Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: Systematic Review and Meta-Analysis—A 2019 Update

  • Ester di Giacomo
  • Laura Iozzino
  • Clarissa Ferrari
  • Cosmo Strozza
  • Matthew Large
  • Olav Nielssen
  • Giovanni de GirolamoEmail author
Part of the Comprehensive Approach to Psychiatry book series (CAP, volume 1)


Violence by patients in acute psychiatric wards affects both patients and staff. This study updates a 2015 meta-analysis of the prevalence of violent patients in acute psychiatric wards. Forty-two studies conducted in high-income countries were located in searches of the electronic databases PubMed, Scopus, and CINAHL. The pooled prevalence of reported acts of violence by patients was 18% (95% CI), although with very high heterogeneity (I2 = 98.7%, Q = 1735.3, p < 0.0001). Analysis of moderator variables found that 17.9% of the between-study heterogeneity was explained by the proportion of males (p = 0.0035), 16.4% by ward size (p = 0.0217), 12.8% by the proportion of involuntary patients (p = 0.0225), and 36.1% by the proportion of patients with alcohol-use disorder (p = 0.0007). The proportion of patients with other diagnoses, including psychotic illness, was not a source of heterogeneity.

The continued high rate of violence confirms the need for improvement in the identification and containment of violent behavior in psychiatric wards in order to provide safer and more therapeutic environments.


Violence Aggression Acute psychiatric ward Psychiatric admission Psychiatric inpatients 


