Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder.

BACKGROUND: Clozapine has been reported to be effective in diminishing violence toward others in psychotic patients. This article describes the impact of clozapine on severe self-mutilation among patients with the dual diagnoses of borderline personality disorder and persistent psychoses. METHOD: Seven subjects known to the authors were selected for careful chart audits. These subjects had been admitted to 2 state psychiatric hospitals owing to severe self-mutilation and/or violence and subsequently treated with clozapine. A mirror-image design anchored to the start date of clozapine treatment and extending in either direction to a maximum of 1 year was used to extract data. Data extracted included incidents of self-mutilation (restraint), seclusion, the as and when needed (p.r.n.) use of medications, injuries to staff and peers, hospital privileges, and Global Assessment of Functioning (GAF) scores. RESULTS: The subjects were all white women with a mean age of 37 years. All subjects carried DSM-III-R or DSM-IV borderline personality disorder diagnoses and an Axis I disorder diagnosis. They had received trials of several psychotropic agents, often in combination and mostly without benefit. After clozapine treatment, there were statistically significant reductions in incidents of self-mutilation (restraint), seclusion, the use of p.r.n. antianxiety medications, and injuries to staff and peers. These subjects received higher levels of hospital privileges, and their GAF scores nearly doubled following clozapine treatment. Four subjects were subsequently discharged from hospital. CONCLUSION: These preliminary but nonetheless favorable results suggest that clozapine deserves careful consideration for a controlled study in patients with borderline personality disorder and psychoses, especially if the clinical issues include severe self-mutilation, aggression, and violence. Until such studies are done, the risk-to-benefit ratio of clozapine treatment needs to be carefully evaluated on an individualized basis in such subjects.     

Impact of risperidone on seclusion and restraint at a state psychiatric hospital.

OBJECTIVE: To evaluate the impact of risperidone on seclusion and restraint in patients at a state psychiatric facility, shortly after risperidone's release. METHODS: Patients who were in the hospital for at least 3 months prior to receiving risperidone and subsequently received risperidone for at least 3 months formed the cohort. A mirror-image design was used with duration to a maximum of 1 year before and 1 year after initiation of risperidone. The hospital population that did not receive either risperidone or clozapine during the same time period was used for comparison of trends of seclusion and restraint. RESULTS: Seventy-four patients (most with schizophrenia) met the inclusion criteria of the risperidone group. There were statistically significant decreases in the number of seclusion hours (2.2 [SD 5.5] to 0.26 [SD 0.06]) and of events (0.23 [SD 0.59] to 0.05 [SD 0.14]) per person per month during risperidone treatment, compared with the prerisperidone treatment period (P = 0.01). The comparison group also evidenced decreases on these measures during the same time period, but the risperidone-treated cohort achieved a proportionally greater reduction. There were similar trends toward reduction in the restraint measures during risperidone treatment compared with prerisperidone, but these did not achieve statistical significance. The comparison group also showed slightly decreased use of restraints over the study period. CONCLUSIONS: Risperidone appears to have had a positive impact on seclusion in this state-hospital psychiatric population. These data support the positive impact of risperidone on violence found in other studies. Violence and aggression are major factors that affect morale among psychiatric patients and staff. So, any benefit in this regard as a result of antipsychotic drug treatment is salutary for patients, families, and health care providers.     

Clozapine reduces violent behavior in heterogeneous diagnostic groups

Violent behavior is a significant problem in the psychiatric hospital setting. Persistently violent patients often require seclusion and/or restraints and typically receive high doses of medication and polypharmacy. Clozapine has been found to be effective in reducing aggression in patients with psychosis. Thus, we examined the effects of clozapine in a heterogeneous group of persistently violent patients. A chart review of the effect of clozapine in persistently violent patients was performed. Changes in the number of violent episodes and the need for seclusion and restraint were assessed for a 3-month period before and after receiving clozapine. In this group of five, carefully selected, persistently violent patients, clozapine treatment resulted in marked decreases in violent episodes and the use of seclusion and restraint. These data suggest a role for clozapine in the treatment of persistently violent patients irrespective of DSM-IV diagnosis.     

Restraint, seclusion, and clozapine.

