Pharmacotherapy and aggressive behaviour in psychiat r ic pat ients

Abstract

Aggressive behaviour is an important problem in mental health care. Aggressive behaviour does not only affect staff and other patients, but also has a negative impact on the patient himself. Studies have shown that aggressive patients are admitted on psychiatric wards longer compared to non-aggressive patients. In psychiatric wards, several interventions are used to manage aggressive behaviour. In the Netherlands, seclusion has for decades been a highly common intervention to manage (imminent) aggression. During recent years, however, the use of seclusion has been heavily criticized. Pharmacotherapy is another commonly used intervention, which is viewed by many as a potential alternative for the management of aggressive behaviour. In this thesis, we focused on the evidence available from clinical trials for the pharmacological management of aggressive behaviour, and juxtaposed that against clinical practice. We systematically searched the literature for randomized controlled trials (RCTs) investigating the pharmacological management of aggression. For the acute situation, both benzodiazepines and antipsychotics appeared to be effective. Weak evidence for anti-aggressive effects of antipsychotics, antidepressants, anticonvulsants, and ?-adrenergic–blocking drugs in maintenance treatment was found. However, RCTs have important methodological limitations, including small study samples, short study durations and strict in-and exclusion criteria. We observed that patients enrolled in RCTs differ greatly from psychiatric patients that are seen in clinical practice for whom aggression is a severe problem. Only 30% to 46% of aggressive psychiatric patients as seen in clinical practice would be eligible to participate in a typical randomized controlled trial based on the most frequently applied exclusion criteria. The comparability of RCTs to clinical practice, and probably also the generalizability, therefore is judged to be low. We investigated medication patterns in relation to aggressive behaviour on psychiatric wards. Despite limited evidence for effectiveness of pharmacological treatment of aggressive behaviour, the conducted observational studies showed that aggressive patients in daily clinical practice use more medication compared to non-aggressive patients: new psychotropics were started more frequently and dosages were more likely to be increased. Furthermore, aggressive patients have an increased use of both psychotropic and somatic as-needed medication. For severely aggressive patients, compared to non-aggressive patients, as-needed medication was more frequently administered on the basis of the nurse’s initiative, instead of the patient’s own initiative. Interestingly, the perceived time of onset of effect of medication was significantly shorter in the perception of the patients compared to the nurses. We hypothesized that apart from pharmacological effects there also appears to be a placebo-effect. Overall, we concluded that difficult behaviour such as aggression, triggers reactive prescribing behaviour. With regard to treatment outcome, defined as a transfer to a more open (positive outcome) or a (more) closed ward (negative outcome), we found that aggressive patients using psychotropic polypharmacy were at highest risk for a negative treatment outcome. Considering this, together with the lack of evidence for the (pharmacological) management of aggressive behaviour we recommend to record aggressive behaviour during admission. Such registrations will facilitate the evaluation of the effects of (pharmacological) interventions aimed at reducing aggression. Furthermore analyses of patterns of aggression of individual patients may provide clues to improve treatment and management of aggressive behaviour.