Trials assessing parmacotherapeutic management of aggression in psychiatric patients: comparability with clinical practice.

INTRODUCTION: In a previous review of randomized controlled trials (RCTs) on the pharmacotherapeutic management of aggression, it was shown that there is only weak evidence of effectiveness. In the present study we aim to determine comparability of patients included in these RCTs and patients of psychiatric long-stay wards. METHODS: Exclusion criteria that were used in at least 20% of the RCTs were applied to a sample of aggressive inpatients from clinical practice, in order to find what proportion of these patients would be eligible to participate in the reviewed, high quality RCTs. RESULTS: Only 30% of aggressive psychiatric patients as seen in clinical practice would be eligible to participate in a typical randomized controlled trial based on the most frequently applied exclusion criteria. DISCUSSION: The low comparability of patients included in RCTs with those seen in clinical practice may decrease the generalizability of the findings form RCTs to clinical practice.

Aggression of psychiatric patients associated with the use of as-needed medication.

INTRODUCTION: Previous studies showed that aggression is an important reason to prescribe as-needed medication. The objective of this study was to compare the use of as-needed medication in aggressive and non-aggressive psychiatric patients and to explore patterns of administration of as-needed medication around aggressive incidents. METHODS: An observational study in three psychiatric wards was conducted. Incidence densities of as-needed medication were determined for aggressive and non-aggressive patients and expressed as incidence density ratios [IDRs]. Intensity of as-needed medication used before and following aggressive incidents were determined within a 48-hours time-window. RESULTS: Aggressive patients had an increased use of both psychotropic and somatic as-needed medication (IDR, 2.5; 95% CI, 2.2-2.7 and IDR, 2.1; 95% CI, 1.8-2.4, respectively). Of the psychotropic medication for aggressive patients, 15% was administered in a time-window of 48 hours around an aggressive incident; in this time-window more as-needed medication was administered following an aggressive incident compared to earlier treatments. CONCLUSION: An increased use of both psychotropic and somatic as-needed medication is associated with aggressive behavior. Psychotropic as-needed medication is more frequently administered shortly after an aggressive incident than shortly before. However, more often as-needed medication is administered outside the 48 hours time-window around an aggressive incident.