Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): a randomized trial. Current practices in managing acutely disturbed patients at three hospitals in Rio de Janeiro-Brazil: a prevalence study Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine Head-to-head comparison of aggressive conventional therapy and three biological treatments and comparison of two de-escalation strategies in patients who respond to treatment: study protocol for a multicenter, randomized, open-label, blinded-assessor, phase 4 study Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine Therapeutic Touch and Agitation in Individuals With Alzheimer's Disease Non-pharmacological management of behavioural symptoms in nursing homes. Calming Music and Hand Massage With Agitated Elderly Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia The effect of the Safer Bars programme on physical aggression in bars: results of a randomized controlled trial. The response of agitated behavior to pain management in persons with dementia. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting. Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management. Behavioural management of aggression in dementia: a randomized controlled trial. Cognitive-behavioural therapy v. social activity therapy for people with psychosis and a history of violence: randomised controlled trial. Group-based cognitive-behavioural anger management for people with mild to moderate intellectual disabilities: cluster randomised controlled trial. Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary. A Brief Motivational Intervention for Physically Aggressive Dating Couples TREC-Rio trial: a randomised controlled trial for rapid tranquillisation for agitated patients in emergency psychiatric rooms [ISRCTN44153243] Impact of Cyberprogram 2.0 on Different Types of School Violence and Aggressiveness
BACKGROUND After de-escalation techniques have failed , restraints , seclusion and /or rapid tranquillization may be used for people whose aggression is due to psychosis . Most coercive acts of health care have not been evaluated in trials . METHOD People admitted to the emergency room of Instituto Philippe Pinel , Rio de Janeiro , Brazil , whose aggression/agitation was thought due to psychosis and for whom staff were unsure if best to restrict using physical restraints or a seclusion room  , were r and omly allocated to one or the other and followed up to 14 days . The primary outcomes were ' no need to change intervention early - within 1 h ' and ' not restricted by 4 h ' . RESULTS A total of 105 people were r and omized . Two-thirds of the people secluded were able to be fully managed in this way . Even taking into account the move out of seclusion into restraints , this study provides evidence that embarking on the less restrictive care pathway ( seclusion ) does not increase overall time in restriction of some sort [ not restricted by 4 h : relative risk 1.09 , 95 % confidence interval 0.75 - 1.58 ; mean time to release : restraints 337.6 ( s.d.=298.2 ) min , seclusion room 316.3 ( s.d.=264.5 ) min , p=0.48 ] . Participants tended to be more satisfied with their care in the seclusion group ( 17.0 % v. 11.1 % ) but this did not reach conventional levels of statistical significance ( p=0.42 ) . CONCLUSIONS This study should be replicated , but suggests that opting for the least restrictive option in circumstances where there is clinical doubt does not harm or prolong coercion Background The medical management of aggressive and violent behaviour is a critical situation for which there is little evidence . In order to prepare for a r and omised trial , due to start in the psychiatric emergency rooms of Rio de Janeiro in 2001 , a survey of current practice was necessary . Methods A seven day survey of pharmacological management of aggressive people with psychosis in the emergency rooms of all four public psychiatric hospitals in Rio de Janeiro , Brazil . Results In one hospital data were not available . Of the 764 people with psychosis attending these ERs , 74 were given IM medication for rapid tranquillisation ( 9.7 % , 2.1/week/100,000 ) . A haloperidol-promethazine mix ( with or without other drugs ) was used for the majority of patients ( 83 % ) . Conclusion The haloperidol-promethazine mix , given intramuscularly for rapid tranquilization , is prevalent in Rio , where it is considered both safe and efficient . However , scientific evaluation of all pharmacological approaches to rapid tranquilization of psychotic people is inadequate or incomplete and a r and omized trial of IM haloperidol-promethazine is overdue Objective To determine whether haloperidol alone results in swifter and safer tranquillisation and sedation than haloperidol plus promethazine . Design Pragmatic r and omised open trial ( January-July 2004 ) . Setting Psychiatric emergency room , Rio de Janeiro , Brazil . Participants 316 patients who needed urgent intramuscular sedation because of agitation , dangerous behaviour , or both . Interventions Open treatment with intramuscular haloperidol 5 - 10 mg or intramuscular haloperidol 5 - 10 mg plus intramuscular promethazine up to 50 mg ; doses were at the discretion of the prescribing clinician . Main outcome measures The primary outcome was proportion tranquil or asleep by 20 minutes . Secondary outcomes were asleep by 20 minutes ; tranquil or asleep by 40 , 60 , and 120 minutes ; physically restrained or given additional drugs within 2 hours ; severe adverse events ; another episode of agitation or aggression ; additional visit from the doctor during the subsequent 24 hours ; overall antipsychotic load in the first 24 hours ; and still in hospital after 2 weeks . Results Primary outcome data were available for 311 ( 98.4 % ) people , 77 % of whom were thought to have a psychotic illness . Patients allocated haloperidol plus promethazine were more likely to be tranquil or asleep by 20 minutes than those who received intramuscular haloperidol alone ( relative risk 1.30 , 95 % confidence interval 1.10 to 1.55 ; number needed to treat 6 , 95 % confidence interval 4 to 16 ; P=0.002 ) . No differences were found after 20 minutes . However , 10 cases of acute dystonia occurred , all in the haloperidol alone group . Conclusions Haloperidol plus promethazine is a better option than haloperidol alone in terms of speed of onset of action and safety . Enough data are now available to change guidelines that continue to recommend treatments that leave people exposed to longer periods of aggression than necessary and patients vulnerable to distressing and unsafe adverse effects . Trial registration Current Controlled Trials IS RCT N83261243 Background New targeted therapies and improved treatment strategies have dramatically improved the outcomes of patients with rheumatoid arthritis ( RA ) . However , it is unknown whether different early aggressive interventions can induce stable remission or a low-active disease state that can be maintained with conventional synthetic disease-modifying antirheumatic drug ( csDMARD ) therapy , and whether they differ in efficacy and safety . The Nordic Rheumatic Diseases Strategy Trials And Registries ( NORD-STAR ) study will assess and compare ( 1 ) the proportion of patients who achieve remission in a head-to-head comparison between csDMARD plus glucocorticoid therapy and three different biological DMARD ( bDMARD ) therapies with different modes of action and ( 2 ) two de-escalation strategies in patients who respond to first-line therapy . Methods / design In a pragmatic , 80–160-week , multicenter , r and omized , open-label , assessor-blinded , phase 4 study , 800 patients with early RA ( symptom duration less than 24 months ) are r and omized 1:1:1:1 to one of four different treatment arms : ( 1 ) aggressive csDMARD therapy with methotrexate + sulphasalazine + hydroxychloroquine + i.a . glucocorticoids ( arm 1A ) or methotrexate + prednisolone p.o . ( arm 1B ) , ( 2 ) methotrexate + certolizumab-pegol , ( 3 ) methotrexate + abatacept , or ( 4 ) methotrexate + tocilizumab . The primary clinical endpoint is the proportion of patients reaching Clinical Disease Activity Index ( CDAI ) remission at week 24 . Patients in stable remission over 24 consecutive weeks enter part 2 of the study earliest after 48 weeks . Patients not achieving sustained CDAI remission over 24 consecutive weeks , exit the study after 80 weeks . In part 2 , patients are re-r and omized to two different de-escalation strategies , either immediate or delayed ( after 24 weeks ) tapering , followed by cessation of study medication . All patients remain on stable doses of methotrexate  . The primary clinical endpoint in part 2 is the proportion of patients in remission ( CDAI ≤2.8 ) 24 weeks after initiating treatment de-escalation . Radiographic assessment will be performed regularly throughout the trial , and blood and urine sample s will be stored in a biobank for later biomarker analyses . Discussion NORD-STAR is the first investigator-initiated , r and omized , early RA trial to compare ( 1 ) csDMARD and three different bDMARD therapies head to head and ( 2 ) two different de-escalation strategies . The trial has the potential to identify which treatment strategy to apply in early RA to achieve the best possible outcomes for both patients and society . Trial registration NCT01491815 and NCT02466581 . Registered on 8 December 2011 and May 2015 , respectively . EudraCT : 2011 - 004720 - OBJECTIVE To examine factors associated with physical restraint in psychiatric emergency rooms . METHOD We extracted variables likely to predict use of physical restraints from a large r and omised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro . We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints . RESULTS Of 301 agitated , aggressive people admitted to emergency rooms , 73 ( 24 % ) were restrained during the first 2 h of admission . In Rio , younger people ( OR=1.03 for each year younger ) , exhibiting intense ( OR=2.53 ) or extreme agitation ( OR=7.71 ) , thought to result from substance misuse ( OR=1.75 ) or diagnoses other than psychosis ( OR=1.88 ) , arriving in the morning ( OR=1.64 ) were at greater risk of  physical restraints  than older , less severely aggressive or agitated people , arriving at the hospital during the afternoon or night . Hospital , gender , first admission to hospital and medication were not associated with risk of being restrained . CONCLUSION Restraint practice s in Rio are predictable and based on a limited clinical assessment . Predictive factors for physical restraint may vary worldwide , but should be