Strategies to De-escalate Aggressive Behavior (DAB) in Psychiatric Patients

Project Summary Title and Description

Title
Strategies to De-escalate Aggressive Behavior (DAB) in Psychiatric Patients
Description
This small systematic review addresses interventions to prevent or de-escalate aggressive behavior and to reduce use of seclusion and restraint for aggressive behaviors. We focus on studies in acute health care settings, as to our knowledge no such review has been done using data from such settings.
Attribution
N/A
Authors of Report
N/A
Methodology description
Data Sources: We searched MEDLINE®, Embase®, the Cochrane Library, Academic Search Premier, PsycINFO, and CINAHL from January 1, 1991, through February 3, 2016. We manually searched reference lists of pertinent reviews, included trials, and background articles to identify relevant citations that our searches might have missed. Eligible studies included randomized controlled trials (RCTs), cluster randomized trials (CRTs), and observational and noncontrolled studies with sample sizes greater than 100. Eligible studies were limited to acute care settings and adult patients with psychiatric disorders or severe psychiatric symptomatology (excluding dementia); they had to report on aggression or seclusion and restraint outcomes. Review Methods: Two investigators independently selected, extracted data from, and rated risk of bias of studies. Risk of bias and strength of evidence (SOE) were assessed only for controlled studies. Twenty-nine primary studies (from 31 articles) met inclusion criteria. Of these, 11 were controlled trials that provided eligible data for SOE grades. Only 4 of these trials took place in the United States. We grouped studies as follows: (1) staff training interventions, (2) risk assessment interventions, (3) multimodal interventions, (4) environmental interventions (including group psychotherapeutic options), and (5) medication protocols versus other medication protocols or alternative strategies. We organized results by three Key Questions; these covered benefits, harms, and potential modifying characteristics of these strategies.
PROSPERO
N/A
DOI
10.26300/ek2z-xn33
Notes
All of the report's study data were entered retrospectively to SRDR, via direct file uploading as four Word documents: 1) Appendix E (detailed characteristics for all included studies, regardless of design); 2) Primary benefits (KQ 1) and harms (KQ 2) outcome results data for all controlled studies; 3) Appendix C (detailed risk of bias ratings for all controlled studies); and 4) Appendix F (Primary benefits and harms results data for all single-group pre/post studies). For both Key Questions 1 and 2, the uploaded data include all four Word documents described above. No studies provided information relevant to Key Question 3. Publication of the final report and PMID are pending.
Funding Source
AHRQ

Key Questions

1. KQ 1: Regarding benefits for adult psychiatric patients in acute care settings: a. For those without active aggression, what are the comparative benefits of strategies to prevent aggressive behavior? b. For those with active aggression, what are the comparative benefits of strategies, including seclusion and restraints, to de-escalate aggressive behavior? c. For those with active aggression, what are the comparative benefits of strategies to reduce the use of seclusion and restraints?
2. KQ 2: Regarding harms for adult psychiatric patients in acute care settings: a. For those without active aggression, what are the comparative harms of strategies to prevent aggressive behavior? b. For those with active aggression, what are the comparative harms of strategies, including seclusion and restraints, to de-escalate aggressive behavior? c. For those with active aggression, what are the comparative harms of strategies to reduce the use of seclusion and restraints?
3. KQ 3: What characteristics [of patients (including age, gender, diagnosis, motivation to receive treatment), of intervention components, or of acute care settings] modify the benefits or harms of interventions for psychiatric patients at risk of, or presenting with, active aggression?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study.2010
Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial.2008
Decreasing the use of restraint and seclusion among psychiatric inpatients.2007
Intramuscular flunitrazepam versus intramuscular haloperidol in the emergency treatment of aggressive psychotic behavior.1999
Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment.2011
P.R.N. (As-needed) orders and exposure of psychiatric inpatients to unnecessary psychotropic medications.2003
Effects of a psychiatric intensive care unit in an acute psychiatric department.2006
Improving alcohol withdrawal outcomes in acute care.2014
Effects of a recovery-oriented cognitive therapy training program on inpatient staff attitudes and incidents of seclusion and restraint.
Early pharmacological treatment of delirium may reduce physical restraint use: a retrospective study.2014
Contemporary management of aggression in an inner city mental health service.2007
Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit.2007
Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses.2006
Association between seclusion and restraint and patient-related violence.2004
A program to reduce use of physical restraint in psychiatric inpatient facilities.2004
Reduction of episodes of seclusion and restraint in a psychiatric emergency service.2004
Datapoints: use of restraint before and after implementation of the new HCFA rules.2002
Reducing seclusion through involuntary medication: a randomized clinical trial.2013
Effectiveness and efficiency of cognitive-behavioral group therapy for inpatients: 4-year follow-up study.2008
Removal from stimuli for crisis intervention: using least restrictive methods to improve the quality of patient care.-- Not Found --
Prevention and management of aggression training and violent incidents on U.K. Acute psychiatric wards.
Case study evaluating the impact of de-escalation and physical intervention training.2010
A double-blind study of lorazepam versus the combination of haloperidol and lorazepam in managing agitation.-- Not Found --
Oral risperidone, olanzapine and quetiapine versus haloperidol in psychotic agitation.2008
Staff training decreases use of seclusion and restraint in an acute psychiatric hospital.1999
A replication study of the City nurse intervention: reducing conflict and containment on three acute psychiatric wards.2008
Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol.
Cost-effective communication skills training for state hospital employees.1995
Use of antipsychotics and benzodiazepines in patients with psychiatric emergencies: results of an observational trial.2008

Downloadable Data Content

Files
  • XLSX Project Data