  1. 1.
    Olofsson B, Jacobsson L. A plea for respect: involuntarily hospitalized psychiatric patients’ narratives about being subjected to coercion. J Psychiatr Ment Health Nurs. 2001;8(4):357–66.PubMedCrossRefGoogle Scholar
  2. 2.
    Daffern M, Mayer M, Martin T. Staff gender ratio and aggression in a forensic psychiatric hospital. Int J Ment Health Nurs. 2006;15(2):93–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Fisher WA. Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital. J Psychiatr Pract. 2003;9(1):7–15.PubMedCrossRefGoogle Scholar
  4. 4.
    Needham I, Abderhalden C, Halfens RJ, Dassen T, Haug HJ, Fischer JE. The effect of a training course in aggression management on mental health nurses’ perceptions of aggression: a cluster randomised controlled trial. Int J Nurs Stud. 2005;42(6):649–55.PubMedCrossRefGoogle Scholar
  5. 5.
    Bowers L, Simpson A, Alexander J, Hackney D, Nijman H, Grange A, et al. The nature and purpose of acute psychiatric wards: the Tompkins Acute Ward Study. J Ment Health. 2005;14(6):625–35.CrossRefGoogle Scholar
  6. 6.
    Authorities ACfL, England tNHSi. Change here!: managing change to improve local services: Audit Commission for Local Authorities & the NHS in England & Wales; 2001.Google Scholar
  7. 7.
    Caldwell MF. Incidence of PTSD among staff victims of patient violence. Hosp Community Psychiatry. 1992;43(8):838–9.PubMedGoogle Scholar
  8. 8.
    Hatch-Maillette MA, Scalora MJ, Bader SM, Bornstein BH. A gender-based incidence study of workplace violence in psychiatric and forensic settings. Violence Vict. 2007;22(4):449–62.PubMedCrossRefGoogle Scholar
  9. 9.
    Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: a systematic review. Psychiatry Res. 2011;189(1):10–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Di Giacomo E, Clerici M. Violence in psychiatric inpatients. Riv Psichiatr. 2010;45(6):361–4.PubMedGoogle Scholar
  11. 11.
    Dack C, Ross J, Papadopoulos C, Stewart D, Bowers L. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatr Scand. 2013;127(4):255–68.CrossRefPubMedGoogle Scholar
  12. 12.
    Iozzino L, Ferrari C, Large M, Nielssen O, de Girolamo G. Prevalence and risk factors of violence by psychiatric acute inpatients: a systematic review and meta-analysis. PLoS One. 2015;10(6):e0128536.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Podubinski T, Lee S, Hollander Y, Daffern M. An examination of the stability of interpersonal hostile-dominance and its relationship with psychiatric symptomatology and post-discharge aggression. Aggress Behav. 2016;42(4):324–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Eriksen BMS, Bjorkly S, Lockertsen O, Faerden A, Roaldset JO. Low cholesterol level as a risk marker of inpatient and post-discharge violence in acute psychiatry—a prospective study with a focus on gender differences. Psychiatry Res. 2017;255:1–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Cullen AE, Bowers L, Khondoker M, Pettit S, Achilla E, Koeser L, et al. Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services. Epidemiol Psychiatr Sci. 2018;27(1):51–61.PubMedCrossRefGoogle Scholar
  16. 16.
    Lockertsen O, Procter N, Vatnar SKB, Faerden A, Eriksen BMS, Roaldset JO, et al. Screening for risk of violence using service users’ self-perceptions: a prospective study from an acute mental health unit. Int J Ment Health Nurs. 2018;27(3):1055–65.PubMedCrossRefGoogle Scholar
  17. 17.
    Shafi A, Gallagher P, Stewart N, Martinotti G, Corazza O. The risk of violence associated with novel psychoactive substance misuse in patients presenting to acute mental health services. Hum Psychopharmacol. 2017;32(3) Scholar
  18. 18.
    Sanghani SN, Marsh AN, John M, Soman A, Lopez LV, Young YA, et al. Characteristics of patients involved in physical assault in an acute inpatient psychiatric setting. J Psychiatr Pract. 2017;23(4):260–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Renwick L, Stewart D, Richardson M, Lavelle M, James K, Hardy C, et al. Aggression on inpatient units: clinical characteristics and consequences. Int J Ment Health Nurs. 2016;25(4):308–18.PubMedCrossRefGoogle Scholar
  20. 20.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7.CrossRefGoogle Scholar
  21. 21.
    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Gilbody SM, Song F, Eastwood AJ, Sutton A. The causes, consequences and detection of publication bias in psychiatry. Acta Psychiatr Scand. 2000;102(4):241–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer J. Predicting inpatient violence using an extended version of the Broset-Violence-Checklist: instrument development and clinical application. BMC Psychiatry. 2006;6:17.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008;193(1):44–50.PubMedCrossRefGoogle Scholar
  27. 27.
    Amore M, Menchetti M, Tonti C, Scarlatti F, Lundgren E, Esposito W, et al. Predictors of violent behavior among acute psychiatric patients: clinical study. Psychiatry Clin Neurosci. 2008;62(3):247–55.CrossRefGoogle Scholar
  28. 28.
    Ash D, Galletly C, Haynes J, Braben P. Violence, self-harm, victimisation and homelessness in patients admitted to an acute inpatient unit in South Australia. Int J Soc Psychiatry. 2003;49(2):112–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Barlow K, Grenyer B, Ilkiw-Lavalle O. Prevalence and precipitants of aggression in psychiatric inpatient units. Aust N Z J Psychiatry. 2000;34(6):967–74.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Beauford JE, McNiel DE, Binder RL. Utility of the initial therapeutic alliance in evaluating psychiatric patients’ risk of violence. Am J Psychiatry. 1997;154(9):1272–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, et al. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009;197(10):772–82.PubMedCrossRefGoogle Scholar
  32. 32.
    Bjorkdahl A, Olsson D, Palmstierna T. Nurses’ short-term prediction of violence in acute psychiatric intensive care. Acta Psychiatr Scand. 2006;113(3):224–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Boggild AK, Heisel MJ, Links PS. Social, demographic, and clinical factors related to disruptive behaviour in hospital. Can J Psychiatry. 2004;49(2):114–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Bowers L, Simpson A, Alexander J. Patient-staff conflict: results of a survey on acute psychiatric wards. Soc Psychiatry Psychiatr Epidemiol. 2003;38(7):402–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Carr VJ, Lewin TJ, Sly KA, Conrad AM, Tirupati S, Cohen M, et al. Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures. Aust N Z J Psychiatry. 2008;42(4):267–82.CrossRefPubMedGoogle Scholar
