| July 22, 2008 | 0 Comments

Psychiatry (Edgemont) 2008;5(7):24-25


Dear Editor:

The article on violence and mental illness by Rueve and Welton[1] 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 autonomy-confirming interventions than their more junior colleagues.

The other factor related to staff-nurse 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 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 Welton[1] 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.

1. Rueve M, Welton R. Violence and mental illness. Psychiatry (Edgemont) 2008;5(5):34-48.
2. Lowe T, Wellman N, Taylor R. Limit-setting and decision making in the management of aggression. J Adv Nurs. 2003;41(2):154–161.
3. 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.
4. Whittington R, Wykes T. Aversive stimulation by staff and violence by psychiatric patients. Br J Clin Psychol. 1996;35:11–20.
5. Nijman HL, Merckelbach HL, Allertz WF, Campo JM. Prevention of aggressive incidents on a closed psychiatric ward. Psychiatr Serv 1997;48:694–698.

With regards,
Adegboyega Oyemade, MD
Addiction Psychiatrist, Heritage Behavioral Health Center, Inc., Decatur, Illinois


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 reimbursement is based upon number of patients enrolled, there is an unconscious bias to rate the depressive symptoms higher than they are to help patients meet the inclusion criteria.

The patients with milder and atypical forms of depression often show high therapeutic response to placebo and psychosocial interventions thus diluting the evidence of an antidepressant’s efficacy with the more severely depressed. Furthermore, the mildly depressed are more likely to show decline of their symptoms spontaneously irrespective of the treatment. This also works against showing differences between the antidepressant and the placebo.

Two: Once the patient is enrolled in the study, there is a strong incentive to rate the treatment response liberally. The investigator has a powerful motivation to see that the drug works. If the drug is effective, it means publication and the honor of bringing a new drug to the market. Thus, when rating the treatment response, there is an unconscious bias to show greater improvement than what is actually occurring. This once again dilutes the differences between the antidepressant and placebo response.

The above two factors were borne upon me while doing my first clinical trial—a four-week, double-blind, placebo–controlled study in depression. I observed how eager we were to enroll anyone who declared himself or herself to be depressed during the screening rounds that we conducted with all the new admissions throughout the state hospital where the research unit was situated. To enable patients to meet the study’s inclusion criteria, there was a strong inner compulsion to downplay comorbid conditions and to exaggerate the intensity of the depression. It did not take me long to realize that all the research subjects were improving quite rapidly, and, therefore, the study would run into the problem of falsely showing that the antidepressant was no better than placebo.

1. Feifel D. More depressing news on antidepressants: Should we panic? Psychiatry (Edgemont) 2008;5(4)–35–36.

With regards,
Surendra Kelwala MD
Livonia, Michigan

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Category: Letters to the Editor, Mental Disorders, Past Articles, Psychiatry

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