Alexandre Dumais

Factors influencing decisions on seclusion and restraint

Seclusion with or without restraint is a measure for managing aggressive or agitated clients and promoting site security, particularly in an emergency psychiatric setting. The decision to control a potentially dangerous persons behaviour by removal or seclusion seems ethically justifiable in such a setting. However, although the decisions on these restrictive measures are based on rational needs, they are also influenced by the healthcare teams perceptions of the client and by the characteristics of the team and the environment. The purpose of this paper is to set out and categorize the factors in play in aggression- and agitation-management situations as perceived by the healthcare teams, particularly the nurses. The first part of the paper deals briefly with the settings in which control measures are applied in a province in eastern Canada and the effect of such measures on patients and healthcare teams. The second part identifies the factors involved in the management of agitation and aggression behaviour. The final part discusses the current spin-offs from this knowledge as well as promising paths for further research on the factors involved. The ultimate objective is to reduce recourse to coercive measures and enhance professional practices.

Staff Perceptions and Organizational Factors as Predictors of Seclusion and Restraint on Psychiatric Wards

OBJECTIVE Several factors have been shown to be involved in decisions to use seclusion and restraint in psychiatric inpatient settings. This study examined whether staff perceptions of factors related to the care team and violence on the ward predicted use of seclusion and restraint in psychiatric wards. METHODS A total of 309 staff members (nurses, rehabilitation instructors, and nurses aides) providing care to patients with serious mental disorders were recruited from eight university psychiatric hospitals and general-hospital psychiatric units in the province of Quebec. Factors assessed included sociodemographic characteristics, psychological distress, staff perceptions of aggression and of interaction between members of the psychiatric team (team climate), and organizational factors. RESULTS Bivariate analyses showed that certain aspects of the team climate, staff perceptions of aggression, and organizational factors were associated with greater use of seclusion and restraint. The final multivariate model indicated that the following factors independently predicted greater use: type of hospital ward (emergency department and intensive care unit), staff perception of a higher level of expression of anger and aggression among team members, perception of the frequency of incidents of physical aggression against the self among patients, and perception of insufficient safety measures in the workplace. CONCLUSIONS These findings represent the first stage of a research program aimed at reducing use of seclusion and restraint in psychiatric settings. They underscore the importance of evaluating a variety of factors, including perceptions of safety and violence, when examining reasons for use of these controversial interventions.

Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2‐year retrospective audit

Seclusion with or without restraint is a measure used to manage patients with challenging behaviours. Although controversial, the intervention remains poorly documented, especially in Canadian psychiatric hospitals. The purpose of this study is to assess the prevalence of the measure and identify any correlated demographic characteristics and psychiatric disorders. Episodes of seclusion with or without restraint were extracted from a computerized, hospital-based system introduced specifically to track such interventions. Of 2721 patients hospitalized during that time, 23.2% (n = 632) were secluded with or without restraint, and 17.5% (n = 476) were secluded with restraint. Younger age, schizophrenia or other psychosis, bipolar and personality disorder, and longer stay in hospital are predictors of an episode of seclusion with or without restraint. Younger age, bipolar and personality disorders and a longer stay in hospital are predictors of an episode of seclusion with restraint. For patients who spent longer in seclusion and under restraint, there is a positive association with longer stay in hospital. In this inpatient psychiatric facility, seclusion with or without restraint thus appears to be common. More research is warranted to better identify the principal factors associated with seclusion and restraint and help reduce resort to these measures.