  36. 36.
    Cookson A, Daffern M, Foley F. Relationship between aggression, interpersonal style, and therapeutic alliance during short-term psychiatric hospitalization. Int J Ment Health Nurs. 2012;21(1):20–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Dumais A, Larue C, Michaud C, Goulet MH. Predictive validity and psychiatric nursing staff’s perception of the clinical usefulness of the French version of the Dynamic Appraisal of Situational Aggression. Issues Ment Health Nurs. 2012;33(10):670–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Eaton S, Ghannam M, Hunt N. Prediction of violence on a psychiatric intensive care unit. Med Sci Law. 2000;40(2):143–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Ehmann TS, Smith GN, Yamamoto A, McCarthy N, Ross D, Au T, et al. Violence in treatment resistant psychotic inpatients. J Nerv Ment Dis. 2001;189(10):716–21.PubMedCrossRefGoogle Scholar
  40. 40.
    Grassi L, Peron L, Marangoni C, Zanchi P, Vanni A. Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study. Acta Psychiatr Scand. 2001;104(4):273–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Hartvig P, Roaldset JO, Moger TA, Ostberg B, Bjorkly S. The first step in the validation of a new screen for violence risk in acute psychiatry: the inpatient context. Eur Psychiatry. 2011;26(2):92–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Ketelsen R, Staude A, Godejohann F, Driesen M. The advisor team in the psychiatric hospital: assignments and experiences in coping with aggression and compulsion. Psychiatr Prax. 2007;34(6):306–10.PubMedCrossRefGoogle Scholar
  43. 43.
    Krakowski MI, Czobor P. Psychosocial risk factors associated with suicide attempts and violence among psychiatric inpatients. Psychiatr Serv. 2004;55(12):1414–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Lam JN, McNiel DE, Binder RL. The relationship between patients’ gender and violence leading to staff injuries. Psychiatr Serv. 2000;51(9):1167–70.PubMedCrossRefGoogle Scholar
  45. 45.
    Mauri MC, Rovera C, Paletta S, De Gaspari IF, Maffini M, Altamura AC. Aggression and psychopharmacological treatments in major psychosis and personality disorders during hospitalisation. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(7):1631–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Nijman HL, Merckelbach HL, Allertz WF, à Campo JM. Prevention of aggressive incidents on a closed psychiatric ward. Psychiatr Serv. 1997;48(5):694–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Nijman H, Merckelbach H, Evers C, Palmstierna T, à Campo J. Prediction of aggression on a locked psychiatric admissions ward. Acta Psychiatr Scand. 2002;105(5):390–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Oulis P, Lykouras L, Dascalopoulou E, Psarros C. Aggression among psychiatric inpatients in Greece. Psychopathology. 1996;29(3):174–80.PubMedCrossRefGoogle Scholar
  49. 49.
    Raja M, Azzoni A, Lubich L. Aggressive and violent behavior in a population of psychiatric inpatients. Soc Psychiatry Psychiatr Epidemiol. 1997;32(7):428–34.PubMedGoogle Scholar
  50. 50.
    Raja M, Azzoni A. Hostility and violence of acute psychiatric inpatients. Clin Pract Epidemiol Ment Health. 2005;1:11.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Saverimuttu A, Lowe T. Aggressive incidents on a psychiatric intensive care unit. Nurs Stand. 2000;14(35):33–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Troisi A, Kustermann S, Di Genio M, Siracusano A. Hostility during admission interview as a short-term predictor of aggression in acute psychiatric male inpatients. J Clin Psychiatry. 2003;64(12):1460–4.PubMedCrossRefGoogle Scholar
  53. 53.
    Cohen DP, Akhtar MS, Siddiqui A, Shelley C, Larkin C, Kinsella A, et al. Aggressive incidents on a psychiatric intensive care unit. Psychiatr Bull. 2008;32:455–8.CrossRefGoogle Scholar
  54. 54.
    Daffern MTS, Ferguson M, Podubinski T, Hollander Y, Kulkhani J, et al. The impact of psychiatric symptoms, interpersonal style, and coercion on aggression and self-harm during psychiatric hospitalization. Psychiatry. 2010;73(4):365–81.PubMedCrossRefGoogle Scholar
  55. 55.
    L. M. Aggression on a psychiatric acute ward: a three-year prospective study. Psychol Rep. 2003;92:1229–48.CrossRefGoogle Scholar
  56. 56.
    Owen CTC, Jones M, Tennant C. Violence and aggression in psychiatric units. Psychiatr Serv. 1998;49(11):1452–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Ross JBL, Stewart D. Conflict and containment events in inpatient psychiatric units. J Clin Nurs. 2012;21:2306–15.PubMedCrossRefGoogle Scholar
  58. 58.
    Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001;52(1):75–80.PubMedCrossRefGoogle Scholar
  59. 59.
    Vaaler AE, Iversen VC, Morken G, Fløvig JC, Palmstierna T, Linaker OM. Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics. BMC Psychiatry. 2011;11:44.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Podubinski TLS, Hollander Y, Daffern M. Patient characteristics associated with aggression in mental health units. Psychiatry Res. 2017;250:141–5.PubMedCrossRefGoogle Scholar
  61. 61.
    Blomhoff S, Seim S, Friis S. Can prediction of violence among psychiatric inpatients be improved? Hosp Community Psychiatry. 1990;41(7):771–5.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ester di Giacomo
    • 1
    • 2
  • Laura Iozzino
    • 3
  • Clarissa Ferrari
    • 4
  • Cosmo Strozza
    • 5
    • 6
  • Matthew Large
    • 7
    • 8
  • Olav Nielssen
    • 9
  • Giovanni de Girolamo
    • 3
    Email author
  1. 1.School of Medicine and Surgery, University of Milan-BicoccaMonzaItaly
  2. 2.Department of Mental Health and AddictionASST MonzaMonzaItaly
  3. 3.Unit of Epidemiological and Evaluation PsychiatryIRCCS Centro San Giovanni di Dio FatebenefratelliBresciaItaly
  4. 4.Unit of StatisticsIRCCS Centro San Giovanni di Dio FatebenefratelliBresciaItaly
  5. 5.Department of Statistical Science‘La Sapienza’ UniversityRomeItaly
  6. 6.Interdisciplinary Centre on Population Dynamics (CPOP)Southern Denmark UniversityOdenseDenmark
  7. 7.Prince of Wales Hospital SydneySydneyAustralia
  8. 8.University of New South WalesSydneyAustralia
  9. 9.Faculty of Medicine and Health Science, Macquarie UniversitySydneyAustralia

Personalised recommendations