BACKGROUND: The effects of clozapine, an unconventional neuroleptic drug, on the use of restraint and seclusion in patients have not been extensively reported on in the United States. METHOD: The records of 107 patients receiving clozapine in Missouri state mental hospitals were reviewed over a 13-month period for frequency and duration of restraint and seclusion. RESULTS: During clozapine treatment, patients had fewer episodes of restraint and seclusion than previously. The duration of restraints and seclusions also decreased, starting the second month after the initiation of clozapine treatment. CONCLUSION: For patients who were restrained or secluded before clozapine treatment, the decrease in the number and duration of restraint and seclusion episodes was dramatic.     

Decreasing the use of restraint and seclusion among psychiatric inpatients

OBJECTIVE: We describe a hospital-wide effort to decrease restraint and seclusion of psychiatric inpatients. Our hypotheses were that interventions could reduce the number of patients as well as patient hours in restraint and seclusion, without an increase in adverse outcomes (fights/assaults, staff injuries, and elopements). METHOD: This study was performed at an urban academic psychiatric hospital (New York State Psychiatric Institute) with 3 inpatient units totaling 58 beds. Interventions included 1) decreasing initial time in restraint or seclusion from 4 to 2 hours before a new order was required; 2) education of staff concerning identification of patients at risk of restraint or seclusion and early interventions to avoid crises; and 3) use of a coping questionnaire to assess patient preferences for dealing with agitation. Data were assessed 20 months before and 67 months following the implementation of these interventions. RESULTS: The mean number of patients restrained went from 0.35 +/- 0.6 to 0.32 +/- 0.5 patients/month; mean hours of restraint decreased from 1.7 +/- 5.2 to 1.0 +/- 2.4 hours/month. The mean number of patients secluded decreased significantly from 3.1 +/- 1.4 to 1.0 +/- 1.1 patients/month. The mean hours of seclusion decreased markedly, from 41.6 +/- 52 to 2.7 +/- 4.5 hours/month. Adverse outcomes (elopements and fights/assaults) also decreased significantly over the follow-up period. CONCLUSIONS: Interventions were successful in decreasing use of restraint and seclusion on both clinical and research units over more than 5 years of follow-up. Such interventions may be adapted to other settings.     

Intramuscular ziprasidone for acute agitation in adolescents

Several neuropsychiatric disorders in children and adolescents often present with aggressive behavior. In fact, aggression is one of the most common reasons for psychiatric admission for inpatient hospitalization. Psychotropic medication can be helpful in reducing the need for more restrictive interventions, such as seclusion or restraint. The use of "as needed " (PRN) medications has been reported to decrease seclusion and restraint in a university-affiliated hospital setting. In our study, we report the cases of 3 youngsters whose escalating aggression responded to intramuscular ziprasidone with an immediate calming effect and good clinical outcome.     

Seclusion and restraint and prediction of violence

The authors studied the use of seclusion and restraint on an inpatient unit in a state psychiatric hospital. Of 69 randomly selected inpatients, 51% experienced seclusion or restraint at least once. More psychotic than nonpsychotic patients required seclusion or restraint. However, neither psychosis/nonpsychosis nor voluntary/involuntary admission status predicted the likelihood of violent threats or actions. Patients experiencing seclusion and restraint showed a nonsignificant trend toward longer mean length of stay in the hospital. The frequency of patient behavior leading to seclusion or restraint appeared to be directly related to the stimulation caused by the presence of many staff members and other patients.     

Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.     

Congresses

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients’ integrity, could harm the provider–patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.     

Staff's attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients' integrity, could harm the provider-patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.     

Antecedents and interventions for aggressive behavior of patients at a geropsychiatric state hospital

Aggressive geropsychiatric patients pose major problems for long-term care facilities. Two exploratory surveys at a geropsychiatric state hospital, separated by brief programs of inservice training on managing aggressive patients, examined several aspects of aggressive behavior and staff interventions. Major findings included a stable overall prevalence of aggressive behavior in both survey periods; a persistently higher prevalence of aggression and a higher rate of physical aggression among dementia patients than among other patients; and staff-patient exchanges as a major triggering event for aggression. In the survey period after the inservice training, staff interventions remained similar for nondementia patients; however, for dementia patients, interpersonal interventions were used less frequently, and p.r.n. medications, alone or in combination with seclusion or restraint, were used more often.     

