Violent Psychiatric Patients Research Articles

Effects of Implementing an Acuity Tool on a Psychiatric Intensive Care Unit.

Staff shortages, reduced budgets, and high acuity of violent psychiatric patients can create challenges in psychiatric intensive care units (PICUs). Staffing of the psychiatric unit was based on patient census rather than evidence-based practices. A pre-/postintervention design was used to examine changes in nursing satisfaction and patient outcomes as measured with the National Database of Nursing Quality Indicators (NDNQI) survey results. A psychiatric specific acuity tool was implemented on the PICU of a Veterans Administration hospital. After an initial decrease related to the COVID-19 pandemic, total acuity and the total number of nurses remained relatively stable while the unit census declined. NDNQI survey results improved with the largest being a 52-percentile increase for the quality-of-care summary measure. An acuity tool can help standardize practice, determine fair patient assignments among staff, increase nurse satisfaction, and promote best practices for patient safety.

Activity Participation and Inpatient Violence in Secure Mental Health

Occupational therapists play a central role in the treatment of offenders with mental illness and violent individuals. Despite this emphasis, little is known about the occupational profile of violent psychiatric patients. This study employed a retrospective design to explore activity participation in a sample of 94 male patients in a secure psychiatric hospital. Activity participation was assessed with the Activity Participation Outcome Measure (APOM) at two time points. APOM successfully discriminated between violent and nonviolent patients and was sensitive to progress over time. The findings suggest that the tool can be successfully used to understand patients’ abilities ahead of discharge.

?What explains the surge of aggression among jihadists, Schizophrenia or violence: ما يفسر فورة العدوان لدى الجهاديين السكيزوفرينيا أم العنف؟ قراءة في أبحاث سيكولوجية عالمية

Schizophrenia is associated with violence and aggressive behavior can be detected, understood and predicted in this context, including jihadist suicide. However, the risk of producing excessive violence in psychiatric patients is quite similar to that of other people, particularly drug users of both sexes. In this article, we present a series of research projects in the field of neuropsychology and psychophysiology that establish a comprehensive suite of promising programs to combat violence. This research is accompanied by an integrated Western theoretical and experimental paradigm aimed at explaining violence based on verifiable scientific hypotheses. In light of the results of this research, leaders can strengthen their role in preventing violence by establishing a plan for treating schizophrenia as a serious mental illness and developing an effective addiction monitoring strategy that allows for the prediction of any individual or collective violent behavior, such as the suicide of jihad.

The validity and utility of violence risk assessment tools to predict patient violence in acute care settings: An integrative literature review.

To examine risk assessment tools to predict patient violence in acute care settings. An integrative review of the literature. Five electronic databases - CINAHL Plus, MEDLINE, OVID, PsycINFO, and Web of Science were searched between 2000 and 2018. The reference list of articles was also inspected manually. The PICOS framework was used to refine the inclusion and exclusion of the literature, and the PRISMA statement guided the search strategy to systematically present findings. Forty-one studies were retained for review. Three studies developed or tested tools to measure patient violence in general acute care settings, and two described the primary and secondary development of tools in emergency departments. The remaining studies reported on risk assessment tools that were developed or tested in psychiatric inpatient settings. In total, 16 violence risk assessment tools were identified. Thirteen of them were developed to assess the risk of violence in psychiatric patients. Two of them were found to be accurate and reliable to predict violence in acute psychiatric facilities and have practical utility for general acute care settings. Two assessment tools were developed and administered in general acute care, and one was developed to predict patient violence in emergency departments. There is no single, user-friendly, standardized evidence-based tool available for predicting violence in general acute care hospitals. Some were found to be accurate in assessing violence in psychiatric inpatients and have potential for use in general acute care, require further testing to assess their validity and reliability.

Aggressiveness and violence in psychiatric patients: a clinical or social paradigm?

Psychiatric disorders are often considered the leading cause of violence. This may be due to a stereotype created by media and general opinion. The Modified Overt Aggression Scale (MOAS) was used to evaluate the severity of aggressive and violent behaviors in 400 patients who attended a post-acute psychiatric service in Milan from 2014 to 2016 and suffered from different psychiatric disorders. The psychopathological clinical picture was evaluated by Clinical Global Impression (CGI). The study also assessed the possible correlation between epidemiologic and sociodemographic factors, clinical variables, and aggression and violence. Of the total number of subjects, 21.50% showed a MOAS score >0, 11.50% presented mild aggression (0-10 MOAS weighted score), 9% moderate aggression (11-20), and 1% severe aggression (MOAS >20). With respect to violent behaviors, 16% of patients showed a score >0 in one MOAS subscale other than verbal aggression according to violence definition. The severity of clinical picture seemed to be related to higher weighted MOAS score. Multivariate testing of different sociodemographic and clinical variables showed that violence was related to unemployment status, and significantly correlated to compulsory admission (TSO), suicide attempts (TS), and personality disorders, while the severity of clinical psychiatric picture seemed to play a secondary role. Results have shown that personality disorders and sociodemographic factors, including economic factors, seem to be major determinants of violence among patients diagnosed with mental disorders.