The Experience of Seclusion and Restraint in Psychiatric Settings: Perspectives of Patients

Many studies report that the use of seclusion and restraint (SR) is experienced negatively by patients who experience feelings of shame, helplessness, and humiliation, and may relive previous trauma events. Since 2000, in Québec, exceptional measures like SR have been framed by a protocol. This protocol provides health care teams with guidelines for relieving, containing, and reducing the suffering caused by SR. We have no knowledge, however, about the views of patients regarding application of the protocol. This study aims to understand the perception of patients regarding application of the SR protocol. For this purpose, a questionnaire was presented to patients (n = 50) who experienced an episode of SR in a psychiatric hospital in Canada. Results show that patients had a nuanced perception of SR: Some felt that SR was a helpful measure, while others felt that SR was not a helpful measure. Patients tended to agree with statements related to the comfort and safety of seclusion rooms and the meeting of their physical needs. Regarding support, they suggested relational, drug, and environmental interventions to prevent seclusion. Finally, nearly all patients perceived that the health care team did not follow-up with the patients after the experience; such follow-up is essential for reconstructing a sometimes confusing event.

Schizophrenia and serious violence: A clinical-profile analysis incorporating impulsivity and substance-use disorders

OBJECTIVES This study is an exploration of the role of SUD and impulsivity in individuals with schizophrenia who are at higher risk of serious violence (SV). METHODS Multiple correspondence analysis (MCA) and cluster analysis (CA) were performed on a sample of 139 males meeting DSM-IV diagnostic criteria for schizophrenia-spectrum disorders (SSD). RESULTS Impulsivity was the main dimension differentiating individuals. SUD and SV were strongly linked. CA yielded four clusters; one related to serious violence, SUD and a higher incarceration rate. CONCLUSIONS Subgroups of SSD at risk of SV were found. SUD appear to be a major risk factor for SV and incarceration.

Psychiatric risk factors for motor vehicle fatalities in young men

Background: Motor vehicle accident (MVA) fatalities are an important cause of death in young men. Psychiatric disorders have been shown to be risk factors for MVA, but only a few studies have investigated MVA fatalities. Method: A case–control study was carried out comparing 61 young male MVA fatalities in which the subject was the driver with an equal number of living male subjects matched for age (case by case with no more than 1 years difference between case subjects and control subjects) with the accident group. We assessed both groups, using structured interviews and psychological autopsies. Results: Our results suggest that cluster B personality disorders (borderline and [or] antisocial) (OR 3.54; 95%CI, 1.38 to 16.01) and substance use disorders in the last 6 months (OR 4.33; 95%CI, 1.42 to 9.25) increased the risk of dying in MVAs. In addition, we observed an age effect, where differences in cluster B personality disorders and substance use disorders in the last 6 months were only significantly more prevalent in case subjects aged 26 years or over, compared with control subjects of the same age. Drivers under age 25 years appeared to be comparable with control subjects on all measures of psychopathology. Finally, this interaction between cluster B personality disorders and age over 26 years was the only significant predictor of car fatalities (adjusted OR 16.25; 95%CI, 1.67 to 158.10). Conclusion: Borderline and antisocial personality disorders in which impulsive-aggressive behaviours play a central role and substance use disorders appear to be risk factors for young male deaths in MVAs. Interestingly, this effect seems to be specific to MVA case subjects aged 26 years or over.

Increasing the clozapine: Norclozapine ratio with co-administration of fluvoxamine to enhance efficacy and minimize side effects of clozapine therapy

Although clozapine is the only antipsychotic agent to have demonstrated superior efficacy in treatment-refractory schizophrenia, one- to two-thirds of patients do not respond adequately despite acceptable dosages and plasma levels. Moreover, a significant number of patients stop the therapy for various reasons, including its side effects, many of which are thought to be related to its active metabolite, norclozapine. However, combining clozapine with the SSRI antidepressant fluvoxamine decreases norclozapine formation by inhibiting the CYP450 1A2 isoenzyme. Lowering norclozapine levels in this way while maintaining therapeutic clozapine levels increases the clozapine: norclozapine ratio; the potential benefits include both a reduction of such side effects as sedation, weight gain, metabolic disturbances, and neutropenia, and an increase in efficacy. The optimal ratio of clozapine to norclozapine has not yet been defined, but a ratio of two or more implies that saturation of clozapine metabolism has been reached. We hypothesize that co-administration of clozapine and fluvoxamine at dosages that will produce therapeutic plasma levels of clozapine and a clozapine: norclozapine ratio of two or more will increase efficacy and tolerability of clozapine therapy in treatment-resistant schizophrenic patients.