Exploring the Use of Seclusion and Restraint with Deaf Psychiatric Patients: Comparisons with Hearing Patients

Archival data of seclusion and restraint events in a group of deaf adults (n = 30) was compared with a random sample of hearing adults with intellectual disabilities (ID) (n = 30) and a random sample of hearing adults without ID (n = 51) admitted to a state hospital from 1998 to 2008. Only 12% of the hearing non-ID group experienced a seclusion or restraint versus 43% of the deaf group. The ID group also showed significantly higher rates of seclusion and restraint than the hearing non-ID group (30 vs. 12%). Patients in the deaf and ID group were significantly more likely to be diagnosed with impulse control disorders (23 and 23%, respectively), which may have contributed to the higher utilization of seclusion and restraint procedures in these groups. Deafness-related cultural and linguistic variables that impact the use of seclusion and restraint are reviewed.     

An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital

OBJECTIVE: The author reviews and evaluates a variety of interventions that were considered to have contributed to the successful reduction of reliance on the use of seclusion and restraint in a public psychiatric hospital for adult patients with severe and persistent psychiatric impairments. METHODS: A multiple regression analysis was applied to monthly seclusion and restraint data covering the period from 1997 to 2002. The independent variables were each of the component efforts to reduce reliance on seclusion and restraint at the hospital: changes in the criteria for administrative review of incidents of seclusion and restraint, changes in the composition of the case review committee, development of a behavioral consultation team, enhancement of standards for behavioral assessments and plans, and improvements in the staff-patient ratio. RESULTS: The use of seclusion and restraint was 75 percent lower during the final year of the five-year study period than it was during the first year. The only variable that was significantly associated with reduction in the use of seclusion and restraint was changes in the process for identifying critical cases and initiating a clinical and administrative case review. CONCLUSION: The results of this analysis underscore the importance of clinical and administrative priorities in efforts to reduce the use of seclusion and restraint in public psychiatric hospitals.     

P.R.N. (As-needed) orders and exposure of psychiatric inpatients to unnecessary psychotropic medications

OBJECTIVE: The objective of this study was to evaluate whether the practice of writing standing p.r.n. (as-needed) orders exposes psychiatric inpatients to unnecessary psychotropic medications. METHODS: Medical records for 223 new hospital admissions between July 15 and October 15, 1999, when p.r.n. orders were allowed, and 224 new admissions between November 15, 1999, and February 15, 2000, when p.r.n. orders were not allowed and only "now" orders were permitted, were reviewed from the three acute adult psychiatric units of the Arkansas State Hospital in Little Rock. Data were collected on demographic and clinical characteristics, scheduled and unscheduled psychotropic medications as noted in the medication administration records, use of seclusion and restraint, and incident reports of physical aggression. The mean numbers of unscheduled psychotropic medication doses administered during the two periods were compared. RESULTS: The number of unscheduled psychotropic medications administered decreased from 1,812 in the first period to 976 in the second period (adjusted mean doses per admission, 7.8 to 4.3). The decrease in use of unscheduled medications when standing p.r.n. orders were no longer allowed was not associated with corresponding increases in adverse events: there were fewer incidents of restraint (four compared with eight), fewer incidents of seclusion (41 compared with 48), and fewer incidents of physical aggression (35 compared with 40). In addition, there were no significant changes in the dosages of scheduled psychotropic medications on day 7 of admission, indicating that physicians were not increasing dosages in response to the elimination of p.r.n. orders. CONCLUSIONS: The practice of writing p.r.n. orders may expose psychiatric inpatients to unnecessary psychotropic medications.     

Prevalence and Precursors of the use of Restraint and Seclusion in a Private Psychiatric Hospital: Comparison of Child and Adolescent Patients

The use of restraint and seclusion is highly regulated in psychiatric inpatient settings. However, the majority of studies of restraint and seclusion are based on public hospitals serving adult patients, with some limited data available on adolescents and children. This paper presents prospectively collected data on restraint and seclusion over a 2-year period at a private psychiatric hospital whose patients include large numbers of both adolescents and pre-adolescent children. 2 years of restraint and seclusion data were analyzed on a total of 2,411 unique patients. Types of seclusion included in-room seclusion on the treatment unit and off-unit seclusion in a separate seclusion annex. Restraints consisted solely of short term (<15 min) and longer term (>14 min) manual restraints. The use of IM medication was also recorded. The precipitants of these events were examined. These included physical and verbal threats, stabbing or throwing objects, attempts to elope, attempts to hurt one’s self or another, or property destruction. Out of 2,411 child and adolescent in-patients admitted during the period under review, only 703 (29%) experienced restraint or seclusion. Among these, the modal number of events per patient was one (n = 156), but the maximum number of occurrences was 163. Child patients had a much higher frequency of events (n = 396, 53%) than adolescents (n = 307, 19%). There were notable differences in the types of seclusion events, with children typically experiencing in-room seclusion on the unit. When age was examined as a continuous variable, younger patients had a higher prevalence of restraint and seclusion, significantly more restraint and seclusion, and these restraint and seclusion events were significantly shorter than those seen in older patients. Multiple other potential determinants of these events were examined, including diagnosis, symptom severity at admission, age, and gender, but none of these predicted these events. Restraint and seclusion events were more common for children and less so for adolescents, with robust age effects for the likelihood of any seclusions, the number of seclusions and restraints, and the duration of seclusions and restraints. Patients who experienced restraint or seclusion typically required it only once during their hospitalization. Only age was found to be a predictor of the restraint and seclusion variables. Given these findings, it appears that management of agitated behavior in children and adolescents may be a qualitatively different phenomenon. Future research should be directed at understanding the determinants of high frequency agitated behavior and developing alternatives to seclusion or restraint.     