Workplace Violence Against Nurses in Psychiatric Hospital Settings: Perspectives from Saudi Arabia.

ObjectivesWorkplace violence (WPV) has become a world-wide concern. This study aimed to measure the prevalence of WPV among nurses working in psychiatric hospitals in Saudi Arabia.MethodsThis cross-sectional study was conducted at three psychiatric hospitals in Saudi Arabia between March and May 2017. Participants completed a self-reported questionnaire which was used to measure the prevalence and explore the associated factors of WPV. A multivariate logistic regression analysis was also performed.ResultsA total of 310 nurses (response rate: 62%) were included in this study. The prevalence of WPV against nurses was 90.3%, of which 57.7% had been exposed to both physical and verbal abuse. More nurses were exposed to WPV during the morning shift than the evening shift (58.4% versus 42.3%). Violent behaviour was exhibited mostly by the patients themselves (81.3%). Over half of the nurses (57.4%) required medical intervention in such cases. The majority of nurses felt either stressed (64.2%) or anxious (53.5%) and 34.2% felt depressed after the incident. Multivariate logistic regression analysis revealed that time of violence, source of violence, patient dissatisfaction with medical care and lack of organisational support for nurses were significantly associated with the occurrence of WPV in psychiatric units.ConclusionWPV has reached an alarming rate among nurses in psychiatric hospitals in Saudi Arabia. It is crucial to invest in the prevention of WPV by constant training of workers and a mutual policy with the police and the civic prosecutor in Saudi Arabia on how to respond to violent psychiatric patients.

Psychiatric disorders associated with intimate partner violence and sexual violence in Thai women: Aresult from the Thai National Mental Health Survey

BackgroundIntimate partner violence (IPV) and sexual violence (SV) occur commonly and are a violation of basic human rights. There are limited studies to date that examine the impact of IPV,...

Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

Violence prevention in psychiatry: an umbrella review of interventions in general and forensic psychiatry

Relative risks of violence in psychiatric patients are high compared to the general population and existing evidence in non-psychiatric populations may not translate to reductions in violence in psychiatric populations. We searched 10 databases including Medline, EMBASE, CINAHL and Scopus, from inception until August 2015 for systematic reviews and meta-analyses of violence prevention interventions in psychiatry. Reviews were included if they used a hard outcome measure (i.e. police or hospital recorded violence, or reincarceration) and contained randomized or non-randomized controlled studies. Five reviews met our inclusion criteria (n = 8876 patients in total), of which four received a GRADE rating of ‘low’ or ‘very low’. Three randomized studies (n = 636) reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with co-occurring mental illness (‘moderate’ GRADE rating). The lack of intervention research in violence prevention in general and forensic psychiatry suggests that interventions from non-psychiatric populations may need to be relied upon.

Clozapine safety, 40 years later.

Clozapine is, and will remain in the coming years, an irreplaceable drug in psychiatry which has elective indication in treatment-resistant schizophrenia, suicide risk in schizophrenia spectrum disorders, aggressiveness or violence in psychiatric patients, psychosis in Parkinson's disease, prevention and treatment of tardive dyskinesia. Unfortunately, the drug is largely underused for many and serious side effects. Only a good knowledge of these side effects and of the main strategies to prevent their occurrence or minimize their impact can allow overcoming the underutilization of this valuable therapy. The article describes the clinical and epidemiological features of the non-motor side effects of clozapine including blood dyscrasias, constipation, diabetes, enuresis, fever, hepatitis, hypersalivation, ileus, myocarditis, nephritis, priapism, seizures, serositis, weight gain and metabolic syndrome. The paper suggests several strategies, supported by scientific evidence, in the management of these side effects. The neuropsychiatric side effects of clozapine are not discussed in this review.

EPA-0469 – Translating hcr-20 risk assessment into evidence based risk management.