Neurocognitive Vulnerability: Suicidal and Homicidal Behaviours in Patients with Schizophrenia:

Objective: Schizophrenia is associated with an increase in the risk of both homicide and suicide. The objectives of this study were to systematically review all published articles that examined the relation between neurocognitive deficits and suicidal or homicidal behaviours in schizophrenia, and to identify vulnerabilities in suicidal and homicidal behaviour that may share a common pathway in schizophrenia. Methods: A systematic review of the literature was performed using MEDLINE to include all studies published up to August 31, 2012. Results: Among the 1760 studies, 7 neuropsychological and 12 brain imaging studies met the selection criteria and were included in the final analysis. The neuropsychological and functional neuroimaging studies were inconclusive. The structural imaging studies reported various alterations in patients with schizophrenia and a history of homicidal behaviour, including: reduced inferior frontal and temporal cortices, increased mediodorsal white matter, and increased amygdala volumes. Patients with a history of suicidal acts showed volumetric reductions in left orbitofrontal and superior temporal cortices, while right amygdala volume was increased, though, these findings have rarely been replicated. Finally, no study has directly compared neurocognitive markers of suicidal and homicidal risk. Conclusion: These results suggest that brain alterations, in addition to those associated with schizophrenia, may predispose some patients to a higher risk of homicide or suicide in particular circumstances. Moreover, some of these alterations may be shared between homicidal and suicidal patients. However, owing to several limitations, including the small number of available studies, no firm conclusions can be drawn and further investigations are necessary.

Predictive Validity and Psychiatric Nursing Staff's Perception of the Clinical Usefulness of the French Version of the Dynamic Appraisal of Situational Aggression

This study seeks to evaluate the predictive validity of the French version of the Dynamic Appraisal of Situational Aggression (DASAfr) and psychiatric nurses’ perceptions of the clinical usefulness of the scale. The study was conducted in a 12-bed psychiatric intensive care unit in a large adult general psychiatric hospital. We found that the total score on the DASAfr has acceptable predictive accuracy for aggression against others and against staff and for seclusion with restraints; predictive accuracy was poorer for aggression against objects. Moreover, the nurses though the scale would be useful to their practice; and, indeed, the team still uses the DASAfr.

Male Inmate Profiles and Their Biological Correlates

Objective: Borderline and antisocial personality disorders (PDs) share common clinical features (impulsivity, aggressiveness, substance use disorders [SUDs], and suicidal behaviours) that are greatly overrepresented in prison populations. These disorders have been associated biologically with testosterone and cortisol levels. However, the associations are ambiguous and the subject of controversy, perhaps because these heterogeneous disorders have been addressed as unitary constructs. A consideration of profiles of people, rather than of exclusive diagnoses, might yield clearer relationships. Methods: In our study, multiple correspondence analysis and cluster analysis were employed to identify subgroups among 545 newly convicted inmates. The groups were then compared in terms of clinical features and biological markers, including levels of cortisol, testosterone, estradiol, progesterone, and sulfoconjugated dehydroepiandrosterone (DHEA-S). Results: Four clusters with differing psychiatric, criminal, and biological profiles emerged. Clinically, one group had intermediate scores for each of the tested clinical features. Another group comprised people with little comorbidity. Two others displayed severe impulsivity, PD, and SUD. Biologically, cortisol levels were lowest in the last 2 groups and highest in the group with less comorbidity. In keeping with previous findings reported in the literature, testosterone was higher in a younger population with severe psychiatric symptoms. However, some apparently comparable behavioural outcomes were found to be related to distinct biological profiles. No differences were observed for estradiol, progesterone, or DHEA-S levels. Conclusions: The results not only confirm the importance of biological markers in the study of personality features but also demonstrate the need to consider the role of comorbidities and steroid coregulation.