B. Wistedt

Staff observation aggression scale, SOAS: Presentation and evaluation

A new psychiatric report and rating scale assessing severity and frequency of aggressive behaviour is presented and evaluated. It is based on the staffs standardized reports of aggressive incidents. By using a special aggression report form, comprehensive and standardized information is obtained, thereby permitting scoring and further analysis of different aspects of aggressive incidents. The reliability of scoring is tested and found to be good as is the scales capacity to discriminate between different patterns of aggressive behaviour in different groups of patients. As a result of this and because of the simplicity of the scale, it is thought to be a potentially useful tool in scientific research on aggressive behaviour from psychiatric inpatients.

The Staff Observation Aggression Scale-revised (SOAS-R)

Proper assessment of aggressive behavior is essential for an understanding of its causes. In 1987, Palmstierna and Wistedt [Acta Psychiatr Scand 76:657-663] introduced the Staff Observation Aggression Scale (SOAS), an instrument for monitoring the frequency, nature, and severity of aggressive incidents. In the present study, the validity of the SOAS severity scoring system was examined, and the severity scores were refined. The SOAS was used to record aggression on six closed wards of three psychiatric hospitals. The SOAS severity scores of 556 aggressive incidents were compared with severity estimates given on Visual Analogue Scales (VASs) by staff members. The original SOAS scores were found to be moderately correlated with the estimates of severity given by staff on the VAS. The SOAS severity scoring system was refined on the basis of the staff severity estimates. The revised scoring method and other refinements in the contents of the instrument led to the construction of the SOAS-R. The SOAS-R seems to be a promising tool for monitoring a wide range of (self-) destructive acts on psychiatric wards.

An educational program on depressive disorders for general practitioners on Gotland: background and evaluation

ABSTRACT General practitioners are the psychiatrists’ most important co‐workers in the treatment of depressive disorders. A high degree of knowledge about this illness in this group of doctors is of decisive importance. However, the value of postgraduate educational programs for general practitioners has been questioned. The Swedish Committee for the Prevention and Treatment of Depression (PTD) offered an educational program on symptoms, etiology, diagnosis, prevention and treatment of depression to all general practitioners on the Swedish island of Gotland. Lectures on suicide, depressive illness in childhood and in old age and psychotherapy of depressive states were also given. In several control periods data were collected on suicides, referrals to the local psychiatric department, emergency admissions, the quantity of sick leave used and the quantity of inpatient care due to depression. Even the prescription of psychopharmacological drugs on the island was investigated. Overall, the results indicated that general practitioners gratefully accepted the educational program and achieved increasing competence and stringency in treating and preventing depressive states. The program was associated with decreases in the use of psychiatric inpatient care and the sick leave frequency of depressed patients. The possibility of preventing suicides was positively influenced.

A depot neuroleptic withdrawal study

A double-blind withdrawal trial in 41 chronic schizophrenic outpatients was carried out during 6 months. Depot neuroleptics (fluphenazine decanoate or flupenthixol decanoate) were compared with placebo to evaluate clinical and neurological effects during continued therapy and during withdrawal. The drugs were significantly more effective than placebo in preventing relapse and rehospitalization. In the placebo group 62% relapsed compared to 27% in the drug group. There was a weak and nonsignificant tendency to a higher relapse frequency in the flupenthixol group compared to the fluphenazine group. After withdrawal for 6 months, plasma levels for fluphenazine were detectable. Plasma levels for flupenthixol were not detectable after 9 weeks of withdrawal. The differences in the plasma levels may possibly explain the difference in relapse rate between the two depot neuroleptics. Furthermore, it was found that the patients who relapsed during fluphenazine treatment had a significantly lower plasma level of the drug than patients who did not relapse during treatment. The results from this study provide some information on the therapeutic levels of fluphenazine and flupenthixol in schizophrenic patients.

Risk factors for suicide among patients with schizophrenia

ABSTRACT: In order to assess risk factors for suicide among patients with schizophrenia, we compared 32 patients with schizophrenia who committed suicide during an 11 year follow‐up with a control group of 64 schizophrenics who did not commit suicide. A history of previous suicide attempts was the factor most strongly related to suicide. In females we found an increased risk for suicide among unmarried, divorced or widowed and among those living alone. In males we found an increased risk among those with a history of alcohol abuse. In contrast to findings in other studies, distribution of age and sex and a history of depressive episodes were factors not associated with an increased risk for suicide. We conclude that suicidal acts among schizophrenics are often impulsive and difficult to predict. Traditional risk scales are of limited value in the clinical assessment of suicidal risk.

