The causes of aggression and violence in psychiatric settings: new systematic review

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Despite what you read in the tabloid press, the vast majority of people with mental health problems are not violent. However, when violence does occur in hospitals, it’s important that healthcare professionals know how to manage the situation.

This new systematic review has been conducted by a team of Italian researchers who searched a range of databases for studies on aggression and violence in psychiatric inpatient settings, going back to 1990. They excluded studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation.

They list the variables most frequently associated with violence and aggression in the 66 studies they found:

  • the existence of previous episodes
  • the presence of impulsiveness/hostility
  • a longer period of hospitalisation
  • non-voluntary admission
  • aggressor and victim of the same gender

They found weaker evidence for the following characteristics being generally associated with violence and aggression:

  • alcohol/drug misuse
  • a diagnosis of psychosis
  • a younger age and the risk of suicide

12 studies looked specifically at patients with psychosis and these found that the following factors were most frequently associated with aggression and violence:

  • alcohol/drug misuse
  • hostility
  • paranoid thoughts and acute psychosis

The researchers concluded that:

Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.

Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: a systematic review. Psychiatry Res. 2011 Aug 30;189(1):10-20. Epub 2011 Jan 13. [PubMed abstract]

There have been many guidelines and reviews dealing with the management of violence in psychiatric settings. Two key resources are listed below although it’s worth noting that both of these were published in 2005 and are therefore due to be updated in the near future:

Davison, SE. The management of violence in general psychiatry (PDF). Advances in Psychiatric Treatment. 2005, 11:362-370.

Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments (PDF). NICE, Feb 2005.

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Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland!

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