Clozapine therapy in a state hospital: Patient care and policy implications

This study assessed the effectiveness and costs of clozapine use with persons experiencing refractory chronic schizophrenia in a state hospital environment. All patients (112) placed on clozapine therapy between May 1990 and March 1992, and who remained on or were discontinued from clozapine therapy and not restarted were followed. Discharge rates, incidents and hours of seclusion and restraint, incidents and hours of authorized leave and scores on the Modified Nurses Observation Scale for Inpatient Evaluation (NOSIE) were collected. The results found that few discharged patients returned to the hospital and lower community maintenance costs produced substantial savings in overall public support costs. Clozapine therapy is a cost effective alternative for the treatment of refractory schizophrenia.An abbreviated version of this paper was presented at the Fourth Annual Conference on State Mental Health Agency Services Research in 1993.     

Clozapine utilization and outcomes by race in a public mental health system: 1994-2000

OBJECTIVE: This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing. METHOD: Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database. RESULTS: A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041). CONCLUSION: Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.     

Clinical review of clozapine treatment in a state hospital.

Medical records of the first 37 patients to begin clozapine treatment at a state hospital in Oregon were reviewed for six months before clozapine treatment and six months after. Patients had a long history of schizophrenia and had responded poorly to antipsychotic medication. Clozapine treatment was generally well tolerated, although the rate of seizures (8 percent) was slightly higher than expected. Psychotic symptoms decreased as measured by the Brief Psychiatric Rating Scale, as did symptoms of tardive dyskinesia as measured by the Abnormal Involuntary Movement Scale. Thirty-four patients remained hospitalized after six months of treatment. However, indicators of social function (hospital privilege level, community passes, violent episodes, and episodes of seclusion and restraint) all showed that patients improved markedly after receiving clozapine.     

The effects of long-term clozapine add-on therapy on the rehospitalization rate and the mood polarity patterns in bipolar disorders

OBJECTIVE: We investigated the effect long-term clozapine add-on therapy has on rehospitalization rate and mood polarity patterns in patients with bipolar disorders. METHOD: Clinical data from medical records of 51 patients with bipolar disorder (DSM-IV) treated with clozapine add-on for more than 6 months at the Refractory Bipolar Disorders Clinic of Seoul National University Hospital were retrospectively analyzed. Patients had been registered from 1995 to 2004. Rehospitalization rates were compared before and after clozapine add-on. The clinical polarity of episodes resulting in hospitalizations was also compared. Twenty-seven bipolar patients treated with clozapine add-on for more than 3 years were further analyzed for long-term stability. RESULTS: The number of hospital days per year was reduced in 90.2% of patients after clozapine add-on. Total number and duration of hospitalizations per year decreased, and the effect size of clozapine add-on was substantially large (Wilcoxon z = -5.48, p < .01 for number of hospitalizations/year; Wilcoxon z = -5.32, p < .01 for hospital days/year; r = -0.54 and -0.53, respectively). Significant reductions were found in the number and duration of hospitalizations associated with manic, depressive, and hypomanic episodes. Number and duration of hospitalizations associated with mixed episodes did not show significant changes. The long-term efficacy of clozapine add-on was supported by continuous reduction in hospital days per year in the 27 selected patients. CONCLUSION: Long-term clozapine add-on therapy was effective in reducing the number and duration of rehospitalizations of bipolar patients resistant to conventional treatment. A significant reduction was found in rehospitalizations associated with manic, depressive, and hypomanic episodes, whereas mixed episode-associated rehospitalizations did not show significant changes.