Assignment: Evidence-Based Project, Part 3: Critical Appraisal of Research

Realtors rely on detailed property appraisals—conducted using appraisal tools—to assign market values to houses and other properties. These values are then presented to buyers and sellers to set prices and initiate offers.

Research appraisal is not that different. The critical appraisal process utilizes formal appraisal tools to assess the results of research to determine value to the context at hand. Evidence-based practitioners often present these findings to make the case for specific courses of action.

In this Assignment, you will use an appraisal tool to conduct a critical appraisal of published research. You will then present the results of your efforts.

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To Prepare:

Reflect on the four peer-reviewed articles you selected in Module 2 and the four systematic reviews (or other filtered high- level evidence) you selected in Module 3.
Reflect on the four peer-reviewed articles you selected in Module 2 and analyzed in Module 3.
Review and download the Critical Appraisal Tool Worksheet Template provided in the Resources.

The Assignment (Evidence-Based Project)

Part 3A: Critical Appraisal of Research

Conduct a critical appraisal of the four peer-reviewed articles you selected by completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template. Choose a total of four peer- reviewed articles that you selected related to your clinical topic of interest in Module 2 and Module 3.

Note: You can choose any combination of articles from Modules 2 and 3 for your Critical Appraisal. For example, you may choose two unfiltered research articles from Module 2 and two filtered research articles (systematic reviews) from Module 3 or one article from Module 2 and three articles from Module 3. You can choose any combination of articles from the prior Module Assignments as long as both modules and types of studies are represented.

Part 3B: Critical Appraisal of Research

Based on your appraisal, in a 1-2-page critical appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Evaluation Table

Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 3A: Critical Appraisal of Research.

Aggression and violence are common behaviors observed in inpatient psychiatric units. The behaviors are also mostly addressed using seclusion, and chemical or physical restrain techniques which can be traumatic to the patients, infringe on their rights, and provoke further aggression and violence. Besides, they are non-therapeutic and do not address the patients’ concerns or offer reasonable solutions (Cho et al., 2019). Thus, it is crucial to implement interventions that improve patient-nurse interaction, restore trust, promote a safe environment, and educate patients on approaches to managing negative behavior. Using simple, inexpensive, yet effective group interventions for cognitive stimulation, interpersonal rehabilitation, and behavioral restructuring to support psychiatric patients creates the impetus for my clinical issue. The PICOT question for the clinical issue is: In adult patients, 18-45 years old with schizophrenia disorder, admitted to an inpatient unit of an acute psychiatric hospital (P), how does participation in unit-level therapeutic group activities (I) compared to non-participation in group activities (C) affect or decrease the use of restraint(O) in one month (T)?

Full APA formatted citation of selected article.

Article #1

Article #2

Article #3

Article #4

Porcelli, S., Bianchini, O., De Girolamo, G., Aguglia, E., Crea, L., & Serretti, A. (2016). Clinical factors related to schizophrenia relapse. International Journal of Psychiatry in Clinical Practice, 20(2), 54–69. https://doi.org/10.3109/13651501.2016.1149195

Lamsma, J., & Harte, J. M. (2015, May). Violence in Psychosis: Conceptualizing its Causal Relationship with Risk Factors. Aggression and Violent Behavior, 24, 75-82. http://dx.doi.org/https://doi.org/10.1016/j.avb.2015.05.003

Dongen, J., Buck, N., & Marleb, H. (2016, March 30). Positive Symptoms, Substance Use, and Psychopathic Traits as Predictors of Aggression in Persons with a Schizophrenia Disorder. Psychiatry Research, 237, 109 -113. http://dx.doi.org/10.1016/j.psychres.2016.01.068

Reinharth, J., Reynolds, G., Dill, C., & Serper, M. (2014, June). Cognitive Predictors of Violence in Schizophrenia: A Meta-Analytic Review. Schizophrenia Research: Cognition, 1(2), 101- 111. http://dx.doi.org/10.10162014.06.001

Evidence Level *

(I, II, or III)

III

Conceptual Framework

Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**

· The theoretical basis is not provided.

· The study was based on the theory that persecutory ideations are related to reactive aggression, and psychopathic traits are more connected with proactive aggression of inpatients.

· The theoretical basis is not provided.

Design/Method

Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria).

· The researchers employed a quantitative approach to reviewing literature published from January 1990 to March 2012 on the risk factors associated with schizophrenia.

