De-escalation techniques for psychosis-induced aggression or agitation

Review question:

Are de-escalation techniques effective for managing psychosis-induced aggression or agitation?

Background

Aggression is 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 management of aggressive or agitated behaviour. It uses techniques that help someone with aggression or agitation to self-monitor their emotions and self-manage their behaviour to try and stop aggressive behaviour escalating.

Searches

We ran electronic searches (last searched April 2016) for trials that randomised people with psychosis who were displaying aggressive or agitated behaviour to receive de-escalation techniques, standard care or other intervention to manage aggression. Three-hundred and forty-five records were found and checked by the review authors.

Results

No trials met the review requirements. There is no trial-based evidence currently available assessing the effectiveness of de-escalation techniques for managing aggression or agitation.

Conclusions

It is unclear why there are no randomised trials. Several issues such as cost, ethical considerations, difficulty recruiting people into trials, as well the ability to accurately quantify the effects of de-escalation itself could all be contributing factors. Meanwhile, de-escalation techniques are currently used without any trial-based evidence that they are effective.

Authors' conclusions: 

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 randomised trials. It is unclear why it has remained such an under-researched area. Conducting trials in this area could be influenced by funding flow, ethical concerns - justified or not - anticipated pace of recruitment as well the difficulty in accurately quantifying the effects of de-escalation itself. With supportive funders and ethics committees, imaginative trialists, clinicians and service-user groups and wide collaboration this dearth of randomised research could be addressed.

Read the full abstract...
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.

Search strategy: 

We searched Cochrane Schizophrenia Group's Study-Based Register of Trials (latest search 7 April, 2016).

Selection criteria: 

Randomised controlled trials using de-escalation techniques for the short-term management of aggressive or agitated behaviour. We planned to include trials involving adults (at least 18 years) with a potential for aggressive behaviour due to psychosis, from those in a psychiatric setting to those possibly under the influence of alcohol or drugs and/or as part of an acute setting as well. We planned to include trials meeting our inclusion criteria that provided useful data.

Data collection and analysis: 

We used the standard methodological procedures expected by Cochrane. Two review authors inspected all abstracts of studies identified by the search process. As we were unable to include any studies, we could not perform data extraction and analysis.

Main results: 

Of the 345 citations that were identified using the search strategies, we found only one reference to be potentially suitable for further inspection. However, after viewing the full text, it was excluded as it was not a randomised controlled trial.

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