Psychiatric In-Patient Violence: Use of Chemical and Physical Restraint at a University Hospital in Karachi, Pakistan

January-June 2006 Volume 3(1)

Original Article

Saman Iqbal, Haider Naqvi, Muhammad Naim Siddiqui
Page No:


Objective: To study the frequency of inpatient-violence and use of physical and chemical restraints in its management.


Design: Prospective observational study.


Place and duration of study: The Department of Psychiatry, Aga Khan University Hospital, Karachi between January 2004 and December 2004.


Subjects and Methods: Information on socio-demographic characteristics, psychiatric diagnoses, routine and as required psychotropic medications was collected for all patients admitted to psychiatric unit. An incidence reporting form was filled for each patient requiring physical restraint.


Result: Out of all the patients admitted (n=393) over the one-year period, 44% (n=175) patients required P.R.N. psychotropic medication. Intramuscular anti-psychotic medication was used in 50% cases, benzodiazepines in 33% while 16% required both. 14% (n=57) required physical restraints. 4-point restrain was used in 31 (54%) cases while 2-point restrain was used in 23 (40%) cases. No serious injury was noticed in any case. According to these two proxy indicators the frequency of violence in this in patients psychiatric setting is estimated to be 14%.


Conclusion: Incidence figures of inpatient violence in our psychiatric setting are alarmingly high. This requires systematic research related to the risk factors and determinants of inpatient violence.


Key words: Violence, Chemical restrain, Physical Restrain, Pakistan.


Elevated rates of violence are seen in people with mental disorder1-3. Due to complexity of this phenomenon and different definitions, existing research includes violence in community4,5, in-patient6,7 and forensic settings. Although various studies have been conducted on in-patient violence, they lack methodological vigor and findings are contradictory8. No study has been carried out in Pakistan. Inpatient violence is determined by various factors such as patient characteristics, number, habits and specific interventions of staff9,10, characteristics of hospital organization and even mental health care11. Incidence varies widely from 0.07 to 7.9 violent incidents per patient per year12. A multi-center study on Australian population reported 13.7% aggression among inpatients13.

Management of violence by inpatient staff includes coercive measures such as seclusion, physical restraint and medication-based restraint14. A number of factors determine which technique is applied when managing violent incidents. Possible influence of patients’ behavior, clinical diagnoses and available clinical supervision remains unexplored in Pakistan.

In a developing country such as ours where psychiatric inpatient care is mostly unregulated and unsupervised, adequate policies and legislation are needed as patients are at risk for abuse.

The objective of this study was to find the incidence of inpatient violence and look at the various methods used for its management.


The Aga Khan University Hospital is a 500-bedded facility that has a 15-bedded psychiatry ward. The Psychiatry Unit is designed to be a locked ward where routine movement of both personnel and property are regulated by a single door with electronic access cards. There is a close circuit central video monitoring system backed by 24-hour shift duties of security personals.

Patients are admitted either through the psychiatry clinics, emergency unit or transferred from general medical floors. Admission procedure mandates prior information to the ward staff. Seriously disturbed, violent and aggressive patients are initially admitted to one of the two seclusion rooms that also serve as observation rooms as they are situated in front of to the nursing station. Such patients are monitored closely with fifteen minute observations. In case of behavioral de-compensation consultant/resident on call is immediately informed.

First-line management is an attempt to de-escalate the crisis by psychological interventions. Secondline approaches include the use of psychotropic per requisite need (P.R.N) medication other than routine drugs and physical restrain. Second-line interventions are carried out only after orders of the consultant. Explicit documentation and incidence reporting for any form of restraint is required as part of hospital policy. Specific data collection forms for P.R.N psychotropic use and physical restraints were designed for the sake of studying violence in psychiatric in-patients’ settings. These forms were filled by on-duty nursing staff and physician. Data was entered and analyzed on SPSS (version 13).


Out of all the patients admitted (n=393) over one year period, 44% (n=175) patients required P.R.N psychotropic medication for management of violent and disturbed behavior. 14% (n=57) required physical restrain. Thus according to two proxy indicators the incidence of violence in inpatients psychiatric setting is estimated to be 14%. The characteristics of these incidences are discussed in following sections.