Structured professional judgement (SPJ) approaches are becoming increasingly influential in the assessment and management of the risk of violence in psychiatric patients. The best example is the HCR-20, that is for example is now mandatory for all patients in high, medium and low secure psychiatric care in the United Kingdom. The clinical utility of these guides has however been called into question, as their ability to be translated from risk assessment to risk management remains elusive. We will present a framework model, designed for the clinical psychiatric setting that helps to turn risk assessment into evidence based risk management. The model assists meaningful clincal implementation of risk informed intevention plans that allows teams to prioritise resources and assess treatment efficiacy and risk management success. The model requires few additional resources but can also help to facilitate communication between clincal teams at times of transition, but also between clinicians and patients.

Deceptive behaviour and instrumental violence among psychopathic and non-psychopathic violent forensic psychiatric patients

Deceptive behaviour and instrumental violence are well-known psychopathic features and as such play important roles in the assessment of psychopathy. This study examined first, the nature of the violence committed by offenders that have been admitted to forensic psychiatric care and whether scores on the Psychopathy Checklist: Screening Version (PCL:SV), Part 1, were associated with the instrumentality of violence. Second, we examined the proneness of offenders to re-frame the instrumentality in their past violent crimes, and whether this was associated with scores on the PCL:SV. The results show that the PCL:SV, Part 1 (interpersonal/affective features), was positively related to the officially coded instrumentality of the violent crimes. As expected, this association disappeared when the instrumentality was self-reported. However, the majority of the patients tended to exaggerate the reactivity of their violent crimes when it was self-reported, indicating that most offenders, independently of level of psychopathy, used deception when questioned about the characteristics of their past violent crimes. The reasons for, and implications of, the use of deception are discussed.

Five simple questions to predict violence in psychiatric patients

Forensic psychiatry is principally concerned with assessing and managing the risk to others (usually of violence) by people with a mental disorder. A variety of lengthy risk assessment instruments help consolidate this expertise, but these instruments do not find favour in day-to-day psychiatry.

Violence Against Mental Health Staff in Nigeria: Some Lessons from Two Mental Hospitals

Background: Psychiatric patient violence against staff is frequentlyencountered in mental health settings. Studies from Africa and Nigeria inparticular are few.Aim: The study aimed at comparing the frequency and type of physicalassaults by individuals with mental illness against staff working in twomental hospitals in Nigeria with a view to identifying some staff contextualvariables that could predispose them to these assaults.Methods: The study was a crosssectional descriptive report by questionnaire survey of physical assaults on 189 staff members(doctors and nurses) working at the Federal Neuropsychiatry Hospital,Yaba (FNHY), Lagos and Federal Neuropsychiatry Hospital Calabar(FNHC), Nigeria.Results : One hundred and twelve participants from the two hospitalswere victims of 202 assaults. Staff of FNHC experienced more assaults(70.4%) than staff of FNHY (49.5%), and this was significant. Nursing staffwere more frequently assaulted than doctors for the two hospitals. Eventhough staff of FNHC attended fewer courses on management andprevention of violence than staff of FNHY, not having received training inmanaging patient violence and gender were not significant risk factors forexposure to patient violence in a multivariate analysis.Conclusion. There is a need to formulate policies and guidelines forthe management and prevention of psychiatric patient violence againststaff in our mental health institutions.

Structured Assessment of Violence Risk in Schizophrenia and Other Psychiatric Disorders: A Systematic Review of the Validity, Reliability, and Item Content of 10 Available Instruments

To undertake a systematic review on structured violence risk assessment tools in individuals with schizophrenia. A systematic search was conducted from 1990 to 2011 to identify violence risk assessment tools and studies examining their predictive validity. Item content of the identified instruments was analyzed, and areas under the curve (AUC) from the studies were extracted. In addition, an 11-item checklist was developed to assess the utility and psychometric properties of these tools. Ten risk assessment tools designed to predict community violence in psychiatric patients were identified, but only 2 studies reporting predictive validity estimates in patients with schizophrenia were found (median AUC = 0.69; interquartile range = 0.60-0.77). When inclusion criteria was broadened to include studies measuring accuracy for any diagnostic group, mixed evidence of predictive validity was found, with median AUCs ranging from 0.62 to 0.85 depending on the population. Item content included mostly clinical, sociodemographic, and criminal history factors. As only 1 tool included a neurobiological item, a structured review of brain-based and cognitive risk factors for violence was included, and 3 clusters (neurocognitive ability, neurocognitive awareness, and attitudinal cognition) were identified. While a number of violence risk assessment tools exist that can be used to predict the likelihood of community violence in psychiatric patients, there is currently little direct evidence for their utility in individuals with schizophrenia. In addition, there is large variation in item content between instruments, and further research is necessary to determine whether the inclusion of alternative factors could improve risk assessment.

Violence against care workers in psychiatry: Is prosecution justified?

