Psychiatry - July 2008 - (Page 24)

Letters to the editor VIOLENCE AND MENTAL ILLNESS DEAR EDITOR: The article on violence and mental illness by Rueve and Welton1 in the May issue of Psychiatry 2008 was quite interesting and informative. One cannot overemphasize the role played by environmental factors, especially staff-patient interactions, as a trigger for violent incidents. There have been several published studies that have highlighted these factors. A study by Lowe, et al.,2 suggests that issues associated with limit setting and autonomy are perceived as most important by nurses, and these issues are most likely to lead to disagreements in judgment between nurses of different status. Nurses of higher grades appear to show a greater preference for respectful and autonomyconfirming interventions than their more junior colleagues. The other factor related to staffnurse interactions is also highlighted in a study by Jansen, et al.,3 in which nurses’ attitudes toward inpatient aggression indicate that personal characteristics (gender and work experience), occupational characteristics (contractual status and type of ward), and national sociocultural values and beliefs all affect the formation of attitudes of nurses. Another earlier study by Whitington and Sykes,4 investigated the frequency in which violence in inpatient psychiatric units was preceded by an aversive interpersonal situation. The investigators found that a significant proportion of assaults in their study were immediately 24 Psychiatry 2008 [ J U L Y ] preceded by the assaulted nurse having delivered an aversive stimulus to the patient (i.e., activity demand or physical contact). Several studies have highlighted the need for a comprehensive training for staff members to address these factors. This training would go a long way to further implement the Joint Commission of Accreditation of Healthcare Organization’s (JCAHO) standards, which have placed an emphasis on limitation of the use of restraints and seclusion on inpatient units. There are several recognized effective training modules available, including Mandt training, Therapeutic Options training, and the Professional Assault Response Training 2000 (PART 2000). The latter training is mainly used internationally. Rueve and Welton1 had a useful table in their article (Table 3), which talked about environmental modifications to control aggression, and in addition to those given in their list, a study by Nijman, et al.,5 discusses certain effective approaches. That study mentions that discussing treatment goals with patients shortly after admission and discussing certain protocol for the facility (e.g., explaining why the doors are locked, explaining exit rules, providing patients with a schedule for staff meetings to explain absence of staff members from the psychiatric inpatient unit, and clarifying the procedure to make appointments with the psychiatrists) all showed a marginally significant difference in severity of aggressive incidents on wards with these interventions compared to control wards. The aspect of violence in mental illness will continue to be a topical issue, and continued research in this area should be encouraged. REFERENCES 1. Rueve M, Welton R. Violence and mental illness. Psychiatry (Edgemont) 2008;5(5):34-48. Lowe T, Wellman N, Taylor R. Limit-setting and decision making in the management of aggression. J Adv Nurs. 2003;41(2):154–161. Jansen G, Middel B, Dassen WN, Reijneveld MSA. Cross-cultural differences in psychiatric nurse’s attitudes to inpatient aggression. Arch Psychiatr Nurs 2006;20(2):82–93. Whittington R, Wykes T. Aversive stimulation by staff and violence by psychiatric patients. Br J Clin Psychol. 1996;35:11–20. Nijman HL, Merckelbach HL, Allertz WF, Campo JM. Prevention of aggressive incidents on a closed psychiatric ward. Psychiatr Serv 1997;48:694–698. 2. 3. 4. 5. With regards, Adegboyega Oyemade, MD Addiction Psychiatrist, Heritage Behavioral Health Center, Inc., Decatur, Illinois REGARDING ANTIDEPRESSANTS AND EFFICACY IN SHORT-TERM CLINICAL TRIALS DEAR EDITOR: I would like to add two more factors besides the ones Dr. Feifel discusses in his article, “More depressing news on antidepressants: Should we panic?” which appeared in the April issue of Psychiatry 2008.1 One: There is a strong incentive for the clinical investigators to push marginally depressed patients into drug trials. Since the

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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