifetimes, however, a minority of patients are violent at some points in the course of their illness. As the illness appears relatively early in life, and typically runs a chronic course, the number of violent incidents caused by patients can be considerable in some cases. Due to the stigma toward SMI, the media often emphasize reporting of these incidents, which fuel the stigma even more. Although violent behavior is a common cause of concern for patients, their families and clinicians, it is not often discussed in scientific meetings. The purpose of this symposium is to bring this relatively neglected, but very important topic into the spotlight in SIRS, in order to summarize the latest evidence for clinicians and researchers, and to foster new work on reducing these risks of violence.Dr. Weiser will present an overview of the prevalence of violent behavior in patients with SMI, and will present a population-based, case-control study from Israel, showing increased rates of violent crime in patients with SMI, particularly in female patients and patients who abuse drugs. Secondary analyses will show increased rates of violent behaviour in siblings of patients as well.Dr. Fazel will present a systematic review on the prognostic (or predictive) accuracy of structured ways to assess violence risk in patients with severe mental illness, and present new work on a scalable and potentially useful predictive model of violent behaviour based on 75,000 patients in Sweden.Dr. Nijman will present a model based on patient, ward and staff variables focused on the causes and triggers of aggressive behavior on (locked) psychiatric wards. Based on this model, a number of preventive measures can be formulated. At the patient level, the administration of anti-psychotic medication is used to reduce the negative cognitive schemes and delusional thoughts that are depicted in the center of the model. A more novel intervention at the patient level may be the additional administration of nutritional supplements with (among others) high levels of omega 3 fatty acids. The results of two Dutch studies on this topic will be briefly presented in the lecture, among which a RCT on the effects of the use of nutritional supplements on aggressiveness. On the staff level, the use of short-term (daily) risks assessments by the ward nursing staff, among others by means of the six item BrØset Violence Checklist (BVC), has been found to reduce aggressiveness as well as the use of coercive measures on psychiatric wards in two cluster randomized RCTs. On the ward level, studies indicate that aggression on psychiatric wards can be reduced by preventing overcrowding on psychiatric wards, and by providing more space and privacy to the patients.Dr. Torrey will present data on rates of re-arrest in patients with SMI, showing that the average five-year re-arrest rate is approximately 40% for those released from psychiatric hospitals and 60% for those released from jails or prisons, and will present comparison data from other countries. He will then present data on the effect of extended conditional release, Forensic Assertive Community Treatment (FACT) teams, and Psychiatric Security Review Boards on re-arrest rates.

14.3 CAUSES AND PREVENTION OF AGGRESSION FROM PSYCHOTIC INPATIENTS

BackgroundPatients with schizophrenia and other psychotic disorders have an increased likelihood of engaging in violent behavior. These increased risks of dangerous and aggressive behavior, in combination with a lack of insight in their own illness, relatively often make involuntary admission of acutely disturbed psychotic patients on locked psychiatric admissions wards often inevitable. On these locked psychiatric admissions wards, aggression from psychotic patients against staff and fellow patients is a prevalent phenomenon, with the mean in the Netherlands being about 18 aggressive incidents per bed per year on locked psychiatric admissions wards.MethodsIn the lecture, a model of what causes or triggers aggressive behavior on (locked) psychiatric wards is presented. In this model, patient, ward and staff variables are integrated to explain why, and in what specific situations, psychotic patients particularly run a high risk of engaging in aggressive behavior.ResultsBased on the presented model, a number of preventive measures can be formulated.On the patient level, the administration of anti-psychotic medication is used to reduce the negative cognitive schemes and delusional thoughts that are depicted in the center of the model. A more novel intervention at the patient level may be the additional administration of nutritional supplements with (among others) high levels of omega 3 fatty acids. The results of two Dutch studies on this topic will be briefly presented in the lecture, among which a RCT on the effects of the use of nutritional supplements on aggressiveness.On the staff level, the use of short-term (daily) risks assessments by the ward nursing staff, among others by means of the six item BrØset Violence Checklist (BVC), has been found to reduce aggressiveness and the use of coercive measures on psychiatric wards in two cluster randomized RCTs.On the ward level, studies indicate that aggression on psychiatric wards can be reduced by preventing overcrowding on psychiatric wards, and by providing more space and privacy to the patients.DiscussionThe proposed model elucidates how certain patient, staff and ward characteristics may interact in causing aggression. The model also emphasizes that repeated inpatient aggression may be the result of a vicious circle, i.e. inpatient violence is often followed by an increase in environmental and/or communication stress on the patient, thereby heightening the risk of a repeated outburst of violence.