monitored and studied to assist training , and to establish programs to evaluate and refine this controversial practice Abstract Objective To compare two widely used drug treatments for people with aggression or agitation due to mental illness . Design Pragmatic , r and omised clinical trial . Setting Three psychiatric emergency rooms in Rio de Janeiro , Brazil . Subjects 301 aggressive or agitated people . Interventions Open treatment with intramuscular midazolam or intramuscular haloperidol plus promethazine . Main outcome measures Patients tranquil or se date d at 20 minutes . Secondary outcomes : patients tranquil or asleep by 40 , 60 , and 120 minutes ; restrained or given extra drugs within 2 hours ; severe adverse events ; another episode of agitation or aggression ; needing extra visits from doctor during first 24 hours ; overall antipsychotic load in first 24 hours ; and not discharged by two weeks . Results 151 patients were r and omised to midazolam , and 150 to haloperidol-promethazine mix . Follow up for the primary outcome was available for 298 ( 99 % ) : 134/151 ( 89 % ) of patients given midazolam were tranquil or asleep after 20 minutes compared with 101/150 ( 67 % ) of those given haloperidol plus promethazine ( relative risk 1.32 ( 95 % confidence interval 1.16 to 1.49 ) ) . By 40 minutes , midazolam still had a statistically and clinical ly significant 13 % relative advantage ( 1.13 ( 1.01 to 1.26 ) ) . After 1 hour , about 90 % of both groups were tranquil or asleep . One important adverse event occurred in each group : a patient given midazolam had transient respiratory depression , and one given haloperidol-promethazine had a gr and e mal seizure . Conclusions Both treatments were effective . Midazolam was more rapidly sedating than haloperidol-promethazine , reducing the time people are exposed to aggression . Adverse effects and re sources to deal with them should be considered in the choice of the treatment Limited effective strategies exist to alleviate or treat disruptive behaviors in people with Alzheimer 's disease . Fifty-one residents of a long-term care facility with Alzheimer 's disease were r and omly assigned to one of three intervention groups . A multiple time series , blinded , experimental design was used to compare the effectiveness of therapeutic touch , simulated therapeutic touch , and usual care on disruptive behavior . Three forms of disruptive behavior comprised the dependent variables : physical aggression , physical nonaggression , and verbal agitation . Physical nonaggressive behaviors decreased significantly in those residents who received therapeutic touch compared with those who received the simulated version and the usual care . No significant differences in physically aggressive and verbally agitated behaviors were observed across the three study groups . The study provided preliminary evidence for the potential for therapeutic touch in dealing with agitated behaviors by people with dementia . Research ers and practitioners must consider a broad array of strategies to deal with these behaviors BACKGROUND Behavioural and psychological symptoms of dementia ( BPSD ) are often reported in institutions for the elderly . OBJECTIVE To evaluate the effectiveness of a staff education intervention to manage BPSD in older people with a diagnosis of dementia . METHODS The trial was conducted in 16 nursing homes ; 306 patients with a diagnosis of dementia and presenting BPSD were selected . Nursing homes were r and omly allocated to an intervention group or a control group . An 8-week staff education and training programme was conducted in the nursing homes in the intervention group . The main outcome measures were the Cohen-Mansfield Agitation Inventory ( CMAI ) and an Observation Scale ( OS ) score . Assessment s were done at baseline ( W0 ) , at the end of the ' intervention ' period ( W8 ) and 12 weeks after ( W20 ) . RESULTS There was a significant decrease in the global CMAI score between baseline and W8 ( -7.8 ; p > 0.01 ) and between baseline and W20 ( -6.5 ; p > 0.01 ) in the intervention group but not in the control group . Results of mixed linear models showed that the CMAI global score , the CMAI physically non-aggressive behaviours subscale score and verbally non-aggressive behaviours subscale score significantly decreased in the intervention group ( p < 0.001 ) although there was no significant evolution in the control group . Direct assessment with the OS produced the same pattern of results , with a significant decrease only in the intervention group . CONCLUSION The intervention reduced BPSD in severely demented nursing home residents and this effect was still present 3 months after the end of the programme Background Agitated behavior is a widespread problem that adversely affects the health of nursing home residents and increases the cost of their care . Objective To examine whether modifying environmental stimuli by the use of calming music and h and massage affects agitated behavior in persons with dementia . Method A four group , repeated measures experimental design was used to test the effect of a 10-minute exposure to either calming music , h and massage , or calming music and h and massage simultaneously , or no intervention ( control ) on the frequency and type of agitated