Combination of Antipsychotic Medication and Crisis Intervention on Outcomes of Acute Mental Illness Patients Scale

1Psychiatric Nursing Department, Faculty of Health Science Universitas Muhammadiyah Surakarta, Jl A Yani Tromol Pos I Solo, 62271 717417. 2Emergency Unit, Psychiatric Hospital of Surakarta, Jl Sutami Kentingan Jebres Solo, 622717890405. 3Acute room, Psychiatric Hospital of Surakarta, Jl Sutami Kentingan Jebres Solo, 62271648920. 4Community and family Nursing Department, Faculty of Health Science Universitas Muhammadiyah Surakarta, Jl A Yani Tromol Pos I Solo 62271 717417.

The crisis intervention program is crucial for the reduction of the violence of emergency and acute mental illnesses, and also provides high-quality access to mental health services. Monitoring the patients' violence during the crisis period is important to determine the patients possibility moved to the sub-acute unit 1,2 . The Brøset instrument is one of the tools that can be utilized to monitor the patient crisis development 3 ; however, it is needs to improvement of the high-quality measuring instruments in a different setting. Crisis intervention is one of the important nursing care in an emergency room where the symptom progress of a patient depends on the intervention 4,5 . On the other hand, the Indonesian Health Department explained that teamwork collaboration is the most significant factor in patients' progress in an emergency room 6 . It is discussed that teamwork in an emergency room are usually comprised of many actions such as triage systems where the team will select the patient's classification, and then determine the level of the patient's exigency 7,8 . Some problems that should generally be handled in a psychiatric emergency unit are the diagnosed acute psychomotor agitation and suicide 9 . In a previous study, many different approached have been proposed to solve this issue, and crisis intervention, further applied on suicide cases (10) . So, the monitoring of patient's violence is important in the recovery.
It is argued that there was lack of professional-patient interactions in a clinical observation of the patient 11 , and there was an association between length of violence treatment and reduced relapse after transferring to the subacute room 12 . Handling critical conditions in acute psychiatric patients is essential. The success of the action during this crisis will affect the next treatment. The treatment usually begin in the emergency unit. Acute room is an area in a hospital that is usually available with a team of specialized skills, and facilities and also infrastructure. This unit provides a range of emergency response services to patients as needed. Acute room is an emergency medical practice provided by a qualified health team to save the patient's life 12 . Emergency services such as an acute room are provided by a competent health team that should be able to classify patients (such as identification of violence risk), managing patients, and report patient. The NSW Health Department describes that the emergency health teams should be explicitly certified, and be able to identify the patients, collaborate, communicate, and take professional action according to patient demands and develop services by research 13 . Emergency or acute team should have personnel capable of performing the action with a rapid reaction to the health assistance according to patients' demands 6,13 .
In the psychiatric hospitals of Indonesia, the acute psychiatric patients were managed with physical restrain and chemical injection. The psychosocial treatment is usually postponed until the maintenance room. Crisis intervention program is such an intervention that can be applied by nurses as modality therapy in the part of the nursing process 14 . It is a structured psychological therapy and was initiated by a psychiatry professor 15 ; Currently, many experts apply this method to manage psychiatric emergency patients. Some studies found that the crisis intervention may decrease symptoms of anxiety and anger in patients 15,16 . Therefore, the crisis intervention program is crucial to reduce the violence of emergency and acute mental illness, as well as provide the better-quality access to mental health services. The monitoring of patients' violence during the crisis period is important to determine the patients' possibility moved to the sub-acute unit. The violence risk instrument is one of the tools that can be applied to monitor the development of patient crisis; however, it needs to improvement of quality measuring instruments in a different setting.
In this study, a violence risk instrument was developed from Brøset. There were two main reasons why development of the Brøset risk violent scale. First, it is shown that there were differences in signs and symptoms of mental illness patient between western and developing countries 17,18,19,20 . For example, some clinical vignette described that when schizophrenia patients anger, they expressed verbal treat as their experience of a western habit 19,20 , on the other hand, a study said that schizophrenic patient from one of ethnic in developing country, express the verbal responses and behaviors as their culture. Furthermore, all acute patients in the emergency room showed behaviors as growth and development history 18 . Second, patients with mental illnesses in acute conditions should receive appropriate health services.
This research proposed adjusted violent scale instrument through implementation of a crisis intervention program that was combined with antipsychotic medicine for patients with acute mental illnesses. The antipsychotic medicine was included Chlorpromazine 300 mg/day, Haloperidol 15 mg/day, and Trihexyphenidyl 6 mg/day. Another purpose of this study was to compare individual violent before and after applied crisis intervention program to reduce the symptoms of people with psychiatric emergency. The hypotheses were that a crisis intervention program can reduce symptoms, and evaluation of the violence risk tool can be modified and improved throughout the crisis intervention program.

