November 5, 2014

Aggressive Inpatients in a Community General Hospital

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Vikrant Mittal, MD, FACHE, FAPA, and Rosemary Nourse, RN, CCRC

St Luke’s University Hospital, Bethlehem, Pennsylvania


Patients who are aggressive and present with characteristics and behaviors associated with a significant risk for physical violence are not uncommon in the acute inpatient behavioral health units of general hospitals.Treating the aggressive patient challenges clinicians to safely, expeditiously, and effectively manage the needs of both the aggressive patient and the unit’s entire patient population.

Several factors contribute to the admission of aggressive patients to general hospitals’ psychiatric units, including the closing of state hospitals; insufficient housing for mentally ill, intellectually disabled, and addicted individuals; the recurrent problem of community treatment unsuccessfully managing aggressive patients; and controversy regarding if or when these patients’ actions necessitate incarceration. And, although staff may hope this trend of admitting aggressive patients abates, studies have stated that this population merely reflects society and will, therefore, continue to be present.

Research has shown that acts of aggression are most likely to occur within the first or second week of hospitalization. Predictors have frequently been utilized to identify which patients are most at risk for aggressive behavior while hospitalized and are typically grouped by categories such as demographics (eg, age, sex, history of violence, psychosocial factors), clinical characteristics (eg, diagnosis, substance use, personality disorders, symptoms, severity of illness), contextual factors (eg, unit environment), and staff contributors (eg, communication skills, aggression training).

The results of our prospective study on aggressive patients cited younger males with a history of previous violence, past psychiatric admissions, and severe symptoms of agitation (defined as excessive, purposeless motor activity) as being more at risk for aggressive behavior during acute psychiatric hospitalization than other patients. Additionally, our results suggested that positive psychotic symptoms, a diagnosis of bipolar disorder, and substance use also contributed to aggressive behavior. We also identified a relationship between the participants’ severity of illness and level of aggressiveness.

In study participants, paranoia was the symptom most successfully reduced/treated by medication. The medications we used for our study participants seemed efficacious, as significant improvements were seen in psychometric scale scores (CGI-S and MOAS) from baseline to last visit; however, the overall positive effects of the therapeutic inpatient environment and routine must also be considered as important contributors to patient improvement.

Our study showed high rehospitalization rates for aggressive patients, which suggests that patients with aggression issues are difficult to treat and difficult to keep in compliance with treatment on an outpatient basis. This finding highlights the need to strengthen community mental health centers through an increase in public-private partnerships.

Financial disclosure:Dr Mittal is a consultant for Janssen, Otsuka, and Teva. Ms Nourse had no relevant personal financial relationships to report.​

Category: Bipolar Disorder , Mental Illness , Schizophrenia , Substance Use Disorder
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6 thoughts on “Aggressive Inpatients in a Community General Hospital

  1. I am unclear if the clients were being treated on a voluntary basis.
    If involuntary I wonder how much treatment response is simply a consequence of incarceration and the client’s natural preference to return to the free world.
  2. I have been in hospital based psychiatric practice for 37 years. The trend of increase aggression is certainly true as well as the factors you have cited. My question is: which psychotropic meds are most effective in helping these patients achieve at least some degree of impulse controll.
  3. “Which psychotropic meds are most effective” is an impossible question to answer. It is clearly different not only BETWEEN types of medication but between different occasions in the case of one individual patient!
  4. I agree, the choice of medication is individually assessed. Based on allergies, past history if known, and severity of aggression at the time and of course, route of administration of medicine.
  5. What are your thoughts on treating a dual diagnosis patient on a med-surg nursing unit? As a med-surg nurse seeing more of these patients what do you feel are the most important things I need to learn about mental illness while medically stabilizing this person?

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