Pharmacotherapy and aggressive behaviour in psychiat r ic pat ients

Aggressive behaviour is an important problem in mental health care. Aggressive behaviour does not only affect staff and other patients, but also has a negative impact on the patient himself. Studies have shown that aggressive patients are admitted on psychiatric wards longer compared to non-aggressive patients. In psychiatric wards, several interventions are used to manage aggressive behaviour. In the Netherlands, seclusion has for decades been a highly common intervention to manage (imminent) aggression. During recent years, however, the use of seclusion has been heavily criticized. Pharmacotherapy is another commonly used intervention, which is viewed by many as a potential alternative for the management of aggressive behaviour. In this thesis, we focused on the evidence available from clinical trials for the pharmacological management of aggressive behaviour, and juxtaposed that against clinical practice. We systematically searched the literature for randomized controlled trials (RCTs) investigating the pharmacological management of aggression. For the acute situation, both benzodiazepines and antipsychotics appeared to be effective. Weak evidence for anti-aggressive effects of antipsychotics, antidepressants, anticonvulsants, and ?-adrenergic–blocking drugs in maintenance treatment was found. However, RCTs have important methodological limitations, including small study samples, short study durations and strict in-and exclusion criteria. We observed that patients enrolled in RCTs differ greatly from psychiatric patients that are seen in clinical practice for whom aggression is a severe problem. Only 30% to 46% of aggressive psychiatric patients as seen in clinical practice would be eligible to participate in a typical randomized controlled trial based on the most frequently applied exclusion criteria. The comparability of RCTs to clinical practice, and probably also the generalizability, therefore is judged to be low. We investigated medication patterns in relation to aggressive behaviour on psychiatric wards. Despite limited evidence for effectiveness of pharmacological treatment of aggressive behaviour, the conducted observational studies showed that aggressive patients in daily clinical practice use more medication compared to non-aggressive patients: new psychotropics were started more frequently and dosages were more likely to be increased. Furthermore, aggressive patients have an increased use of both psychotropic and somatic as-needed medication. For severely aggressive patients, compared to non-aggressive patients, as-needed medication was more frequently administered on the basis of the nurse’s initiative, instead of the patient’s own initiative. Interestingly, the perceived time of onset of effect of medication was significantly shorter in the perception of the patients compared to the nurses. We hypothesized that apart from pharmacological effects there also appears to be a placebo-effect. Overall, we concluded that difficult behaviour such as aggression, triggers reactive prescribing behaviour. With regard to treatment outcome, defined as a transfer to a more open (positive outcome) or a (more) closed ward (negative outcome), we found that aggressive patients using psychotropic polypharmacy were at highest risk for a negative treatment outcome. Considering this, together with the lack of evidence for the (pharmacological) management of aggressive behaviour we recommend to record aggressive behaviour during admission. Such registrations will facilitate the evaluation of the effects of (pharmacological) interventions aimed at reducing aggression. Furthermore analyses of patterns of aggression of individual patients may provide clues to improve treatment and management of aggressive behaviour

Aggression of Psychiatric Patients Associated with the Use of As-needed Medication

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Aggression and as-needed medication: patients’ and nurses’ beliefs

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Licht verstandelijke beperking in de DSM-5: Het belang van adaptief functioneren: Ontwikkeling en onderzoek van de adaptieve vragenlijst verstandelijke beperking

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De farmacologische behandeling van agressie

Item does not contain fulltextAgressie is een veelvoorkomend probleem binnen de psychiatrie. In de dagelijkse praktijk is farmacotherapie een vaak toegepaste interventie. In dit artikel wordt de wetenschappelijke onderbouwing van de farmacotherapeutische benadering van agressie besproken. Voor de acute behandeling van agressie lijken zowel benzodiazepines als antipsychotica werkzaam. Er valt, methodologisch gezien, veel aan te merken op het klinisch onderzoek naar acute behandeling van agressie: kleine groepen, korte studieduur en vaak strenge in- en exclusiecriteria. Deze beperkingen gelden ook voor de trials die de werkzaamheid van de langdurende medicamenteuze behandeling van agressie onderzoeken. Veel verschillende middelen zijn onderzocht op werkzaamheid voor de langdurende medicamenteuze behandeling van agressie, waarbij de evidence matig blijkt te zijn

