Faculty Bibliography

BACKGROUND: Inpatient aggression is a serious challenge in pediatric psychiatry. METHODS: A chart review study in adolescent psychiatric inpatients consecutively admitted over 24 months was conducted, to describe aggressive events requiring an intervention (AERI) and to characterize their management. AERIs were identified based on specific institutional event forms and/or documentation of as-needed (STAT/PRN) medication administration for aggression, both recorded by nursing staff. RESULTS: Among 408 adolescent inpatients (age: 15.2+/-1.6 years, 43.9% male), 1349 AERIs were recorded, with >/=1 AERI occurring in 28.4% (n=116; AERI+). However, the frequency of AERIs was highly skewed (median 4, range: 1-258). In a logistical regression model, the primary diagnosis at discharge of disruptive behavior disorders and bipolar disorders, history of previous inpatient treatment, length of hospitalization, and absence of a specific precipitant prior to admission were significantly associated with AERIs (R(2)=0.32; p<0.0001). The first line treatment of patients with AERIs (AERI+) was pharmacological in nature (95.6%). Seclusion or restraint (SRU) was used at least once in 59.4% of the AERI+ subgroup (i.e., in 16.9% of all patients; median within-group SRU frequency: 3). Treatment and discharge characteristics indicated a poorer prognosis in the AERI+ (discharge to residential care AERI+: 22.8%, AERI-: 5.6%, p<0.001) and a greater need for psychotropic polypharmacy (median number of psychotropic medications AERI+: 2; AERI-: 1, p<0.001). CONCLUSIONS: Despite high rates of pharmacological interventions, SRU continue to be used in adolescent inpatient care. As both of these approaches lack a clear evidence base, and as adolescents with clinically significant inpatient aggression have increased illness acuity/severity and service needs, structured research into the most appropriate inpatient aggression management is sorely needed.

Objective: The purpose of this study was to determine if persons with a diagnosis of schizophrenia lack insight into their illness because cognitive deficits prevent them from applying an internal schema of mental illness to themselves. The study examines the ability of subjects to "insightfully" classify a series of short, fictional vignettes from a third-person perspective. Method: Investigators wrote 20 one-to three-sentence stories, 11 illustrating subtypes of psychotic symptoms, 3 illustrating non-psychotic psychiatric diagnoses, 3 indicating medical problems, and 3 no illness. The investigators read these stories to a sample of inpatients with a diagnosis of schizophrenia and a random community sample control group, and asked if subjects considered the person in each story to be mentally ill. Results: Subjects and controls were able to make accurate, fine distinctions among medical illness, no illness, and psychiatric illness categories. Conclusions: Patients did not demonstrate a deficit in the cognitive processing of illness schema, yet still failed to relate their own illness schema to themselves. This would encourage further study of the relationship between insight, denial, the mental representation of the self, and the meaning of the "mental illness" label to persons with psychosis