Subjects and Methods
In this study, the mixed method design was applied with concurrent embedded strategy. It is argued that the design is an addition process of qualitative data during the period when the participants experience the intervention in an experimental trial 21 . In another word, it is an experimental trial to inform the development of procedures. This study compared the patients' violence before and after the intervention. During the intervention program, the study was also evaluating the Brøset's violence risk instrument using qualitative (trial, verification, validation) and quantitative (agreement test). One of the family members of the patient and one of the nurses were informed of the purposes, procedures, and potential risks of the study and provided verbal consent of their approval to participate in the investigation. The Ethics Committee approved all of the procedures of the mental hospital where the research was conducted. Data were gathered from 72 patients during three months in an acute psychiatric hospital within January and April 2018. Each patient was given a crisis intervention program for approximately 2 hours during staying in the acute unit per-day for 7 to 12 days. Previously, all patients with the characteristics of adult, Paranoia schizophrenia based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, panic level, and receiving similar medicine (Chlorpromazine 300 mg/day, Haloperidol 15 mg/day, and Trihexyphenidyl 6 mg/day). The patients were measured using a violent risk tool. The implementation of crisis intervention program was conducted for the number of patients in the acute inpatient room by a psychiatric clinical instructor nurse, ten professional nurse students, and five attending nurses in the acute room; Part of the team were the researchers in this study. The psychiatric clinical instructor nurse led the program and trained the research procedure before the study be held. Each patient that presented in an acute room was applied of crisis intervention. During applying the crisis intervention, the development of patients' violence was evaluated using a violent risk scale instrument. Modifications were made continuously following comments from mental health experts through group discussion. Two nurses applied the content of the violent instrument to 30 acute patients. Finally, the agreement toward the instrument (inter-ratter reliability) was analyzed using the Kappa test.

Process of Data Analysis
Data analysis in this study included three stages. First, a dependent t-test was used to compare the patients' violent risk before and after the crisis intervention. Second, the amended version was utilized through the trial, verification, and validation to improve the content of the instrument. The review of an expert team enhanced the content validity included five senior nurses that were attending the emergency and acute department, and the researcher. Content analysis was held through group discussions throughout ongoing research to fix the instrument. The process of validation was initially described by the original 6 items of the Brøset's violent risk scale. The range of scales was as follows: low violence risk, moderate violence risk, and high violence risk. The present study was elaborated become sub-items to be 22 items, which were developed based on the patients' cognition, attitude, and behavior. After that, the range of scales was modified to be "Yes" (2) and "NO" (1). Third, to assess the interrater reliability of 22 items, Brøset's violence risk scale was applied to the nurses' agreements resulted from the Kappa test.