behaviors in nursing home residents with dementia ( N = 68 ) . A modified version of the Cohen-Mansfield Agitation Inventory was used to record agitated behaviors . Results Each of the experimental interventions reduced agitation more than no intervention . The benefit was sustained and increased up to one hour following the intervention ( F = 6.47 , p < .01 ) . The increase in benefit over time was similar for each intervention group . When types of agitated behaviors were examined separately , none of the interventions significantly reduced physically aggressive behaviors ( F = 1.93 , p = .09 ) , while physically nonaggressive behaviors decreased during each of the interventions ( F = 3.78 , p < 01 ) . No additive benefit result ed from simultaneous exposure to calming music and h and massage . At one hour following any intervention , verbally agitated behavior decreased more than no intervention . Conclusion Calming music and h and massage alter the immediate environment of agitated nursing home residents to a calm structured surrounding , off setting disturbing stimuli , but no additive benefit was found by combining interventions simultaneously This study aim ed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis . We prospect ively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period ( n = 157 ) . We used the Modified  Overt Aggression Scale  to retrospectively assess aggression ( a hostile or destructive mental attitude , including verbal aggression , physical aggression and /or violence ) and  violence  ( the exercise of physical force ) , blind to diagnosis . One in three patients with psychosis was aggressive at the time of presentation . One patient in 14 engaged in violence that caused , or was likely to cause , injury to other people . Aggression was independently associated with drug misuse ( odds ratio ( OR ) 2.80 , 95 % confidence interval 1.12 - 6.99 ) and involuntary admission status ( OR = 3.62 , 95 % CI 1.45 - 9.01 ) . Violence in the week prior to presentation was associated with drug misuse ( OR = 2.75 , CI 1.04 - 7.24 ) and involuntary admission status ( OR = 3.21 , CI 1.21 - 8.50 ) . Violence in the week following presentation was associated with poor insight ( OR 2.97 , CI 1.03 - 8.56 ) and pre-contact violence ( OR 3,82 , CI 1.34 - 10.88 ) . In patients with schizophrenia , violence in the week following presentation was associated with drug misuse ( OR = 7.81 , CI 1.33 - 45.95 ) and high psychopathology scores ( OR = 20.59 , CI 1.66 - 254.96 ) . Overall , despite a high rate of verbal aggression , physical violence towards other people is uncommon in individuals presenting with first episode psychosis Objectives : This study , as part of a larger programme of research , sought to investigate the effect that participation in a 40-min live group music programme , involving facilitated engagement with song-singing and listening , three times a week for eight weeks , had on agitation and anxiety in older people with dementia . Methods : A r and omized cross-over design , with music and reading control groups , was employed . Forty-seven participants with mild – moderate dementia , from two aged care facilities in Queensl and , Australia , were recruited . Participants were assessed three times on the Cohen-Mansfield Agitation Inventory – Short Form ( CMAI-SF ) and the Rating Anxiety in Dementia Scale ( RAID ) . Results : A sub- analysis of 24 participants attending ≥50 % of music sessions found a significant increase in the frequency of verbal aggression over time , regardless of group ( F(2,46 ) = 3.534 , p < 0.05 ) . A series of multiple regressions found cognitive impairment , length of time living in the facility and gender to be predictors of agitation overall and by subtype . Conclusion : Participation in the music programme did not significantly affect agitation and anxiety in older people with dementia . Both the music and reading group activities , however , gave some participants a ‘ voice ’ and increased their verbalization behaviour . Agitation was found to be predicted by a number of background factors ( namely level of cognitive impairment , length of time in the facility and gender ) . Future studies would benefit more from in-depth participant assessment prior to study commencement , helping to moderate the influence of low scores , and by undertaking interventions at times when assessed symptoms are most prevalent The purpose of this study was to evaluate the effectiveness of Safer Bars , an intervention to reduce aggression in bars . A total of 734 pre - post-intervention observations were conducted by trained observers on Friday and Saturday nights between midnight and 2 a.m. in 18 large capacity ( > 300 ) Toronto bars and clubs assigned r and omly to receive the intervention ( 69 % participation rate of the 26 assigned ) and 12 control bars .  