Safe Spaces: Mitigating Potential Aggression in Acute Care Psychiatry

Although at times restraint and seclusion remain necessary to protect patients and staff, the risk to both groups must be carefully weighed against the benefit in any given case. Staff and patients alike are at risk of injury during such interventions.

Assessing a patient’s risk of becoming violent affords the treatment team the opportunity to mitigate risk factors and to prevent violence, thereby improving patient and staff well-being. Diagnostic categories associated with aggression include bipolar disorder (e.g., manic phase), psychotic disorders (especially symptoms of paranoia and/or referential thinking), substance use disorders (especially during intoxication or withdrawal), and cognitive impairment (e.g., disinhibition). As previously noted, however, aggression should not automatically be assumed on the basis of diagnoses, and aggression may be present independent of diagnoses.

Symptoms rarely occur in a vacuum, and intersecting clinical features increase risk additively. For example, a study of 216 patients with bipolar disorder (23) experiencing their first psychotic episode indicated significant increases in risk associated with recent suicide attempt, alcohol use disorder, learning disabilities, and initial manic episode. Interestingly, the study did not demonstrate significant association with age, gender, or personality disorder.

Precipitating factors for violence include unsatisfactory patient-staff interactions, such as limit setting, real or perceived power struggles, and a patient being informed of an involuntary commitment. Peer-to-peer disputes are also frequent triggers. Mood or psychotic symptoms, for example, can cause or contribute to negative interactions or cause a patient to misinterpret a neutral exchange. Demographic and historical characteristics associated with higher risk include male gender, younger age, history of trauma, and history of aggression in the treatment setting (24).

Use of validated tools, such as the Dynamic Appraisal of Situational Aggression (DASA) and the Broset Violence Checklist, may reduce incidence of aggression, and by extension, reduce the use of restrictive interventions (25–27). Such practices provide clinicians with the capacity to influence whether a person becomes aggressive. Knowledge of these tools can increase staff members’ sense of control and safety and may lead to lower rates of burnout and turnover.

A large-scale review (28) of available literature aimed to create a glossary of techniques from interventions and quality improvement projects aimed at reducing restrictive practices, such as restraint and seclusion, chemical sedation, and constant observation. The authors classified the components of each intervention and explored the evidence regarding clinical efficacy and cost-effectiveness. Although Baker et al. (28) identified 16 clusters of techniques, they noted that four clusters were present in more than two-thirds of the interventions. Those clusters were “goals and planning” (staff setting goals, such as reducing occurrence of a type of restrictive intervention and implementing a plan to meet the goal); “shaping knowledge” (providing education about the antecedents of restrictive interventions and the performance of specific techniques); identifying “antecedents” (anticipating and attempting to mitigate factors that could result in patient distress or agitation), and providing “feedback and monitoring” (analyzing practices and outcomes).

The Baker et al. (28) review identified some promising findings and underscored the need for more rigorous and structured research in this area. For example, changes to the physical environment, such as reducing noise; adding comfort objects, such as weighted blankets; and creating more private spaces for people to engage in de-escalation, were used in a number of interventions associated with decreases in restrictive interventions. Other commonly used and potentially effective techniques included instructing staff on how to perform interventions, conducting problem solving, and providing feedback on outcomes (28).

Studies have also been done on the effects of music in acute inpatient settings. One such study (29), conducted across 3 months, with the prior 3 months serving as a control, showed promising findings of reduction in seclusion, assault, and as-needed medication administrations. In this relatively affordable intervention (less than $400), patients were given wireless headphones and were able to listen to their choice of a musical genre for 30 minutes (29). Limitations of the study included a low rate of survey response from the patients. The authors also noted an incidental finding of a modestly reduced length of stay, and they recommended further research on this finding. Further study of this intervention seems warranted and achievable. Of note, this intervention was distinct from formalized music therapy, another nonpharmacologic intervention.

