Behavioral Strategies to Mitigate Violent Behavior Among Inpatients: A Literature Review

TO THE EDITOR: Research has shown that although most people with mental illness are not violent, having a mental illness increases a person’s risk of violent behavior (1). However, a recent study estimated that anywhere from 8% to 44% of psychiatric inpatients engage in violence (2). Several studies have focused on pharmacotherapy strategies, such as valproic acid and clozapine, to reduce aggressive or violent behavior (3). However, hospital administrators could benefit from evidence-based suggestions to guide the development of violence risk reduction programs to complement medications for high-risk and acutely ill psychiatric patients on inpatient units.

To explore evidence for the effectiveness of behavioral interventions to reduce violence among individuals with a history of violence and severe mental illness, we conducted a systematic literature review using PubMed and MEDLINE. We included English-language publications about adults hospitalized or recently discharged from an inpatient psychiatric unit or state forensic hospital that emphasized behavioral strategies targeting violent behavior. Titles and abstracts were examined to determine whether publications met inclusion and exclusion criteria. We also searched the reference lists of identified articles for additional publications. We supplemented our literature review by interviewing forensic psychiatry experts in violence risk assessment.

Our search identified 13 articles. Four of the 13 (31%) focused exclusively on inpatient psychiatry. [A table summarizing the 13 articles is available in an online supplement to this letter.] Although several authors recommended techniques to reduce violence, such as containment strategies (for example, locked units, verbal redirection, and behavioral contracts) or behavioral methods involving positive or negative reinforcement, only two randomized controlled trials (RCTs) examined behavioral interventions to reduce violence among psychotic patients (4,5). Both of the RCT interventions were based on principles of cognitive-behavioral therapy and showed efficacy; however, both studies had multiple limitations, including small samples, selection bias, and heterogeneous samples, which could limit the applicability of research findings, and neither study controlled for personality factors and potential treatment contamination at study sites. In addition, the 13 studies provided limited guidance on whether certain behavioral strategies may be more effective for patients with specific psychiatric diagnoses.

Even though the findings are limited, both the publications and the expert consultants emphasized the importance of using a formal violence risk assessment to develop an effective plan to manage violent behavior among inpatients with severe mental illness. Both the publications and the experts also highlighted the importance of medication adherence and of reducing comorbid substance abuse.

Our review revealed a dearth of high-quality intervention studies examining the efficacy of behavioral techniques to reduce violence among psychiatric inpatients. The studies also provided limited information on whether certain behavioral strategies may be more effective for patients with a specific diagnosis or etiology of mental illness. Large randomized trials are desperately needed to compare the effectiveness of various behavioral techniques. Given the lack of evidence of efficacy and the prevalence of violence on inpatient psychiatry units—even with medication management—these RCTs could help guide hospital administrators in developing programs to better serve this patient population and protect them and the staff serving them from violence.