Aggressive behavior in hospitalized psychogeriatric patients

The frequency and characteristics of aggressive and hostile behavior in 40 psychogeriatric inpatients was investigated using the Staff Observation Aggression Scale (SOAS). Most aggressive acts were directed towards nursing staff when providing help with activities of daily living. A positive correlation was found between age and the frequency of aggressive behavior, while severity was most strongly correlated to length of admission. A significant decrease in frequency was observed during the six weeks of observation. The causes of this decrease are discussed together with the implications for future studies on the treatment of aggressive behavior in this group of patients.

Effect of an educational program for general practitioners on Gotland on the pattern of prescription of psychotropic drugs

During the years 1983–1984, an educational program was given to all general practitioners on the island of Gotland. This report evaluates changes in prescription habits from 1982 to 1985. To correct for general trends that occurred simultaneously, the prescription habits were compared to the habits in the rest of Sweden. Both on Gotland and in Sweden as a whole, the use of antidepressants increased from 1982–1985, but significantly more on Gotland. In 1982, the use of antidepressants was low on Gotland, 54% of that in the rest of Sweden. After the educational programs, Gotland reached 77% of the use in the rest of Sweden. In 1982, the use of lithium was 123% of that in the rest of Sweden. After the educational programs, the use of lithium was unchanged, and a small increase of 5.6% was seen in the rest of Sweden. After the educational programs, the prescription of sedatives on Gotland decreased (– 8.2%), and an increase of 4.5% was seen in the rest of Sweden. The use of major tranquilizers also decreased significantly (– 23%) on Gotland. Even in the rest of Sweden, a significant but much smaller decrease was seen: – 13%. On Gotland the frequency of hypnotics remained stable from 1982–1985, and a significant increase was seen in the rest of Sweden.

Validity of the diagnosis schizophrenia in a psychiatric inpatient register: A retrospective application of DSM-III criteria on ICD-8 diagnoses in Stockholm county

In order to assess the quality of the Stockholm county inpatient register for use in epidemiological studies on schizophrenia, a retrospective validity study was performed on a 10% sample of all patients discharged with the diagnosis schizophrenia from hospitals in Stockholm county during 1971. In order to assess fulfillment of the DSM-III criteria for schizophrenia, 102 medical records with an ICD-8 diagnosis of schizophrenia were scrutinized. Seventy-eight patients (76%) were classified as positively fulfilling the DSM-III criteria. In a global assessment, taking into account a lack of documentation on some criteria, 85 patients (83%) were judged as fulfilling the DSM-III criteria for schizophrenia. Excluding the ICD-8 schizo-affective subgroup, 88% of the patients fulfilled the DSM-III criteria for schizophrenia. The DSM-III schizophrenia criteria seem to fit the Swedish diagnostic tradition, except for the age limit of 45 years which excluded 36% of the paranoid group. The study confirms that the ICD ...

Changes in the pattern of aggressive behaviour among inpatients with changed ward organization.

Aggressive behaviour by psychiatric inpatients was investigated on the same ward during two separate 6‐month periods before and after a 50% decrease in number of beds but without changes in catchment area. Character of the patient group, patient turnover and medical practices as well as total number of staff on duty on the ward was virtually the same during the two periods. It is therefore assumed that differences in aggressive behaviour are mainly explained by effects due to the decreased number of beds per se. It was found that the 50% reduction did not affect the overall aggression frequency. However, inter‐patient violence increased while the number of more severe aggressive incidents towards staff members decreased.

Violence and threats of violence within psychiatric care – a comparison of staff and patient experience of the same incident

This study compared staff members’ and psychotic patients’ experiences of one and the same violent incident. The staff exposed to the violence completed the Staff Observation Aggression Scale (SOAS). The patients who had exhibited the violent behaviour were interviewed prior to discharge from the ward. When comparing the SOAS data with the patient interviews, it was found that the staff members were able to identify less than 50% of the provocations that the patient experienced. According to the patient interviews, giving the patient medication was far more often experienced as a provocation, resulting in violence, than the staff perceived. Knowledge about how to interpret the patients’ body language and other signals, and how patients perceive the staffs behaviour, must be understood for an efficient prevention of violence in psychiatric care.