A Cochrane review of standardized music therapy for patients with schizophrenia spectrum disorders (30) identified low-to-moderate evidence for positive effects of music therapy given in addition to standard care. Data specifically examining patient behavior indicated that, in the medium-term trials (3–4 months), patients could benefit significantly. A comparison study on an inpatient unit, before and after implementation of music therapy and specifically studying aggressive or disruptive behavior, may prove useful.

The aforementioned studies have primarily been conducted in inpatient psychiatric settings, and there is need for further study in ED settings. One group of authors (31) described “an unambiguous gap in the literature regarding the efficacy of interventions for ABD [acute behavioral disturbance] management in EDs [emergency departments].”

Overall, the literature clearly indicates the potential for nonpharmacologic interventions to reduce severe agitation and aggression without the use of restrictive interventions. Further research is needed to systematically evaluate specific intervention programs and methods. Ideally, these interventions should be tested separately in general ED, psychiatric ED, and inpatient hospital settings.

Pharmacological considerations vary depending on the patient’s age, etiology of symptoms, and individual factors, such as prior response to medications. For example, in a patient with a known history of severe dystonic reactions, first-generation antipsychotics may not be the clinician’s first choice. Certain underlying conditions, such as arrhythmias, may affect medication choice, particularly if repeated administrations are needed. In short, medication and dosage choices should be tailored to the individual whenever possible.

Furthermore, whereas interventions should target the underlying cause of agitation, and there may be overlap between long- and short-term management, this discussion focuses on the management of acute agitation. Long-term approaches differ and are beyond the scope of this article.

Project Best Practices in the Evaluation and Treatment of Agitation (BETA) was the product of a 2012 collaboration of five interdisciplinary work groups led by the American Association of Emergency Psychiatry. As described by Roppolo et al. (32), the BETA groups defined five principles for the management of acute agitation. When possible, the first approach to managing agitation should be verbal de-escalation. Pharmacotherapy aimed at treating the underlying cause of the agitation should be started. Similarly, each patient should receive an appropriate medical evaluation to recognize potential organic causes, such as electrolyte abnormalities, toxidromes, and head injuries. Identification of such phenomena is essential to the safety of patients as well as staff. A psychiatric evaluation should also be done as soon as feasible in order to try to understand the underlying cause or illness spectrum and to help guide thinking regarding pharmacotherapy or nonpharmacological interventions that may be useful. For example, a patient with acute mania who is willing to take oral medications may benefit from prompt initiation of lithium or valproic acid, or even benzodiazepines. Finally, the authors indicated that restraint and seclusion should be a last resort, and if needed, optimally should be done by a team of five trained staff.

The Project BETA team assembled a list of medications commonly used to manage agitation and the risks associated with each; this list has been updated by Roppolo et al. (32). Some key points follow:

Benzodiazepines should be avoided among patients with suspected or confirmed delirium caused by an underlying medical condition and among patients who have taken a central nervous system depressant. For patients with psychosis or undifferentiated aggression, benzodiazepines can be helpful. These agents are typically required for the treatment of alcohol or benzodiazepine withdrawal.

The term “chemical restraint” is often used when medications are given in response to agitation. However, the intent of the administration must be considered. The Centers for Medicare and Medicaid Services define chemical restraint as “a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition” (33). For psychosis or mania that results in aggression, however, administration of an antipsychotic may be the first step in treating the underlying cause as well as the symptom (agitation).

Indeed, medications given for acute agitation often overlap with those routinely used to treat the underlying psychiatric conditions. For example, administration of 5–10 mg of olanzapine to a patient for agitation caused by acute mania or psychosis likely does not meet the definition of chemical restraint. In this context, the medication is not intended to restrict the patient and may in fact help the patient stabilize and reintegrate to a less restrictive setting. Similarly, patients experiencing psychiatric emergencies are entitled to safety and relief of their symptoms. Zun et al. (34) eloquently summarized this point: “The appropriate goal of treatment is to calm the patient, and this treatment should be tailored to the underlying cause of the agitation.”