Background
Methods
Literature search
Inclusion criteria and study selection
Quality assessment
Barlow
|
Carr
|
Compton
|
Flood
|
Jaffe
|
Legris
|
Mellesdal
|
Peiró
|
Putkonen
|
Steinert
| |
---|---|---|---|---|---|---|---|---|---|---|
2000
|
2008
|
2006
|
2008
|
2009
|
1999
|
2003
|
2004
|
2013
|
1999
| |
1. Are the study objectives relevant and well defined?
| Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
2. Are the methods of the study appropriate to realize the study objectives?
| Yes | Yes | Retrospective study based on the reviews of clinical charts | The method for estimating costs is based on interviews with key personnel (probability of recall bias) | Retrospective study based on review of clinical charts | Retrospective study based on review of clinical charts | Yes | Retrospective study based on review of clinical charts | Yes | Retrospective study based on review of clinical charts |
3. Were the data collected with sufficient quality (review of patient’s chart, patient interview, missing data…)?
| Yes | Yes | Yes | Yes | Yes | Yes. Some scales had low rates of inter-rater agreement and could not be used in the analysis | Yes | No. High rates of missing data are reported on sociodemographic and clinical variables | Yes | Yes |
4. Was the analysis strategy adequate taking into account the study objectives and methods (statistical methods of analysis well-designed and executed, data adjusted for confounding variables,…)?
| The analysis strategy is adequate but the analyses are not adjusted for confounding variables | Yes | Yes | Yes | Yes | Yes | Yes | The analysis strategy is adequate but the analysis did not take into account missing data and could be biased. | Yes | Yes |
5. Is the presentation of results complete and of good quality (all objectives are addressed, raw and adjusted results are presented, information on variability is presented (i.e., SD, SE or confidence intervals), …)?
| All the objectives are addressed but only raw results are presented. Lacks information on variability | Yes | Yes | Yes | Absence of possible confounding issues in the analyses (e.g., relevant physical-mental comorbidities) | Yes | Yes | 28% of data is missing for important variables (age, length of illness) | Yes | Yes |
6. Are the results discussed in the context of previously published studies?
| Yes | Yes | Yes | The results are compared only to those previously obtained in USA | Yes | Yes | Yes | Yes | Yes | Yes |
7. Are the limitations of the study discussed and the results discussed taking into account these limitations?
| The limitations of the study are not adequately discussed | Yes | Yes | Yes | Yes | The limitations of the study are not discussed or taken into account when drawing conclusions | Yes | Yes | Yes | Yes |
8. Are the conclusions of the study supported by the results?
| Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
QUALITY
| Low-Moderate | High | High | Moderate-High | Low-Moderate | Moderate | High | Low-moderate | High | High |
Data abstraction
Results
Literature search and study selection
Study quality
Study characteristics
Paper
|
Country and period of study (year)
|
Design
|
Setting
|
Diagnosis (%)
|
Mean age
|
% of men (N)
|
Total sample size
|
Agitated sample size
|
---|---|---|---|---|---|---|---|---|
Barlow K et al. 2000 [18] | Australia, 18 months (1996–1997) | Prospective observational study | 3 acute psychiatric units and 1 subacute unit | Schizophrenia (21.3) | 37 (range: 13–97) | 52.2 (663) | 1,096 | 174 |
Psychotic disorder (14.0) | ||||||||
Bipolar affective (7.2) | ||||||||
Adjustment disorder (18.5) | ||||||||
Depression (18.5) | ||||||||
Personality disorder (3.0) | ||||||||
Anxiety disorder (5.0) | ||||||||
Other (12.4) | ||||||||
Carr VJ et al. 2008 [19] | Australia, 12 months (n.a.) | Prospective observational study | 11 mental health units (8 general psychiatric units, 2 high-dependency units and 1 specialized unit) | Drug and alcohol disorder (44.6) | 37.1 (SD 14.4) | 55.0 (weighted percentage) (2,210) | 3,242 | 849 (Aggressive incidents: 363; Less serious aggressive incidents: 486) |
Schizophrenia or related disorder (38.0) | ||||||||
Depression (25.3) | ||||||||
Personality disorder (18.9) | ||||||||
Adjustment disorder (14.2) | ||||||||
Bipolar disorder (14.0) | ||||||||
