Severity Of Aggressive Incidents Research Articles

Effectiveness of De-Escalation in Reducing Aggression and Coercion in Acute Psychiatric Units. A Cluster Randomized Study.

ObjectiveMost guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards.MethodsA multi-center cluster randomized study was conducted in the acute wards of all psychiatric hospitals in Slovenia. The research was carried out in two phases, a baseline period of five consecutive months and an intervention period of the same five consecutive months in the following year. The intervention was implemented after the baseline period and included training in verbal and non-verbal de-escalation techniques for the staff teams on experimental wards.ResultsIn the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease.ConclusionDe-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [NCT05166278].

Reducing Aggressive Incidents Among Chronically Admitted Psychiatric Patients Through Nutritional Supplementation: A Randomized Double-Blind, Placebo-Controlled Trial

Aggressive incidents are highly prevalent among psychiatric inpatients. Previous studies demonstrated the potential benefit of nutritional supplementation to reduce aggression in maladjusted children and forensic populations. We aimed to test whether supplementation reduces the incidence and severity of aggressive incidents among chronic psychiatric inpatients.

A Study Into the Severity of Forensic and Civil Inpatient Aggression.

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

Response to Joshi and Langley-Degroot

Response to Joshi and Langley-Degroot

The Relation Between Aggression and the Living Group Climate in a Forensic Treatment Unit for Adolescents: A Pilot Study.

In the current study, the associations between inpatient aggression and the living group climate as perceived by the adolescents admitted to a forensic psychiatric treatment unit, are investigated based on carefully registered longitudinal data. Multilevel regression analyses revealed a significant inverse relation between the number and severity of aggressive incidents and the amount of support, as well as with the possibilities of growth perceived by the adolescents. No significant associations of aggression and the perception of repression or atmosphere are found. Our study reveals preliminary evidence for the relation between the prevalence of aggressive incidents and how the adolescents perceive social contextual factors in daily forensic treatment practices. Moreover, preliminary evidence that evidence-based treatment programs and psychiatric care have an important influence on experienced possibilities for growth and support and as such prevent institutional aggression, is found.

Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial

There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care. To assess whether such risk assessments decrease the incidence of violence and coercion. A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients. Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease. Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards.

Pilot Study Evaluating the Effect of Massage Therapy on Stress, Anxiety and Aggression in a Young Adult Psychiatric Inpatient Unit

The aim of the present pilot study was to examine the effectiveness of a relaxation massage therapy programme in reducing stress, anxiety and aggression on a young adult psychiatric inpatient unit. This was a prospective, non-randomized intervention study comparing treatment as usual (TAU) with TAU plus massage therapy intervention (MT) over consecutive 7 week blocks (May-August 2006). MT consisted of a 20 min massage therapy session offered daily to patients during their period of hospitalization. The Kennedy Nurses' Observational Scale for Inpatient Evaluation (NOSIE), the Symptom Checklist-90-Revised (SCL-90-R), the State-Trait Anxiety Inventory (STAI) and stress hormone (saliva cortisol) levels were used to measure patient outcomes at admission and discharge from the unit. The Staff Observation Aggression Scale-Revised (SOAS-R) was used to monitor the frequency and severity of aggressive incidents on the unit. There was a significant reduction in self-reported anxiety (p < 0.001), resting heart rate (p < 0.05) and cortisol levels (p < 0.05) immediately following the initial and final massage therapy sessions. Significant improvements in hostility (p = 0.007) and depression scores (p < 0.001) on the SCL-90-R were observed in both treatment groups. There was no group x time interaction on any of the measures. Poor reliability of staff-reported incidents on the SOAS-R limited the validity of results in this domain. Massage therapy had immediate beneficial effects on anxiety-related measures and may be a useful de-escalating tool for reducing stress and anxiety in acutely hospitalized psychiatric patients. Study limitations preclude any definite conclusions on the effect of massage therapy on aggressive incidents in an acute psychiatric setting. Randomized controlled trials are warranted.

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

BackgroundAggression 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.ObjectiveTo describe the frequency and severity of aggressive incidents in acute psychiatric wards in the German speaking part of Switzerland.MethodsWe 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.ResultsA 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.ConclusionAggressive 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.