ReSultS
There was a total of 72 patients from the acute inpatient care that was involved at the end of the study. Medical record, observatios, and therapeutic communication technique were applied to all selected patients. The demographic characteristics of the respondents are described in [ Table 1].
It can be seen in the table 1, it shows that the majority of the respondents were male, aged more than 40 years old, junior high school, and suffering from mental illness more than ten years Table 2 shows the part of the vary patients' depiction of behavior. The examples of the  Table 3 describes that a paired-samples t-test was conducted to compare the panic level of 72 patients before and after a crisis intervention program. The results of the paired-samples t-test show that the mean of panic level of patients differs before and after applying the crisis intervention program (M = -.10600; SD = .76369) at the 0.05 level of significance (t=-7617, df = 4, n = 8, p < 0.05, 95% CI with Probability .000). Furthermore, other items in each area that comprised of confused (t=11.420 with Probability .000), irritable (t=38.513 with Probability .000), boisterous (t=21.556 with Probability 0.000), verbal treat (t=26.556 with Probability .000), physical threat (t=19.315 with Probability .000) and attacking objects(t=32.634 with Probability .000) show that there were difference before and after intervention.
The value of Cronbach's alpha coefficient were low before the modification; there were just 12 number of reliable items with Cronbach's alpha reliability equal to .805 for violence checklist. Other items that reported to be unreliable encompass the items of verbal threats, physical threats, and attacking objects [ Table 4].
Thereafter, the instrument then be applied between two observers. During the implementation of crisis intervention and in the last verification, the instrument was repaired, which indicated that the internal consistency was excellent for all number of items [ Table 5]. Table 5 shows that there are two raters did assessment whether an acute patient was nonviolent (1) and violent (2). The response data are paired observations of a number of same acute patients. There were 30 paired observations. The statistics analysis of cross-tabulation of the categories of the two variables from two routers and kappa reliability are given as follows on table 5. It can be seen that the table demonstrates the two non-violent and violent, which are related In addition, both officers agreed that there were 16 patients who displayed violent behavior. Therefore, there were 14 patients (i.e., 6 + 4 + 4= 14) for whom the two nurses observer could not agree on their patients' behavior. Cohen's ê was run to determine if there was agreement between two nurses' judgments on whether 30 individuals in a psychiatric acute room were showed violent or non-violent behaviors. There was moderate agreement between the two officers' judgements, ê = .667 (95% CI, 0.300 to 0.886), and p < 0.05. It can be seen that Cohen's kappa (ê) is .667. This is the proportion of agreement over and above chance agreement. Cohen's kappa (ê) can range from -1 to +1. It means a kappa (ê) of .667 represents a moderate strength of agreement. Furthermore, since Probability was very low (which actually means p < 0.05), the kappa (ê) coefficient is statistically and significantly different from zero.