The number of (severe) violent incidents against staff caused by psychiatric inpatients is high. Victims often do not report these incidents to the police, because of various reasons. But if they do report these incidents, the judicial authorities are often reluctant in prosecuting and convicting these patients. The central question in this article is ‘in which cases is it appropriate to prosecute assaultive psychiatric patients?’ In order to identify the influential factors in the decision in respectively reporting, prosecuting and convicting psychiatric patients who assault staff, a literature review has been performed. On the basis of this literature it is advised to report and investigate a case when the incident resulted in severe injury, the incident is a sexual offence, or when a patient repetitively causes violent incidents. Moreover, it appears that, although large amount of studies has been published on violence in psychiatry, the prosecution of violent psychiatric patients has hardly received any attention in the international literature. Empirical studies on this subject are suggested, in order to develop a uniform policy, which is embraced by all parties involved.

Aggression in Schizophrenia

Aggression in Schizophrenia

Clozapine Safety, 35 Years Later

Clozapine is the best treatment option in several clinical circumstances, including treatment-resistant schizophrenia, non treatment-resistant schizophrenia, suicide risk in schizophrenia spectrum disorders, aggressiveness or violence in psychiatric patients, psychosis in Parkinson's disease, prevention and treatment of tardive dyskinesia. However, clozapine is associated with many serious side effects. Furthermore, monitoring requirements, i.e., frequent blood draws and frequent visits, discourage clozapine use. Therefore, the drug is underused. The only way to avoid the underuse of clozapine is full awareness of its side effects and competence to minimize them. The aim of the paper is reviewing the safety profile of clozapine and the suggested strategies in the management of its side effects, including neutropenia, eosinophilia, seizures, myocarditis, weight gain, diabetes, metabolic syndrome, hypersalivation, fever, constipation, ileus, urinary incontinence, sweating. The neuropsychiatric side effects of clozapine are not discussed in this review.

Risk factors for violence among long-term psychiatric in-patients: a comparison between violent and non-violent patients

The problem of the prediction of violence in psychiatric patients has led to a proliferation of research over the last decade. This study focuses on enduring patient related risk factors of violence, and investigates which long-term patients in Weskoppies Hospital (a specialist psychiatric hospital) are the most likely to commit violent acts. Nursing statistics on violent incidents and other security breaches were collected for 262 long-term in-patients over a six month period (April - September 2007). The 41 patients who committed violent acts were compared to the 221 non-violent patients in terms of demographic and clinical variables, using two-way tables and Chi-Square or Fisher's Exact Tests. The prevalence of violence among the long-term patients was 16%. Fighting among patients was the most common form of violence (58%). The most significant risk factors of violence among the long-term patients are: A diagnosis of mental retardation; first hospital admission before the age of 40 years; total hospital stay >12 years; current accommodation in a closed ward; habitual verbal aggression; absence of disorganised behaviour; and being clinically evaluated as unsuitable for community placement. The findings will help to identify those long-term patients most at risk of violence. The subgroup of patients with mental retardation is responsible for a isproportionately large number of violent acts in the hospital. The risk lies not so much in their psychiatric symptoms, but more in their cognitive ability, coping skills and inappropriate admission circumstances. Efforts should be directed - at a provincial level - towards their community placement.

YPSP01-10 - Blood cholesterol and serum creatine kinase levels in violent psychiatric patients

ObjectivesIndividuals with severe mental illness display significantly higher rates of violence than general population. In previous reports, violent behavior was found associated with mean serum creatine kinase activity (MSCK) and with reduced levels of total blood cholesterol (LTBC). The aim of study was to assess an association between MSCK and LTBC in two groups of male violent forensic psychiatric offenders.MethodsThe study population was 256 offenders from the closed ward, of whom 214 were schizophrenia patients and 42 were patients with personality disorders. The prevalence of murderers was 21.7% in the schizophrenia group and 21.3% in the group with personality disorders.ResultsSchizophrenia patients had significantly higher MSCK and LDH levels then subjects with personality disorders. There were no significant between-groups differences on other biological parameters. No significant differences on these parameters were found between murderers and nonmurderers in both groups. In the overall sample, significant negative correlation was found between MSCK activity and total cholesterol levels. Similar correlation pattern was found in the schizophrenia group, but not in subjects with personality disorders.ConclusionsThe results show for the first time identifiable MSCK/LTBC pattern in violent schizophrenia patients but not in subjects with personality disorders. It is possible that different character of association between MSCK and LTBC in two groups of violent forensic psychiatric offenders (schizophrenia patients vs. subjects with personality disorders) reflects different biological origins of violent behavior. Further investigation of described MSCK/LTBC pattern in larger population of forensic and non-forensic, psychiatric and non-psychiatric subjects, is warranted.