Ø The inclusion criteria included:

· Articles are written in English.

· Articles that examined the risk of relapse in SCZ patients.

· Both randomized controlled trials (RCTs) and observational studies were included.

· For mixed samples, only data related to SCZ patients were considered.

· The articles included had to have a follow-up of at least six months.

· Articles excluded included those not written in English, case reports, and descriptive reviews.

· The researchers conducted a qualitative structured narrative review of pertinent studies published from 1990 to 2013, found through online databases and bibliographies.

· PubMed, PsycINFO, Science Direct, and Google Scholar were used to search for studies.

· Reviews and empirical studies were included.

· No restrictions were applied to the study design, language, sample characteristics, and measurement of psychosis and violence.

· Studies examining specific psychosis symptoms were included.

· Exclusion- Case reports and studies about self-harm.

· The researchers employed a quantitative study design.

· Inclusion- Patients diagnosed with schizophrenia spectrum disorder present for at least two years.

· Patients aged 18-60 years

· Exclusion- Patients with cognitive deficits, intellectual disabilities, or a history of another neurological disorder other than schizophrenia.

· This meta-analytic study investigated the relationship between cognitive impairment and schizophrenia acts of aggression.

· Electronic databases were used to search articles published up to April 2013 using the words and word stems “aggressive, psychotic, risk, cognitive, neurocognitive, and neurobiological.”

· Inclusion- Studies had to have an outcome measure that evaluates aggression and a predictor variable that can be considered cognitive or neurocognitive.

· Exclusion- Studies whose participants had psychosis of a clear biological origin; original neurocognitive data was not given; or if there were no comparisons between the neurocognitive and the aggression variables.

Sample/Setting

The number and characteristics of

patients, attrition rate, etc.

· 219 studies were included in the literature review.

· A sample of 69 studies was used.

· Sample-59 inpatients with schizophrenia.

· Setting- Two different general psychiatric hospitals.

· 29 studies were used.

Major Variables Studied

List and define dependent and independent variables

· Dependent variables- Schizophrenia relapse.

· Independent variables- Pharmacotherapy, Psychotherapy, and General Risk factors.

· Dependent variables- Violence in psychosis.

· Independent variables-

Demographic factors, social factors, substance use, insufficient insight, treatment non-compliance, and physiological factors.

· Dependent variables- Proactive aggression, reactive aggression, general aggression, and aggression on the ward.

· Independent variables- Positive symptoms, persecutory ideation, substance use, and psychopathy.

· Dependent variables- Violence

· Independent variables- Cognitive deficits.

Measurement

Identify primary statistics used to answer clinical questions (You need to list the actual tests done).

· The New Castle–Ottawa scale (NOS) was used to assess the quality of the studies.

· Mean.

· Mean score of Total PANSS score; Positive scale; Negative scale; General psychopathology scale.

· Data was represented in various ways, including odds ratios, independent groups, correlations, student T-tests, and frequencies.

Data Analysis Statistical or

Qualitative findings

(You need to enter the actual numbers determined by the statistical tests or qualitative data).

· 107 articles were analyzed for the relationship between general risk factors and relapse, 85 for the relationship between pharmacotherapy and relapse, and 28 investigated the effects of psychotherapy on relapse.

· The qualitative data conceptualized the causal relationships between risk factors and violence in psychosis.

· All variables were normally distributed apart from the Social Dysfunction and Aggression Scale (SDAS) scores.

· After the log transformation of the SDAS scores, the scores were approximately normally distributed.

· A correlation analysis was performed to examine the relations between the predictor variables and aggression measures.

· The meta-analysis employed a fixed-effects model.

· The heterogeneity of variance among the articles was assessed using the I2 statistic.

Findings and Recommendations

General findings and recommendations of the research

· The three main factors associated with relapse were: Factors connected with pharmacological treatment, Add-on psychotherapeutic treatments, and General risk factors.

· The study recommendations include a thorough assessment of the risk factors in daily clinical practice to individualize the relapse risk for each patient and offer a tailored treatment in high-risk subjects.

· The study found that violence is a potential outcome of various interrelated risk factors, including demographics, persecutory delusions, social factors, command hallucinations, comorbid antisocial personality pathology, substance use, inadequate insight, treatment non-adherence, and physiological factors.

· The study recommends that psychosis be evaluated at the symptom level via structured interviews. At the same time, collecting data on violent behavior should include case notes, criminal records, collateral information, and self-report measures.