Atypical Antipsychotic Agents in the Treatment of Violent Patients With Schizophrenia and Schizoaffective Disorder

Violent behavior of patients with schizophrenia prolongs hospital stay and interferes with their integration into the community. Finding appropriate treatment of violent behaviors is of primary importance. To compare the efficacy of 2 atypical antipsychotic agents, clozapine and olanzapine, with one another and with haloperidol in the treatment of physical assaults and other aggressive behaviors in physically assaultive patients with schizophrenia and schizoaffective disorder. Randomized, double-blind, parallel-group, 12-week trial. Physically assaultive subjects with schizophrenia or schizoaffective disorder who were inpatients in state psychiatric facilities were randomly assigned to treatment with clozapine (n = 37), olanzapine (n = 37), or haloperidol (n = 36). Number and severity of physical assaults as measured by the Modified Overt Aggression Scale (MOAS) physical aggression score and the number and severity of all aggressive events as measured by the MOAS overall score. Psychiatric symptoms were assessed through the Positive and Negative Syndrome Scale (PANSS). Clozapine was superior to both olanzapine and haloperidol in reducing the number and severity of physical assaults as assessed by the MOAS physical aggression score and in reducing overall aggression as measured by the MOAS total score. Olanzapine was superior to haloperidol in reducing the number and severity of aggressive incidents on these 2 MOAS measures. There were no significant differences among the 3 medication groups in improvement of psychiatric symptoms as measured by the PANSS total score and the 3 PANSS subscales. Clozapine shows greater efficacy than olanzapine and olanzapine greater efficacy than haloperidol in reducing aggressive behavior. This antiaggressive effect appears to be separate from the antipsychotic and sedative action of these medications.

Measuring aggression with the staff observation aggression scale--revised.

The staff observation aggression scale (SOAS; Palmstierna & Wistedt, 1987) was developed to measure nature, number, as well as severity of aggressive incidents. In 1999, a revised version of the SOAS (i.e. the SOAS-R), with a more fine-grained severity scoring system, was presented. In the current paper, the development and testing of the revised severity scores of the SOAS-R are addressed. In two consecutive studies, staff members recorded inpatient aggression on SOAS-R forms, but also expressed their opinion about the severity of incidents on 100 mm visual analogue scales (VASs). Correlations were calculated between SOAS and SOAS-R severity scores, on the one hand, and clinical judgements of severity, on the other. In both studies, revised SOAS severity scores were more closely related to clinical judgements of aggression severity than the original ones. The SOAS-R is a promising tool for research on the prevalence, severity and determinants of inpatient aggression.

The staff observation aggression scale-revised (SOAS-R)

Proper assessment of aggressive behavior is essential for an understanding of its causes. In 1987, Palmstierna and Wistedt [Acta Psychiatr Scand 76:657-663] introduced the Staff Observation Aggression Scale (SOAS), an instrument for monitoring the frequency, nature, and severity of aggressive incidents. In the present study, the validity of the SOAS severity scoring system was examined, and the severity scores were refined. The SOAS was used to record aggression on six closed wards of three psychiatric hospitals. The SOAS severity scores of 556 aggressive incidents were compared with severity estimates given on Visual Analogue Scales (VASs) by staff members. The original SOAS scores were found to be moderately correlated with the estimates of severity given by staff on the VAS. The SOAS severity scoring system was refined on the basis of the staff severity estimates. The revised scoring method and other refinements in the contents of the instrument led to the construction of the SOAS-R. The SOAS-R seems to be a promising tool for monitoring a wide range of (self-) destructive acts on psychiatric wards.

The staff observation aggression scale–revised (SOAS-R)

Proper assessment of aggressive behavior is essential for an understanding of its causes. In 1987, Palmstierna and Wistedt [Acta Psychiatr Scand 76:657-663] introduced the Staff Observation Aggression Scale (SOAS), an instrument for monitoring the frequency, nature, and severity of aggressive incidents. In the present study, the validity of the SOAS severity scoring system was examined, and the severity scores were refined. The SOAS was used to record aggression on six closed wards of three psychiatric hospitals. The SOAS severity scores of 556 aggressive incidents were compared with severity estimates given on Visual Analogue Scales (VASs) by staff members. The original SOAS scores were found to be moderately correlated with the estimates of severity given by staff on the VAS. The SOAS severity scoring system was refined on the basis of the staff severity estimates. The revised scoring method and other refinements in the contents of the instrument led to the construction of the SOAS-R. The SOAS-R seems to be a promising tool for monitoring a wide range of (self-) destructive acts on psychiatric wards. Aggr. Behav. 25:197–209, 1999. © 1999 Wiley-Liss, Inc.