Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature.

INTRODUCTION: On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards. METHOD: In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included. RESULTS: The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy. CONCLUSION: Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

The incidence and outcome of subclinical psychotic experiences in the general population.

OBJECTIVES: To examine the incidence and 2-year stability and outcome of subclinical psychotic experiences in the general population. DESIGN: The Netherlands Mental Health Survey and Incidence Study (NEMESIS), a longitudinal general population study. METHODS: A representative population sample of 7,076 participants was interviewed with the composite international diagnostic interview at baseline, 1 year later at T(1) and again 2 years later at T(2). A sample of individuals was identified who had onset of a new, broadly defined psychotic experience between baseline and T(1) (N = 79; incidence = 2%). Stability and outcome of these incident positive psychotic experiences was reassessed by interview at T(2), at which 25 individuals had a CIDI rating of broadly defined psychotic experience (subclinical outcome) and 11 individuals had psychotic experiences with functional impairment and need for care (clinical outcome). RESULTS: The majority of individuals with an incident psychotic experience did not display persistence of the experience. Only 8% of individuals with a T1 incident psychotic experience had evidence of a T2 subclinical outcome, and only 8% had evidence of a T2 clinical outcome. The emotional context and the number of the T1 incident psychotic experiences were strong modifiers of predictive power for the clinical outcome, but not (or to a much lesser extent) for the subclinical outcome. CONCLUSIONS: The incidence of positive psychotic experiences in the general population is around 100 times greater than traditional estimates of incidence of psychotic disorder such as schizophrenia. The far most likely outcome for these experiences is discontinuity. For the small proportion who display continuity, there is an equally large likelihood of subclinical and clinical 2-year outcomes. Emotional appraisal and degree of intrusiveness of psychotic experiences are important modifiers not for continuity per se but for clinical outcome specifically.