Compton MT et al. 2006 [20] | USA, 7 months (2003–2004) | Retrospective database cohort study | 2 inpatient psychiatric units (a crisis stabilization unit (CSU) and a longer-stay milieu unit (LSMU)) | Schizophrenia or other psychotic disorders (65.0) | LSMU: 37.4 (SD 12.6) CSU: 40.8 (SD 11.8) | LSMU: 40.7 (60), CSU: 48.9 (43) | LSMU: 146; CSU: 88 | n.a. |
Unipolar depression (15.8) | ||||||||
Bipolar disorder (12.4) | ||||||||
Anxiety disorders (0.9) | ||||||||
Substance-related disorders (4.3) | ||||||||
Other (1.3) | ||||||||
Flood C et al. 2008 [13] | United Kingdom, 1 year (2005) | Epidemiological, cross-sectional study | 136 adult acute inpatient psychiatric wards | n.a. | n.a. | n.a. | ||
Jaffe A et al. 2009 [21] | USA, 6 months (2005) | Retrospective database cohort study | 17 state-run adult civil facilities | Schizophrenia (41.4) | 41.5 (SD 13.6) | 63 (257) | 1,673 | 415 |
Schizoaffective (31.9) | ||||||||
Bipolar (10.4) | ||||||||
Depression (5.7) | ||||||||
Other (10.6) | ||||||||
Legris J et al. 1999[22] | Canada, n.a. (n.a.) | Retrospective database cohort study | Urban general hospital with two adult psychiatric wards and a special care unit | Schizophrenia (54) | 41 (SD 16) | 41 (35) | 85 | 41 |
Bipolar or schizoaffective (23) | ||||||||
Psychotic depression (12) | ||||||||
Other (11) | ||||||||
Mellesdal L 2003 [23] | Norway, 3 years (1997–2000) | Prospective observational study | Psychiatric acute ward | Affective disorders (34.7) | 41.1 (SD 15.5) | 51 (476) | 934 | 98 |
Schizophrenic disorders (19.2) | ||||||||
Alcohol/substance abuse (10.4) | ||||||||
Personality disorders (9.4) | ||||||||
Neurotic/stress-related somatoform disorders (7.1) | ||||||||
Other (19.2) | ||||||||
Peiró S et al. 2004 [24] | Spain, 6 months (1999–2001) | Retrospective database cohort study | Acute inpatient units from 8 general hospitals and psychiatric hospitals | Schizophrenic disorders (64.0) | 39.2 (SD 14.5) | 44.8 (56) | 200 | 175 |
Affective psychosis (22.0) | ||||||||
Paranoid states (4.5) | ||||||||
Other non-organic psychosis (8.5) | ||||||||
Transient organic psychosis (1.0) | ||||||||
Putkonen A et al. 2013 [26] | Finland, 6 months (2009) | Cluster-randomized controlled trial | Four high-security wards for men with psychotic illness. | Psychotic illness with a history of severe violence (100) | Control group: 40.0 (SD 10.6) Intervention group: 38.4 (SD 10.6) | 100 | Control group: 930–1,003 patient-days per month (38 beds) Intervention group: 1,306-1,400 patient-days per month (50 beds) | n.a. |
Steinert T et al. 1999 [25] | Germany, 4 years (1990–1993) | Retrospective database cohort study | Psychiatric hospital | Paranoid type schizophrenia (78.9) | 32.4 (SD 12.7) | 55.8 (77) | 138 | 96 |
Schizoaffective disorder (15.9) | ||||||||
Accompanying substance abuse (29.7) | ||||||||
Accompanying somatic disease (21.0) |
Impact of aggressiveness and/or agitation
Impact of seclusion and/or restrain
Costs of conflictive behaviors and containment
Conflict behaviors costs
|
Cost per ward
|
Cost nationally
|
Verbal abuse, aggression towards objects and physical assault | 47,529€ [£37,785] | 23,764,980€ [£18,892,816] |
Self harm | 10,284€ [£8,176] | 5,142,434€ [£4,088,161] |
Smoking in non-smoking areas or refusing to eat, drink, wash, get up, go to bed or see workers | 55,319€ [£43,978] | 27,659,246€ [£21,988,701] |
Alcohol or drug use | 11,565€ [£9,194] | 5,782,210€ [£4,596,773] |
Attempts to abscond or absconding | 31,807€ [£25,286] | 15,903,323€ [£12,642,912] |
Refused regular or Pro Re Nata medicines or demand of Pro Re Nata medicines | 26,112€ [£20,759] | 13,055,998€ [£10,379,330] |
Cost of all conflict behavior | 182,616€ [£145,177] | 91,308,194€ [£72,588,694] |
Containment events costs
|
Cost per ward
|
Cost nationally
|
Given Pro Re Nata or intramuscular medicines | 28,916€ [£22,988] | 14,457,777€ [£11,493,724] |
Sent to Intensive Care Unit or Intermediate Care Area | 2,549€ [£2,026] | 1,274,497€ [£1,013,207] |
Intermittent and constant special observation | 204,072€ [£162,234] | 102,035,487€ [£81,116,737] |
Show of force, manual restraint and seclusion | 28,518€ [£22,671] | 14,259,142€ [£11,335,812] |
Time out | 3,015€ [£2,397] | 1,507,595€ [£1,198,516] |
Cost of all containment events | 267,069€ [£212,316] | 133,534,500€ [£106,157,997] |