Physical restrain / Seclusion:

Among the 57 patients requiring physical restrain, 69% were males while 31% were females. 64% patients were less than 35 years of age. Table 1 shows psychiatric diagnoses of patients restrained. The most common condition among these patients was schizophrenia (31%) followed by Bipolar disorder (30%). Violent, threatening and agitated behavior was the most common reason for physical restrain. Of the 57 patients, 6 patients were restrained because of confusion and agitation resulting from their underlying clinical condition or psychotropic medications. Table 2 gives type and timing of restraint. Four-point restrain was used in more than half (54%) of patients. About 80% patients were restrained for less than half an hour. Most incidences of restrain were reported in the evening shift (42%). In 56 cases written physician orders were available prior to restrain while in one case verbal

Table 1:

Restrain pattern across different Psychiatric Diagnoses

Image Attached here...

Table 2:

Characteristics of Physical Restrain

Image Attached here...

Table 3:

Medications used for Chemical Restraint

Image Attached here...

orders were taken. In 70% cases family members of the patients were present in the ward and were notified/explained prior to the restrain, the rest were not available at the time for restrain. Skin condition of the limbs and peripheral pulses were checked periodically in all the cases. No serious injury was noticed except for minor abrasions and bruises in two cases.

Medications-Based Restraint:

In the patients requiring P.R.N medications male to female ratio was 3:1. 42% patients were less than 30 years. Depressive disorders (27%), followed by schizophrenia (20%) were the two most common clinical conditions requiring P.R.N medication (Table 1) Overt violence was the commonest presentation in 15% of cases.

Table 3 gives frequency of P.R.N. medications used, with conventional anti-psychotics, intramuscular Zuclopenthixol (27.6 %) and Haloperidol (23%) being the most commonly used, followed by benzodiazepines (33%).

All patients who required restrain (medications or/ and physical) were already on first line therapy for their primary disorder. These included anti-psychotic medications (55%), anti-depressants (23%), mood stabilizers (16%) and benzodiazepines (26%).


We believe this is the first study from Pakistan that looks at one-year prevalence of violent and disturbed behavior in psychiatric inpatients setting. From our study we have estimated it to be 14%. This figure appears to be an over-estimate compared to other studies. This may be due to the fact that at AKUH relatively more disturbed patients are admitted and hence a greater number requiring restraint. Only approximately 2% of patients seen in the outpatients setting (average attendance 7000/year) in a given year are admitted to the unit. The vast majority of the admissions are through the emergency room where the more disturbed patients in states of acute emergency tend to present. In our study the typical patient who is likely to be restrained is male, less than 35 years of age with acute psychotic symptoms.

Our study confirmed the higher risk of violence in psychiatry inpatients with the diagnosis of Schizophrenia as shown in previous studies2,3. Two factors heighten the risk of violence in patients with schizophrenia: comorbid substance abuse15 and acute psychotic symptoms16. Taylor et al17 estimated that 46% of sample of psychotic offenders were definitely or probably driven by delusions. Male gender is related to higher rates of violence15 and constituted majority of both chemically and physically restrained groups.

An important issue is how violence is defined because it varies greatly and reporting rates differ, depending on the levels of violence measured. Our study sample included both patients’ verbal threats as well as physical contact, hence the relatively higher reported violence. This highlights the need for the development of a standardised, validated and reliable rating instrument to screen for violence.

Drugs commonly used to manage agitation and violence in emergency situations include anti-psychotics, benzodiazepines or their combination18-20 as both are equally effective in controlling violent behavior21. Our study findings confirm this.

In managing inpatients’ aggression clinicians face the dual challenge of managing the patient’s violence while preserving the treatment alliance. Chemical restrain is a controversial issue22 in psychiatry and raises important issues for patient autonomy and infringement of human rights.

In the UK National Institute of Clinical Excellence (NICE) guidelines 200523 recommend the need for staff training in intermediate life support, availability of emergency resuscitation equipment, and the avoidance under all circumstances of applying pressure on the neck or thorax during manual restraint.

In Pakistan, where there is little regulation of psychiatric practice, the potential of abuse of disturbed psychiatric patients by inappropriate and excessive use of both physical and chemical restrain is huge. Unfortunately, the recently introduced Mental Health Ordinance, 2000 does not address the issue of physical and chemical restrain adequately.

At AKUH, policy and procedure documentation serves as a guideline in staff training and patient management. Physical restraint cannot be initiated with out a comprehensive multidisciplinary risk assessment and patient-carer’s involvement. Once restrained, patients’ peripheral pulses and skin is assessed periodically. In all circumstances a nursing staff aid keep the patient under observation throughout the period the patient is restrained.

