2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

2.1 Medication for promoting de‑escalation

Which medication is effective in promoting de-escalation in people who are identified as likely to demonstrate significant violence?

Why this is important

Although there are studies that demonstrate the value of medication in the management of violence and aggression, there is little information on management before violence becomes overt. Often p.r.n. medication is given at this point but there is little evidence of efficacy. It is clearly preferable to avoid violence whenever possible.

This question should be addressed by a randomised controlled trial in which people at risk of becoming violent are randomised, with their consent, to 1 or more of the medications commonly used to effect rapid tranquillisation or other medication not normally used for this purpose. Outcomes should include measures of violence, degree of sedation, acceptability of the medication and adverse effects, all recorded over a suitable timescale to match the pharmacokinetic properties of the drugs.

2.2 Violence related to drug or alcohol misuse

What is the best environment in which to contain violence in people who have misused drugs or alcohol?

Why this is important

There are major problems in managing drug- and alcohol‑related violence. The risk of severe violence can last for many hours in people who have misused drugs and alcohol and most settings in which violence takes place (such as emergency departments) do not have the facilities needed to contain people for several hours with an adequate level of supervision. As a consequence many people are taken, often inappropriately, to police cells. It is likely that there are less expensive and more effective environments available for this purpose.

Data about the size of this problem and an epidemiological survey of its frequency and duration, as well as current methods of managing drug- and alcohol‑related violence, are needed to start answering this question.

2.3 Advance statements and decisions

What forms of management of violence and aggression do service users prefer and do advance statements and decisions have an important role in management and prevention?

Why this is important

There are widely differing opinions among service users about the best way of managing violence and decisions are often made according to personal preference. Advance statements and decisions are not widely used, although they might have an important role in management and prevention.

The question could be answered by randomising people who are at risk of becoming violent or who have demonstrated repeated violence into 2 groups: a control group with no advance statements and decisions, and a group who make advance statements and decisions indicating the forms of management they prefer and those they do not want. The subsequent frequency of violent episodes and their outcomes could then be compared.

2.4 Content and nature of effective de‑escalation

What is the content and nature of effective de‑escalatory actions, interactions and activities used by mental health nurses, including the most effective and efficient means of training nurses to use them in a timely and appropriate way?

Why this is important

Although it is regularly recommended, there has been little research on the nature and efficacy of verbal and non‑verbal de‑escalation for adults with mental health problems who become agitated. Research is needed to systematically describe current techniques for de‑escalation and develop and test these techniques with adults who have cognitive impairment or psychosis. In addition, research should be carried out to develop methods of training staff and test the outcomes of these methods.

There is a similar lack of research on the nature and efficacy of verbal and non‑verbal de‑escalation of seriously agitated children and young people with mental health problems. These techniques need to take account of and be adapted to the specific background, developmental/cognitive and psychiatric characteristics of this age group. Additional research should therefore be commissioned on the lines recommended for adults. The research should systematically describe expert practice in adults, develop and test those techniques in aroused children and young people with mental health problems, and develop and test different methods of training staff working with children and young people with mental health problems.

2.5 Long duration or very frequent manual restraint

In what circumstances and how often are long‑duration or repeated manual restraint used, and what alternatives are there that are safer and more effective?

Why this is important

Adults who are agitated and violent sometimes continue to struggle and fight during manual restraint and rapid tranquillisation may fail. This results in long periods of restraint and further doses of medication. These occurrences are used as justifications for seclusion and, very rarely, for the use of mechanical restraint if repeat episodes occur. Yet there is no information about the frequency of such events or the demography and symptomatology of the adults who are subject to such measures. Exploratory survey work should be commissioned as a matter of urgency to assess the scope of this problem and potential measures for prevention or alternative management that minimise excessive, severe and risky containment methods.

The reasons why children and young people with mental health problems need long‑duration or very frequent manual restraint may be expected to vary from those in adults but have similarly been little investigated. Exploratory survey work should therefore specifically address the scope of this problem as it affects children and young people and assess potential measures for prevention or alternative management that minimise any existing excessive, severe or risky containment methods.

  • National Institute for Health and Care Excellence (NICE)