Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, Coker-Schwimmer E, Weber RP, Sheitman B, Zarzar T, Viswanathan M, Lohr KN. Psychiatr. Serv. 2017; 68(8): 819-831.
Affiliation
Dr. Gaynes, Dr. Brown, Dr. Brownley, and Dr. Zarzar are with the Department of Psychiatry, University of North Carolina (UNC) at Chapel Hill School of Medicine, Chapel Hill. Dr. Brown is also with the Center for Excellence in Community Mental Health, and Mr. Coker-Schwimmer and Dr. Weber are with the Sheps Center for Health Services Research, UNC at Chapel Hill. Ms. Lux, Dr. Van Dorn, Dr. Edlund, Dr. Viswanathan, and Dr. Lohr are with Research Triangle Institute International, Research Triangle Park, Durham, North Carolina. Dr. Sheitman is with the Department of Psychiatry, UNC Health Care System, Chapel Hill.
OBJECTIVE: The project goal was to compare the effectiveness of strategies to prevent and de-escalate aggressive behaviors among psychiatric patients in acute care settings, including interventions for reducing use of seclusion and restraint.
METHODS: Relevant databases were systematically reviewed for comparative studies of violence prevention and de-escalation strategies involving adult psychiatric patients in acute care settings. Studies (trials and cohort studies) were required to report on aggression or seclusion or restraint outcomes. Both risk of bias, an indicator of quality of individual studies, and strength of evidence (SOE) for each outcome were independently assessed by two study personnel.
RESULTS: Seventeen primary studies met inclusion criteria. Evidence was limited for benefits and harms; information about characteristics that might modify the interventions' effectiveness, such as race or ethnicity, was especially limited. All but one study had a medium or high risk of bias and thus presented worrisome limitations. For prevention, risk assessment reduced both aggression and use of seclusion and restraint (low SOE), and multimodal interventions reduced the use of seclusion and restraint (low SOE). SOE for all other interventions, whether aimed at preventing or de-escalating aggression, and for modifying characteristics was insufficient.
CONCLUSIONS: Available evidence about strategies for preventing and de-escalating aggressive behavior among psychiatric patients is very limited. Two preventive strategies, risk assessment and multimodal interventions consistent with the Six Core Strategies principles, may effectively lower aggressive behavior and use of seclusion and restraint, but more research is needed on how best to prevent and de-escalate aggressive behavior in acute care settings.