As part of the intervention , owners/managers completed the  risk assessment workbook  to identify ways of reducing environmental risks , and 373 staff and owners/managers ( 84 % participation rate ) attended a 3-hour training session focused on preventing escalation of aggression , working as a team and resolving problem situations safely . The main outcome measures were rates of severe aggression ( e.g. punching , kicking ) and moderate physical aggression ( e.g. shoving , grappling ) . Hierarchical linear modelling ( HLM ) comparing pre - post aggression for intervention versus control bars indicated a significant effect of the intervention in reducing severe and moderate aggression . This effect was moderated by turnover of managers and door/security staff with higher post-intervention aggression associated with higher turnover in the intervention bars . The findings indicate the potential for a st and -alone relatively brief intervention to reduce severe and moderate physical aggression in bars OBJECTIVES Behavioral disturbances and pain are common in nursing home ( NH ) patients with dementia . An association between pain and increased agitation has been suggested , and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia . We now examined which specific agitated behaviors respond to individualized pain treatment . DESIGN Cluster r and omized clinical trial . SETTING 60 clusters ( i.e. , clusters defined as single independent NH units ) in 18 NHs within five municipalities of Western Norway . PARTICIPANTS 352 patients with moderate to severe dementia and clinical ly significant behavioral disturbances . INTERVENTION The control group received usual treatment and care . According to a predefined scheme for 8 weeks , all patients in the intervention group received individual daily pain treatment with acetaminophen , extended release morphine , buprenorphine transdermal patch , and /or pregabaline . MEASUREMENTS Cohen-Mansfield Agitation Inventory subscales and items . RESULTS Analyses demonstrated that Factor 3 ( Verbally agitated behaviors ) showed the largest significant difference ( DF = 1204.0 , t = -4.308 , p < 0.001 ) , followed by Factor 2 ( Physically non-aggressive behaviors ) ( DF = 1198.0 , t = -2.672 , p = 0.008 ) , and Factor 1 ( Aggressive behaviors ) ( DF = 1196.0 , t = -2.093 , p = 0.037 ) after 8 weeks , by a linear r and om intercept mixed model in two-way repeated- measures configuration with adjustment for heteroscedasticity . CONCLUSION We found that verbal agitation behaviors such as complaining , negativism , repetitious sentences and questions , constant request for attention , and cursing or verbal aggression responded to pain treatment . In addition , restlessness and pacing were sensible to analgesics . Such behaviors should therefore lead to an assessment of pain , and pain treatment . Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed BACKGROUND The pharmacological management of violence in people with psychiatric disorders is under- research ed . AIMS To compare interventions commonly used for controlling agitation or violence in people with serious psychiatric disorders . METHOD We r and omised 200 people to receive intramuscular lorazepam ( 4 mg ) or intramuscular haloperidol  ( 10 mg ) plus promethazine ( 25 - 50 mg mix ) . RESULTS At blinded assessment s 4 h later ( 99.5 % follow-up ) , equal numbers in both groups ( 96 % ) were tranquil or asleep . However , 76 % given the haloperidol-promethazine mix were asleep compared with 45 % of those allocated lorazepam ( RR=2.29,95 % CI 1.59 - 3.39 ; NNT=3.2,95 % CI 2.3 - 5.4 ) . The haloperidol-promethazine mix produced a faster onset of tranquillisation/sedation and more clinical improvement over the first 2 h. Neither intervention differed significantly in the need for additional intervention or physical restraints , numbers absconding , or adverse effects . CONCLUSIONS Both interventions are effective for controlling violent/agitated behaviour . If speed of sedation is required , the haloperidol-promethazine combination has advantages over lorazepam OBJECTIVES To examine the prevalence , correlates , and medication management of behavioral symptoms in elderly people living in residential care/assisted living ( RC/AL ) facilities . DESIGN Cross-sectional study . SETTING S A stratified r and om sample of 193 RC/AL facilities in four states ( Florida , Maryl and , New Jersey , North Carolina ) . PARTICIPANTS A total of 2,078 RC/AL residents aged 65 and older . MEASUREMENT Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory . Additional items on resistance to care were also examined . RESULTS Approximately one-third ( 34 % ) of RC/AL residents exhibited one or more behavioral symptoms at least once a week . Thirteen percent exhibited aggressive behavioral symptoms , 20 % demonstrated physically nonaggressive behavioral symptoms , 22 % expressed verbal behavioral symptoms , and 13 % resisted taking medications or activities of daily living care . Behavioral symptoms were associated with the presence of depression , psychosis , dementia , cognitive impairment , and functional dependency , and these relationships persisted across subtypes of behavioral symptoms . Overall , behavioral symptoms were more prevalent in smaller facilities . More than 50 % of RC/AL residents were taking a psychotropic medication  , and two-thirds had some mental health problem indicator ( dementia , depression , psychosis , or other psychiatric illness ) . CONCLUSION Integrating mental health services within the process of care in RC/AL is needed to manage and accommo date the high prevalence of behavioral symptoms in this evolving long-term setting OBJECTIVE To evaluate the efficacy of a brief behaviour management training