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Strategies To De-escalate Aggressive Behavior in Psychiatric Patients
Comparative Effectiveness Reviews, No. 180
Investigators: Bradley N Gaynes, MD, MPH, Carrie Brown, MD, MPH, Linda J Lux, MPA, Kimberly Brownley, PhD, Richard Van Dorn, PhD, MSW, Mark Edlund, MD, PhD, Emmanuel Coker-Schwimmer, MPH, Theodore Zarzar, MD, Brian Sheitman, MD, Rachel Palmieri Weber, PhD, Meera Viswanathan, PhD, and Kathleen N Lohr, PhD.
Author Information and AffiliationsStructured Abstract
Objective:
To compare the effectiveness of strategies to prevent and de-escalate aggressive behaviors in psychiatric patients in acute care settings, including interventions aimed specifically at reducing use of seclusion and restraint.
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 method:
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.
Results:
Evidence was limited for benefits and, especially, for harms; information about modifying characteristics was completely absent. No key questions had data supporting SOE grades better than low, indicating limited confidence that the estimate of effect lies close to the true effect for these outcomes. The available evidence comprised primarily pre/post studies whose inherent high risk of bias precludes drawing inferences of causality. Of the 11 trials eligible for SOE assessment, all but 1 had medium (or high) risk of bias. Risk assessment had low SOE for decreasing subsequent aggression and reducing use of seclusion and restraint, but only when applied in a preventive manner (e.g., as unit-wide programs). SOE for all other interventions, whether aimed at preventing aggression or de-escalating aggressive behavior, was insufficient.
Conclusions:
Given the ethical imperative for treating all patients with dignity, the clinical mandate of finding evidence-based solutions to these mental health challenges, and the legal liability associated with failure to assess and manage violence risk across the treatment continuum, the need for evidence to guide decisionmaking for de-escalating aggressive behavior is critical. The available evidence about relevant strategies is very limited. Only risk assessment decreased subsequent aggression or reduced use of seclusion and restraint (low SOE). Evidence for de-escalating aggressive behavior is even more limited. More research is needed to guide clinicians, administrators, and policymakers on how to best prevent and de-escalate aggressive behavior in acute care settings.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Appendix A Literature Search Strategies and Yields
- Appendix B Excluded Studies
- Appendix C Risk of Bias Ratings
- Appendix D Strength of Evidence Grade Tables
- Appendix E Detailed Study Characteristics Tables
- Appendix F Summary of Findings for Pre-Post Studies, Not Rated for Risk of Bias
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1. Contract No. 290-2015-00011-I. Prepared by: RTI-UNC Evidence-based Practice Center, Research Triangle Park, NC
Suggested citation:
Gaynes BN, Brown C, Lux LJ, Brownley K, Van Dorn R, Edlund M, Coker-Schwimmer E, Zarzar T, Sheitman B, Palmieri Weber R, Viswanathan M, Lohr KN. Strategies To De-escalate Aggressive Behavior in Psychiatric Patients. Comparative Effectiveness Review No. 180. (Prepared by the RTI-UNC Evidence-based Practice Center under Contract No. 290-2015-00011-I) AHRQ Publication No. 16-EHC032EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the RTI-UNC Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00011-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality-enhancement tools, or reimbursement or coverage policies may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at: www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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