Objective: To evaluate the relationship between medications used to treat acute agitation (antipsychotics, mood stabilizers, and benzodiazepines) and subsequent assault incidence in the psychiatric emergency department.
Methods: Medication orders and assault incident reports were obtained from electronic health records for 17,056 visits to an urban psychiatric emergency department from 2014 to 2019. Assault risk was modeled longitudinally using Poisson mixed-effects regression.
Results: Assaults were reported during 0.5% of visits. Intramuscular (IM) medications were ordered in 23.3% of visits overall and predominantly were ordered within the first 4 hours of a visit. IM medication orders were correlated with assault (incident rate ratio [IRR] = 24.2; 95% CI, 5.33–110.0), often because IM medications were ordered immediately subsequent to reported assaults. Interacted with time, IM medications were not significantly associated with reduction in subsequent assaults (IRR = 0.700; 95% CI, 0.467–1.04). Neither benzodiazepines nor mood stabilizers were associated with subsequent changes to the risk of reported assault. By contrast, antipsychotic medications were associated with decreased assault risk across time (IRR = 0.583; 95% CI, 0.360–0.942).
Conclusions: Although assault prevention is not the sole reason for ordering IM medications, IM medication order rates are high relative to overall assault incident risk. Of the 3 major categories of medications ordered commonly in the psychiatric emergency setting, only antipsychotic medications were associated with measurable decreases in subsequent assault risk. As antipsychotic medication can have a significant side effect burden, careful weighing of the risks and benefits of medications is encouraged.
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Binder RL, McNiel DE. Emergency psychiatry: contemporary practices in managing acutely violent patients in 20 psychiatric emergency rooms. Psychiatr Serv. 1999;50(12):1553–1554. PubMedCrossRef
Sullivan C, Yuan C. Workplace assaults on minority health and mental health care workers in Los Angeles. Am J Public Health. 1995;85(7):1011–1014. PubMedCrossRef
Sullivan C, Yuan C. Workplace assaults on minority health and mental health care workers in Los Angeles. Am J Public Health. 1995;85(7):1011–1014. PubMedCrossRef
Sanghani SN, Marsh AN, John M, et al. Characteristics of patients involved in physical assault in an acute inpatient psychiatric setting. J Psychiatr Pract. 2017;23(4):260–269. PubMedCrossRef
Biancosino B, Delmonte S, Grassi L, et al; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009;197(10):772–782. PubMedCrossRef
Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients. Soc Psychiatry Psychiatr Epidemiol. 1997;32(7):428–434. PubMed
Iozzino L, Ferrari C, Large M, et al. Prevalence and risk factors of violence by psychiatric acute inpatients: a systematic review and meta-analysis. PLoS One. 2015;10(6):e0128536. PubMedCrossRef
Edwards JG, Jones D, Reid WH, et al. Physical assaults in a psychiatric unit of a general hospital. Am J Psychiatry. 1988;145(12):1568–1571. PubMedCrossRef
Grassi L, Peron L, Marangoni C, et al. Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study. Acta Psychiatr Scand. 2001;104(4):273–279. PubMedCrossRef
Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001;52(1):75–80. PubMedCrossRef
Lehmann LS, McCormick RA, Kizer KW. A survey of assaultive behavior in Veterans Health Administration facilities. Psychiatr Serv. 1999;50(3):384–389. PubMedCrossRef
Krakowski M, Czobor P. Gender differences in violent behaviors: relationship to clinical symptoms and psychosocial factors. Am J Psychiatry. 2004;161(3):459–465. PubMedCrossRef
Hillbrand M, Foster HG, Spitz RT. Characteristics and cost of staff injuries in a forensic hospital. Psychiatr Serv. 1996;47(10):1123–1125. PubMedCrossRef
Cornaggia CM, Beghi M, Pavone F, et al. Aggression in psychiatry wards: a systematic review. Psychiatry Res. 2011;189(1):10–20. PubMedCrossRef
Goedhard LE, Stolker JJ, Heerdink ER, et al. Pharmacotherapy for the treatment of aggressive behavior in general adult psychiatry: a systematic review. J Clin Psychiatry. 2006;67(7):1013–1024. PubMedCrossRef
Lam JN, McNiel DE, Binder RL. The relationship between patients’ gender and violence leading to staff injuries. Psychiatr Serv. 2000;51(9):1167–1170. PubMedCrossRef
Dietz PE, Rada RT. Battery incidents and batterers in a maximum security hospital. Arch Gen Psychiatry. 1982;39(1):31–34. PubMedCrossRef
Owen C, Tarantello C, Jones M, et al. Violence and aggression in psychiatric units. Psychiatr Serv. 1998;49(11):1452–1457. PubMedCrossRef
Ketelsen R, Zechert C, Driessen M, et al. Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk. J Psychiatr Ment Health Nurs. 2007;14(1):92–99. PubMedCrossRef
Stowell KR, Hughes NP, Rozel JS. Violence in the emergency department. Psychiatr Clin North Am. 2016;39(4):557–566. PubMedCrossRef
Lawrence RE, Rolin SA, Looney DV, et al. Physical assault in the psychiatry emergency room. J Am Acad Psychiatry Law. 2020;48(4):484–495. PubMed
Ball R, Brown P. An empirical evaluation of accounting income numbers. J Account Res. 1968;6(2):159. CrossRef
Amore M, Menchetti M, Tonti C, et al. Predictors of violent behavior among acute psychiatric patients: clinical study. Psychiatry Clin Neurosci. 2008;62(3):247–255. PubMedCrossRef
Lavelle S, Tusaie KR. Reflecting on forced medication. Issues Ment Health Nurs. 2011;32(5):274–278. PubMedCrossRef
Georgieva I, Mulder CL, Wierdsma A. Patients’ preference and experiences of forced medication and seclusion. Psychiatr Q. 2012;83(1):1–13. PubMedCrossRef
Hankin CS, Bronstone A, Koran LM. Agitation in the inpatient psychiatric setting: a review of clinical presentation, burden, and treatment. J Psychiatr Pract. 2011;17(3):170–185. PubMedCrossRef
Bowden CL, Brugger AM, Swann AC, et al; The Depakote Mania Study Group. Efficacy of divalproex vs lithium and placebo in the treatment of mania. JAMA. 1994;271(12):918–924. PubMedCrossRef
Simpson SA, Joesch JM, West II, et al. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113–118. PubMedCrossRef
Arnetz JE, Hamblin L, Ager J, et al. Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents. Workplace Health Saf. 2015;63(5):200–210. PubMedCrossRef
Sarver WL, Radziewicz R, Coyne G, et al. Implementation of the brøset violence checklist on an acute psychiatric unit. J Am Psychiatr Nurses Assoc. 2019;25(6):476–486. PubMedCrossRef
Anderson KK, Jenson CE. Violence risk-assessment screening tools for acute care mental health settings: literature review. Arch Psychiatr Nurs. 2019;33(1):112–119. PubMedCrossRef
Chang G, Weiss AP, Orav EJ, et al. Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: a prospective study. Ann Emerg Med. 2011;58(2):127–136.e1. PubMedCrossRef
Zhu JM, Singhal A, Hsia RY. Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002–11. Health Aff (Millwood). 2016;35(9):1698–1706. PubMedCrossRef