programme for family carers of patients with dementia and aggressive behaviour . DESIGN A r and omized controlled trial of a four-session , community-based behaviour management programme . The primary outcome measure was the Rating Scale for Aggressive Behaviour in the Elderly . PARTICIPANTS 62 patients with dementia , and their co-resident carers . RESULTS There were no significant differences in aggression scores between behaviour management and control groups at follow-up . After adjusting for baseline differences in Rating Scale for Aggressive Behaviour in the Elderly scores , there was a trend towards a reduction in aggressive behaviour in the patients in the behaviour management group compared with those in the control group ( F = 3.37 , P = 0.071 ) . CONCLUSIONS This study adds to the small evidence base for the effectiveness of behavioural management strategies in dementia BACKGROUND Aggression and violence are serious problems in schizophrenia . Cognitive-behavioural therapy ( CBT ) has been shown to be an effective treatment for psychosis although there have been no studies to date evaluating the impact of CBT for people with psychosis and a history of violence . AIMS To investigate the effectiveness of CBT on violence , anger , psychosis and risk outcomes with people who had a diagnosis of schizophrenia and a history of violence . METHOD This was a single-blind r and omised controlled trial of CBT v. social activity therapy ( SAT ) with a primary outcome of violence and secondary outcomes of anger , symptoms , functioning and risk . Outcomes were evaluated by masked assessors at 6 and 12 months ( trial registration : NRR NO50087441 ) . RESULTS Significant benefits were shown for CBT compared with control over the intervention and follow-up period on violence , delusions and risk management . CONCLUSIONS Cognitive-behavioural therapy targeted at psychosis and anger may be an effective treatment for reducing the occurrence of violence and further investigation of its benefits is warranted BACKGROUND Many people with intellectual disabilities find it hard to control their anger and this often leads to aggression which can have serious consequences , such as exclusion from mainstream services and the need for potentially more expensive emergency placements . AIMS To evaluate the effectiveness of a cognitive-behavioural therapy ( CBT ) intervention for anger management in people with intellectual disabilities . METHOD A cluster-r and omised trial of group-based 12-week CBT , which took place in day services for people with intellectual disabilities and was delivered by care staff using a treatment manual . Participants were 179 service users identified as having problems with anger control r and omly assigned to either anger management or treatment as usual . Assessment s were conducted before the intervention , and at 16 weeks and 10 months after r and omisation ( trial registration : IS RCT N37509773 ) . RESULTS The intervention had only a small , and non-significant , effect on participants ' reports of anger on the Provocation Index , the primary outcome measure ( mean difference 2.8 , 95 % CI -1.7 to 7.4 at 10 months ) . However , keyworker Provocation Index ratings were significantly lower in both follow-up assessment s , as were service-user ratings on another self-report anger measure based on personally salient triggers . Both service users and their keyworkers reported greater usage of anger coping skills at both follow-up assessment s and keyworkers and home carers reported lower levels of challenging behaviour . CONCLUSIONS The intervention was effective in improving anger control by people with intellectual disabilities . It provides evidence of the effectiveness of a CBT intervention for this client group and demonstrates that the staff who work with them can be trained and supervised to deliver such an intervention with reasonable fidelity Background Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms . This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia . Methods This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant r and omised controlled trials . We search ed electronic data bases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and up date d search es in October 2016 . We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care setting s. This paper presents findings from a narrative synthesis of 48 r and omised controlled trials evaluating interventions for people living with dementia alone , family carers alone and patient-carer dyads . Results We retrieved 17,871 de-duplicated records and screened them for potential inclusion . Evidence from 48 r and omised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes . Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms , but professional comparisons are lacking and there is no shared language about or underst and ing of behavioural and psychological symptoms amongst professionals , or between professionals and family carers . Conclusions Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms . It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms OBJECTIVES New treatment options for dementia and its behavioral disturbances have become available since publication of The Expert Consensus Guidelines on the Treatment of Agitation in Older Persons with Dementia in 1998 . While only 2 cholinesterase inhibitors , donepezil and tacrine , were available in 1998 , 3 new cognitive-enhancing agents have been introduced since that time as well as several new atypical antipsychotics and antidepressants . However , there are still limited data from controlled studies to guide clinicians in choosing among these agents and sequencing and combining treatments . We therefore conducted a new survey study of expert opinion on the treatment of cognitive impairment and behavioral disturbances associated with dementia . METHODS Based on a literature review , a 61- question survey was developed with 1,225 options . Most options were scored using a modified version of the R AND 9-point scale for rating appropriateness of medical decisions . For other options , the experts were asked to write in answers . The survey was sent to 50 North American experts on dementia , 100 % of whom completed it . In analyzing responses to items rated on the 9-point scale , consensus was defined as a nonr and om distribution of scores by chi-square " goodness-of-fit " test . Based on the 95 % confidence interval around the mean , we assigned a categorical rank ( first line/preferred , second line/alternate , third line/usually inappropriate ) to each option . Guidelines indicating preferred treatment strategies were then developed for selected clinical situations . RESULTS For patients at risk for dementia , the experts recommended control of hypertension and diabetes . They also recommended aspirin and would consider a lipid-lowering agent in patients at risk for vascular dementia . Cholinesterase inhibitors were an option for patients with mild cognitive impairment ( i.e. , at risk for Alzheimer 's dementia [ AD ] ) . To slow cognitive impairment in mild/moderate AD , the experts recommended a cholinesterase inhibitor alone or combined with vitamin E. Donepezil and  galantamine  were the preferred cholinesterase inhibitors . The experts recommended combining a cholinesterase inhibitor with a N-methyl-D-aspartate ( NMDA ) antagonist ( e.g. , memantine ) if a patient with mild/moderate dementia has an inadequate response to monotherapy . Control of hypertension and diabetes was the treatment of choice , in patients with mild/moderate vascular or mixed AD/vascular dementia , with aspirin another first-line option . Cholinesterase inhibitors were also a first-line option for mild/moderate mixed AD/vascular dementia . Among nonpharmacological interventions for mild/moderate dementia , the experts recommended caregiver education , supportive therapy for caregivers , referral to day treatment , exercise programs , and respite care . For moderate/severe AD or mixed AD/vascular dementia , the experts recommended combining an NMDA antagonist with a cholinesterase inhibitor . For moderate/severe vascular or mixed AD/vascular dementia , they recommended control of hypertension and diabetes . The experts ' ratings underscore the importance of nonpharmacological strategies aim ed at reducing caregiver burden in more severe dementia . Management of agitation and other behavioral disturbances was another focus of this study . The experts recommended using an atypical antipsychotic for agitation associated with delirium , psychosis , aggression , or anger . They would also consider divalproex to manage anger with a risk of physical aggression . Selective serotonin reuptake inhibitors were recommended for the treatment of depression or anxiety in patients with dementia . Benzodiazepines or atypical antipsychotics were viewed as short-term options for acute anxiety .  Trazodone was recommended for insomnia . The experts also gave recommendations concerning dosage levels , duration of treatment , and choice of medications for patients with different complicating conditions . CONCLUSIONS The experts reached high levels of consensus on key steps in treating dementia and associated behavioral disturbances . Within the limits of expert opinion and with the expectation that new research data will take precedence , these guidelines may provide direction for clinicians offering care to patients with dementia Motivational interviewing is a brief non-confrontational intervention design ed to enhance motivation to reduce harmful behavior ( Miller and Rollnick 2002 ) . The purpose of this study was to examine the effectiveness of motivational interviewing as a targeted prevention approach for partner aggression in emerging adulthood . Participants were 50 college dating couples between 18 and 25 years old who reported at least one act of male-to-female physical aggression in their current relationships . After completing a 2-hour assessment session , half of all couples were r and omly assigned to a 2-hour individualized motivational feedback session targeting physical aggression and risk factors for aggression . The remaining couples received minimal , non-motivational feedback . Follow-up surveys were conducted 3 , 6 , and 9 months later . Hierarchical linear modeling analyses indicated that , compared to the control condition , the motivational feedback intervention led to reductions in physical aggression and harmful alcohol use and to less acceptance of female psychological aggression and male psychological aggression ( among women only ) . Lagged analyses