· Psychopathy explained most of the variance in self-reported proactive and reactive aggression.

· Persecutory ideations explained most of the variance in aggression on the ward.

· The study recommends identifying comorbid factors in patients with schizophrenia for more accurate risk assessment and appropriate treatment in aggressive patients with schizophrenia.

· Study findings revealed that schizophrenia cognitive impairment had a significant risk for aggression.

· Global cognitive impairment and lack of insight were significant risk indicators for aggression.

· The study recommends assessing patients’ global cognitive ability to increasing variance in the comprehensive assessment and prediction of the risk of violence for patients with schizophrenia.

Appraisal and Study Quality

Describe the general worth of this research to practice.

What are the strengths and limitations of study?

What are the risks associated with implementation of the suggested practices or processes detailed in the research?

What is the feasibility of use in your practice?

· The study is valuable to clinical practice since it identified risk factors associated with a risk of relapse in schizophrenia patients.

· Relapse is a major deterrence in schizophrenia treatment.

· Thus, knowing these risk factors can enable clinicians to take initiatives to mitigate them, promoting better outcomes in schizophrenia patients.

· The strength of this study is in using 22 years of research and data collection.

· Limitations- The study did not directly compare the specific risk factors since data was largely unsuitable for a meta-analytic approach.

· The meta-analysis conducted on a single risk factor could not overcome the methodological limitations present in the currently available studies.

· No risks are associated with conducting an assessment of relapse risk factors.

· The proposed intervention is feasible in our clinical practice since clinicians can easily and fast assess general risk factors for relapse like the Patients’ clinical features, Gender, Age of onset, Duration of untreated psychoses, Substance misuse, Pre-morbid function, Social support, and insight.

· The study is essential to clinical practice since it helps clinicians to understand violence in psychosis.

· This enables them to improve its prevention and treatment, reduce the stigma associated with psychosis, and improve a patient’s legal position.

· Strengths- The study has conceptualized the causal relationship between violence and psychosis.

· It has proposed 41 probable causal pathways between the risk factors and violent behavior, constituting the most comprehensive overview of hypotheses regarding violence in psychosis.

· Limitations- The selection of literature used for this review was not exhaustive.

· The methodological quality of the articles included in the study was not systematically weighted for analysis.

· Risks- Using criminal records, case notes, collateral information, and self-report independently when evaluating risk for violence can result in incomplete or selective data.

· The approach is feasible in our clinical practice since clinicians can assess patients’ risk of violence using factors like persecutory delusions, command hallucinations, comorbid antisocial personality pathology, substance use, lack of insight, and non-adherence to treatment.

· The research is valuable to mental health practice since it explains factors contributing to aggression in schizophrenia patients.

· Aggression is a major concern in schizophrenia patients.

· Thus, recognizing factors that can make patients have reactive and proactive aggression and aggression in the ward is crucial to reducing aggressive behavior.

· Strength- This is the first study to examine the predictive value of various factors in different measures of aggressive behavior in patients with schizophrenia.

· Limitations- The study had a limited sample size, limiting the number of variables included as predictors in the regression models.

· The time frame of aggression on the ward was very limited.

· Risk- Clinicians may face hostile, disagreeable, and highly psychopathic patients when assessing risk factors for aggression.

· The proposed approach to evaluating patients at risk of aggression is feasible in our practice.

· Clinicians can assess risk factors like Persecutory ideations, psychopathic traits, and substance use using available screening tools like

Persecutory Questionnaire, Psychopathic Personality Inventory, and Comprehensive Assessment of Symptoms and History (CASH).

· The study is valuable to practice since the ability to assess and predict aggressive acts in schizophrenia patients reliably has essential implications for preventing and treating aggression.

· Strength- The study reviewed 29 original research articles that associated neurocognitive measurements with aggressive behavior in psychosis.

· Limitations- The heterogeneity of the data used made it difficult to take specific interventions in areas like executive functioning and impulsivity.

· Risks- Measurement of patients’ global cognitive ability is associated with no potential risk to patients or clinicians.

· The proposed strategy is feasible in our clinical setting since clinicians can easily assess patients’ cognitive factors that may increase their likelihood of schizophrenia aggression.

Key findings

· Schizophrenia patients with no maintenance therapy and treatment with first-generation antipsychotics were linked with a higher risk of relapse.