It is important to keep in mind this is a descriptive study and inferences should be made in light of its strengths and weaknesses. We have drawn some empirical conclusions without focusing on any specific predictors of violence. Also our sample of patients may not be representative of the mentally ill population of Karachi, hence generalizations should be made with caution.


Inpatient violence in psychiatric setting is a frequent occurrence and its proper management is a major concern. More research is needed in measuring risk factors and determinants of inpatient violence in Pakistan. Based on findings, practice guidelines and policies need to be developed at organizational, institutional and national level. Academic bodies like College of Physicians and Surgeons, Pakistan (CPSP) and Pakistan Psychiatric Society (PPS) could organize research forums and conferences in liaison with other stake holders in order to facilitate this process.


1. Steuve A, Link BG. Violence and psychiatric disorders: results from an epidemiological study in Israel. Psychiatry Q 1997; 68: 327-42.

2. Coid JW. Dangerous patients with mental illness: increased risks warrant new policies, adequate resources, and appropriate legislation. Br Med J 1996; 312: 965-6.

3. Modestin J, Ammann R. Mental disorder and criminality: male schizophrenia. Schizophr Bull 1996; 22, 69-82.

4. Hodgins S. Mental disorder, intellectual deficiency and crime. Evidence from a birth cohort. Arch Gen Psychiatry 1992; 49: 476-83.

5. Wessely SC, Castle D, Douglas AJ, Taylor PJ. The criminal careers of incident cases of schizophrenia.

Psychol Med 1994; 24: 483–502.

6. Linaler OM, Busch-Iversen H. Predictors of imminent violence in psychiatric inpatients. Acta Psychiatr

Scand 1995; 92: 250-4.

7. Kiejna A, Janska-Skomorowska M, Baranowski P. Medical procedure with aggressive patients: experiences of the psychiatric clinic. Wroclaw Psychiatr Pol 1993; 27: 501–13.

8. Steinert T. Prediction of inpatient violence. Acta Psychiatr Scand 2002: 106 (Suppl 412): 133–41.

9. Rasmussen K, Levander S. Crime and violence among psychiatric patients in a maximum-security psychiatric hospital. Crim Just Behav 1996; 23: 455–71.

10. Lanza ML, Kayne HL, Hicks C, Milner J. Environmental characteristics related to patient assault. Issues Ment Health Nurs 1994; 15: 319–35.

11. Snyder W. Hospital downsizing and increased frequency of assaults on staff. Hosp Community Psychiatry 1994; 45: 378–80.

12. Soliman AE, Reza H. Risk factors and Correlates of Violence among Acutely ill adult Psychiatric inpatients. Psychiatric services 2001; 52: 75-80.

13. Barlow K, Grenyer B, Ilkiw-Lavalle O. Prevalence and precipitants of aggression in psychiatric inpatient

units. Aust NZ J Psychiatry 2000; 34: 967-74.

14. Gudjonsson GH, Rabe-hesketh S and Szmukler G. Management of psychiatric in-patient violence: patient ethnicity and use of medications, restraint and seclusion. Br J Psychiatry 2004; 184: 258-62.

15. Soyka M. Substance misuse, psychiatric disorder and violent and disturbed behaviour. Br J Psychiatry 2000; 176: 345-50.

16. Steinert T, Wolfle M, Gebhardt RP. Measurement of violence during inpatient treatment and association

with psychopathology. Acta Psychiatr Scand 2000; 102: 107-12.

17. Taylor JP, Gunn J. Homicide by people with mental illness; myth and reality. Br J Psychiatry 1999; 174: 9-14.

18. Allen MH. Managing the agitated psychotic patient: a reappraisal of the evidence. J Clin Psychiatry 2002; 6 (Suppl 14): 11–20.

19. Coutinho E, Fenton M, Adams C. Zuclopenthixol acetate in psychiatric emergencies: looking for evidence from clinical trials. Schizophr Res 2000; 46: 111–8.

20. McAllister-Williams RH, Ferrier IN. Rapid tranquillisation: time for a reappraisal of options for parenteral therapy. Br J Psychiatry 2002; 180:485–9.

21. Alexander J, Tharyan P. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting: Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Br J Psychiatry 2004; 185: 63-9.

22. Chemical Restraints: Clinical, research, and Ethical Implications. American Psychiatric Association (APA) Clinical highlight Program. [on Line] 2002 [Cited on 2005 May 01]. Available from: http://URL://

23. National Institute for Clinical Excellence. The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-Patient Settings and Emergency Departments. [on Line] 2005 [Cited on 2005 May 01] Available from: URL://