indicated that changes in physical aggression were predicted by reductions in psychological aggression and by lower acceptance of both male and female psychological aggression . Reductions in physical aggression predicted lower anxiety and greater relationship investment and male relationship commitment over time . These findings suggest that a brief motivational intervention is a useful prevention approach for high-risk dating couples , with benefits to both individual and relationship functioning Background Agitated or violent patients constitute 10 % of all emergency psychiatric treatment . Management guidelines , the preferred treatment of clinicians and clinical practice all differ . Systematic review s show that all relevant studies are small and none are likely to have adequate power to show true differences between treatments . Worldwide , current treatment is not based on evidence from r and omised trials . In Brazil , the combination haloperidol-promethazine is frequently used , but no studies involving this mix exist . Methods TREC-Rio ( Tranquilização Rápida-Ensaio Clínico [ Translation : Rapid Tranquillisation- Clinical Trial ] ) will compare midazolam with haloperidol-promethazine mix for treatment of agitated patients in emergency psychiatric rooms of Rio de Janeiro , Brazil . TREC-Rio is a r and omised , controlled , pragmatic and open study . Primary measure of outcome is tranquillisation at 20 minutes but effects on other measures of morbidity will also be assessed . TREC-Rio will involve the collaboration of as many health care professionals based in four psychiatric emergency rooms of Rio as possible . Because the design of this trial does not substantially complicate clinical management , and in several aspects simplifies it , the study can be large , and treatments used in everyday practice can be evaluated Some antibullying interventions have shown positive outcomes with regard to reducing violence . The aim of the study was to experimentally assess the effects on school violence and aggressiveness of a program to prevent and reduce  cyberbullying . The sample was comprised of a r and omly selected sample of 176 adolescents ( 93 experimental , 83 control ) , aged 13–15 years . The study used a repeated measures pre-posttest design with a control group . Before and after the program , two assessment instruments were administered : the “ Cuestionario de Violencia Escolar-Revisado ” ( CUVE-R [ School Violence Question naire – Revised ] ; Álvarez-García et al. , 2011 ) and the “ Cuestionario de agresividad premeditada e impulsiva ” ( CAPI-A [ Premeditated and Impulsive Aggressiveness Question naire ] ; And reu , 2010 ) . The intervention consisted of 19 one-hour sessions carried out during the school term . The program contains 25 activities with the following objectives : ( 1 ) to identify and conceptualize bullying/cyberbullying ; ( 2 ) to analyze the consequences of bullying/cyberbullying , promoting participants ’ capacity to report such actions when they are discovered ; ( 3 ) to develop coping strategies to prevent and reduce bullying/cyberbullying ; and ( 4 ) to achieve other transversal goals , such as developing positive variables ( empathy , active listening , social skills , constructive conflict resolution , etc . ) . The pre-posttest ANCOVAs confirmed that the program stimulated a decrease in : ( 1 ) diverse types of school violence — teachers ’ violence toward students ( ridiculing or publicly humiliating students in front of the class , etc . ) ; students ’ physical violence ( fights , blows , shoves … aim ed at the victim , or at his or her property , etc . ) ; students ’ verbal violence ( using offensive language , cruel , embarrassing , or insulting words … toward classmates and teachers ) ; social exclusion ( rejection or exclusion of a person or group , etc . ) , and violence through Information and Communication Technologies ( ICT ; violent behaviors by means of electronic instruments such as mobile phones and the Internet)— ; and ( 2 ) premeditated and impulsive aggressiveness . Pre-posttest MANCOVA revealed differences between conditions with a medium effect size . This work contributes an efficacious intervention tool for the prevention and reduction of peer violence . The conclusions drawn from this study have interesting implication s for educational and clinical intervention
Using de-escalation techniques  for people with psychosis induced aggression or agitation appears to be accepted as good clinical practice but is not supported by evidence from r and omised trials .
BACKGROUND Aggression is a disposition , a willingness to inflict harm , regardless of whether this is behaviourally or verbally expressed and regardless of whether physical harm is sustained .
De-escalation is a psychosocial intervention for managing people with disturbed or aggressive behaviour .
Secondary management strategies such as rapid tranquillisation , physical intervention and seclusion should only be considered once de-escalation and other strategies have failed to calm the service user .
OBJECTIVES To investigate the effects of de-escalation techniques in the short-term management of aggression or agitation  thought or likely to be due to psychosis .
It is unclear why it has remained such an under- research ed area .