Association between aggression and medication changes

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Trials Assessing Parmacotherapeutic Management of Aggression in Psychiatric Patients: Comparability with Clinical Practice

Introduction: In a previous review of randomized controlled trials (RCTs) on the pharmacotherapeutic management of aggression, it was shown that there is only weak evidence of effectiveness. In the present study we aim to determine comparability of patients included in these RCTs and patients of psychiatric long-stay wards. Methods: Exclusion criteria that were used in at least 20% of the RCTs were applied to a sample of aggressive inpatients from clinical practice, in order to find what proportion of these patients would be eligible to participate in the reviewed, high quality RCTs. Results: Only 30% of aggressive psychiatric patients as seen in clinical practice would be eligible to participate in a typical randomized controlled trial based on the most frequently applied exclusion criteria. Discussion: The low comparability of patients included in RCTs with those seen in clinical practice may decrease the generalizability of the findings form RCTs to clinical practice

The Correspondence Between the Staff Observation Aggression Scale-Revised and Two Other Indicators for Aggressive Incidents

Contains fulltext : 77300.pdf (publisher's version ) (Closed access)Previous research has shown good psychometric properties of the Staff Observation Aggression Scale-Revised (SOAS-R). However, it has never been investigated what proportion of aggressive incidents occurring in facilities is documented with the SOAS-R. Furthermore, if incidents are underreported, the consequences for the categorization of clients into aggressive and nonaggressive subgroups based on the SOAS-R are unknown. To examine this, in four inpatient psychiatric facilities for adults with mild intellectual disabilities, aggressive incidents were documented with the SOAS-R and two other indicators of aggressive incidents: the daily staff reports on clients' behavior and reports on of the use of restraints. Less than half of the incidents documented with the staff and restraint reports were also documented with the SOAS-R. On the other way around, however, it was also found that a substantial proportion of incidents reported on SOAS-R forms were not documented in the daily staff reports, which points to a more general problem of underreporting aggressive behavior. Apart from that, categorization of clients into an aggressive and a nonaggressive subgroup with SOAS-R data collected during 1 month or longer corresponded largely with the categorization based on both other indicators. This study showed that underreporting of aggressive incidents is likely to occur with the SOAS-R, making the instrument less suitable to assess absolute aggression incidence in facilities. Still, the SOAS-R seems a good instrument to categorize clients into aggressive and nonaggressive subgroups. Ways to improve the compliance of the ward team to document all aggressive incidents are addressed in the Discussion section of this article

The ADaptive Ability Performance Test (ADAPT): A new instrument for measuring adaptive skills in people with intellectual disabilities and borderline intellectual functioning

Contains fulltext : 232097.pdf (Publisher’s version ) (Open Access)Background: Since the DSM‐5, adaptive functioning has taken a prominent place in the classification of intellectual disability (ID). The ADAPT was developed to assess adaptive skills in individuals with ID. Method: A total of 2,081 ADAPTs from clients with suspected ID or borderline intellectual functioning and 129 ADAPTs from people from the general population (non‐ID) were collected, along with background characteristics. Results: Internal consistency of the ADAPT was high (α = 0.98). ADAPT scores were positively associated with IQ, educational level and level of independent living. Furthermore, individuals without ID scored significantly higher than the clients on all of the 65 ADAPT items. Reference values were established for different IQ groups and living situations. Conclusion: Results suggest that the ADAPT is a valid instrument for measuring adaptive skills in individuals with ID. The reference values may be used for the purpose of estimating the level of ID and the needed intensity of support.10 p