· Psychotherapy add-on, especially with cognitive behavior therapy and psycho-education for patients and relatives, demonstrated good efficacy in reducing the relapse rate.

· Some general risk factors could be modified, like the duration of untreated psychosis and substance misuse, while others could not be modified, like male gender and low pre-morbid level of functioning.

· Low self-control related to being male or young of age predisposes a patient toward violent behavior.

· A patient’s violent behavior may be driven by particular features of persecutory delusions and command hallucinations.

· Substance use can cause violence directly through decreased behavioral control or indirectly by placing a person in a criminogenic and unsupportive social environment.

· Only psychopathy had a marked unique contribution to the prediction of proactive aggression.

· Impulsive-antisocial traits of psychopathy were more strongly connected with proactive self-reported aggressive behavior, than fearless-dominance traits.

· None of the factors predicted an aggressive response.

· The study found that cognitive factors played a modest but consistent and significant role in the probability of schizophrenia aggression.

· Poorer insight into one’s illness, global cognitive capability, and the ability for perceptual reasoning relate to a slight increase in the probability of aggression.

Outcomes

· Patients on maintenance therapy, with long-acting formulations and generation antipsychotics (SGAs) treatments.

· The most effective SGAs for relapse prevention were clozapine and Olanzapine.

· The study did not causally explain the association between psychosis and violence.

· Psychopathy was found to be predictive of self-reported proactive aggression and reactive aggression.

· Self-reported reactive aggression was related to positive symptoms and persecutory ideations.

· Impaired cognitive functioning in patients with schizophrenia was associated with an increase in the probability of aggression.

General Notes/Comments

· Maintenance therapy, treatment with SGA, Cognitive Behavior therapy, and reduced periods of untreated psychosis are associated with a lower risk of relapse.

· Thus, clinicians can ensure schizophrenia patients are maintained on treatment, enrolled in CBT, and do not stay for prolonged periods without treatment to prevent relapse.

· Violent behavior in patients with psychosis is etiologically complex and can be caused by multiple interacting risk factors.

· Clinicians must acknowledge different motives for aggressive behavior in patients with schizophrenia.

· There is a major need to understand the factors that lead to aggressive behavior in schizophrenia in order to address their needs and prevent future acts of violence toward health providers, family members, and people in the community.

Part 3B: Critical Appraisal of Research

Conducting a thorough assessment of the risk factors in schizophrenia patients in order to individualize the relapse risk for each patient and develop a tailored treatment plan in high-risk subjects is the best practice that emerges from the literature search. Porcelli et al. (2016) explain that the assessment can help identify modifiable factors that increase patients’ risk of relapses like substance misuse, a long duration of untreated psychoses (DUP), low pre-morbid function, a poor relationship with provider and family, and lack of insight. Patients with relapse have a high risk of being aggressive and violent in the hospital and community. DUP is one of the most crucial factors since it is more easily modifiable than most general risk factors. Thus, when the mental health provider identifies a patient with DUP during the assessment, they can initiate immediate pharmacological and psychotherapy treatment, improving patient outcomes and reducing the incidences of aggression and violence. Furthermore, identifying patients with substance misuse can reduce aggression and violence since it is associated with aggressive behaviors (Cho et al., 2019).

Patients with poor insight can also be identified through assessment and measures taken to improve awareness of their diagnosis. This can reduce the aggression and violence associated with a lack of insight, especially when schizophrenia patients perceive that they are admitted for no medical reason. Porcelli et al. (2016) also identify pharmacological treatment and psychotherapy as crucial interventions in preventing relapse, eventually preventing aggression and violence. The article recommends including Maintenance therapy, Second Generation Antipsychotics, and Cognitive Behavior therapy for schizophrenia patients to reduce the risk of relapse. This practice can be applied in the clinical setting by clinicians ensuring that all schizophrenia patients are prescribed maintenance medication to suppress schizophrenic symptoms and are referred to a CBT program as an adjunct therapy to medication. This can help lower the cases of inpatient admission of schizophrenia patients and eventually aggression and violent behavior in the inpatient psychiatric settings.

References

Cho, W., Shin, W., An, I., Bang, M., Cho, D., & Lee, S. (2019). Biological aspects of aggression and violence in schizophrenia. Clinical Psychopharmacology and Neuroscience, 17(4), 475-486. https://doi.org/10.9758/cpn.2019.17.4.475

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Assignment: Evidence-Based Project, Part 3: Critical Appraisal of Research