DiScuSSion
Majority the patients were 40 years old. The respondents in this study are schizophrenic patients when the respondents were identified using ICD-10. It is argue that Schizophrenia is a severe mental illness that disturbs an individual's ability to think rationally, manage emotions, make decisions, and interact 1,22 . It was found in a previous study about the risk of schizophrenia that this illness commonly occurs in the early 20s for men and the late 20s to early 30s for women. It is unusual for schizophrenia to be diagnosed in a person younger than 12 or older than 40 23 . Next, a number of the schizophrenic patients then were conducted crisis intervention. Crisis intervention is a strategy to reduce symptoms of the risk of patients' violence 16 . The Roberts' seven-stage crisis intervention model is comprised of (1) Psychosocial and Lethality Assessment, (2) Rapidly Establish Rapport, (3) Identify the Major Problems or Crisis Precipitants, (4) Deal With Feelings and Emotions, (5) Generate and Explore Alternatives, (6) Implement an Action Plan, and (7) Follow-Up 15 . The Brøset violence checklist (BVC) is an instrument for a relatively short period of time to predict the patient's violence 24 .
During observation of the acute patients, the nurses and other observers confuse when they should choose each component in the Brøset items. For example, it can be seen on the table 2, on the item of "confused", a theme came from the patient expression showed "tangential speech". It is argued that one type of communication disorder on schizophrenic patients is loss of concentration, where usually show the verbal expression related to their experience 17,1,22 . This one of proved why Brøse check list should be adjusted. Another illustration is the psychical treat item, it was hard to identify in the first adjusted because the patients were applying extremity of restraint. In the case of physical violence, commonly the patients had a history of break glasses, and hit a person, were the acts most reported threat or actual use of weapons of the family or relative frequently. When application the assessing of the patient's violent behavior, the nurses and other observers in the acute inpatient psychiatric unit appeared attention of their own psychological comfort. Seeing the patient in a number of panic signs and symptoms, these likely increase the nurses stress in acute unit and affect their action during a crisis intervention therapy program.
Change of the patients' violent that were analysed by using a dependent t-test is concluded that there was statistical significance before, and after the intervention. These attitude and behavior responses to crisis intervention of the patients was different each other, resulting in improvement health outcomes. This result may prove that a study of relaxation therapy which show the positive relationships between the music therapy with the frequency of hallucination 25 . Another study concluded that this finding is also in accordance with the concept of relaxation therapy that human's physiological response could be reduced with the stimulation of Alpha wave in the brain through relaxation therapy, like music therapy. The music therapy is one of the stage of crisis intervention in the escalation stage; therefore, relaxation therapy easily facilitates the phycological relaxation 26,27 . Furthermore, a study proved that in their study of relaxation therapy on mental illness patient, where may release the patients stress level 28 . Another study found that relaxation therapy may be reduce anxiety and depression 29 . Among the 81 participants accidental sampling, 9 fail in the de-escalation stage. There were differences between the 72 patients before and after the crisis intervention. However, they may influenced by medical treatment. It is suggested that on de-escalation stage (one on stage in crisis intervention) should involve environmental modification techniques and pharmacological treatment together during the intervention process 30 . After crisis intervention, the participants reported better scores for the patients' violence responses. On the other hand, it could be found that during the crisis intervention, in the initial phase, 9 patients showed aggressive behavior, like shouted and screaming (I am feeling hot, go way, I am bored). Study by Bryan and team concluded that patients began to subside their negative symptoms after several times were given crisis interventions 31 . Secondary outcomes of improving Brøset were comprised of elaboration of the sentences and providing example actions at each stage; there were suggested that the items have relatively high internal consistency.
The kappa (ê) coefficient is statistically and significantly different from zero. The observation was conducted among 30 acute patients identified by the two nurses, they were judged for a detailed assessment of Brøset modification.
Interrater reliability with the Kappa is moderate, that means the Brøset modification can be applied. The validity test differs between before and after interventions, this may support that culture, grow, and development factors of the patients should be considered in accurately applying and interpreting the modification of Brøset's violence checklist. For instance, it is described in some clinical vignette that when schizophrenia patients got anger, they expressed verbal treat as their experience of a western habit 18 . On the other hand, the studies carried out by Pratiwi, McEldowney, Richardson, and He concluded that schizophrenic patients from one of ethnics in the developing counties express the verbal responses and behaviors as their cultures 17 . It is argued that the patients and families across these cities may involve their culture when it comes to help seeking for problem solving related mental illness 32 .

concluSion
The interrater (kappa) testing for the Brøset's instrument revealed that the strength of the agreement is good. Crisis intervention of mental illness and emergency reduces violent responses. The level of the patient's violence variable is an important outcome, so using a valid and reliable instrument may enhance the research quality. According to validity, reliability, and verification results, it was found that the violence risk scale instrument was applicable to the acute patient. Combination of anti-psychotic medication and crisis intervention for the acute patients lead to the reduction of violence responses.

Financial support and sponsorship
This study as a competitive funding from the Universitas Muhammadiyah Surakarta; thus, many thank for the institute of research and community service, thank you very much for the patients with mental illness patients and their families, and also all nurses in acute and emergency room unit, and professional students who already facilitates in obtaining data selection.

Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this article.