V-RISK-10: Validation of a Screen for Risk of Violence After Discharge from Acute Psychiatry

Risk assessment for aggressive behaviour in schizophrenia

BACKGROUND

Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings.

OBJECTIVES

To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach.

MAIN RESULTS

We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs.

AUTHORS' CONCLUSIONS

Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study

BACKGROUND

Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions.

METHODS

A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC).

RESULTS

Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent.

CONCLUSIONS

This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

The predictive validity of the V-RISK-10 and BVC among involuntarily admitted patients

Although endangerment towards others is a criterion for an involuntary admission in many countries, research on risk assessment of endangerment among involuntarily admitted individuals is limited. In this retrospective case-control study, we calculated scores for a German-translated version of the Violence Risk Screening-10 (V-RISK-10) and the Brøset Violence Checklist (BVC) in a sample of 111 people undergoing an involuntary admission in Reinickendorf, Berlin. Outcomes were violence, coercive measures, and readmission. In line with our hypotheses, the BVC demonstrated stronger predictive validities for short-term, and V-RISK-10 for long-term events. There was an incremental validity for both instruments for restraint 24 hours after admission and any violence until discharge. These findings support the evidence that structured risk assessment instruments may be useful for individuals undergoing an involuntary admission. Ethical considerations about screening procedures are discussed.

Validation of a violence risk screening for youth in psychiatric inpatient care-a pilot study of V-RISK-Y

The reason for this study was the void of validated risk assessment screening tools for violence in adolescence psychiatry. Our aims were to test the predictive validity and feasibility of a pilot version of the Violence Risk Screening for Youth (V-RISK-Y). The V-RISK-Y was based on a violence risk screen for adults, the V-RISK-10, and adapted to adolescents, resulting in 12 risk items that are scored for (a) presence and (b) relevance for future violence. In this naturalistic, prospective observational study, the V-RISK-Y was scored at admission and compared with recorded episodes of violent acts and threats during hospital stay. The target population was all 92 patients admitted to the emergency department of adolescent psychiatry at Oslo University Hospital for 1 year, of which 67 patients were scored with the V-RISK-Y at admission and constituted the study sample. The predictive validity of the V-RISK-Y for violent behavior showed an AUC of 0.762 (p = 0.006). Staff approved the screener and found it to be equally or better usable than the V-RISK-10, which was previously used in the department. Still, a high proportion of raters failed to follow the scoring instructions of relevance scores, reducing feasibility. The results must be interpreted within the limits of a pilot study and low power. We conclude that results suggest changes of certain parts of the V-RISK-Y and provide a basis for testing a revised edition of the screener in a more comprehensive study, preferably with a multicenter design.

Short-term risk assessment in the long term: A scoping review and meta-analysis of the Brøset Violence Checklist

INTRODUCTION

Existing literature on the Brøset Violence Checklist (BVC) is examined in the context of usability, implementation and validity to provide evidence-based recommendations on its application and identify opportunities for future development.

AIM/QUESTION

To identify current knowledge on the BVC and guide clinicians and researchers toward the next steps in using this tool in clinical practice to prevent violence in healthcare settings.

METHOD

A scoping review approach with a meta-analysis supplement was adopted to broadly identify and map available evidence on the BVC and provide specific estimates of predictive validity in different contexts.

RESULTS

Sixty-two studies conducted in 23 countries addressed the implementation of the BVC across various settings. Many studies adapted the original BVC, and the clinical utility was noted as an important feature. A meta-analysis of the original BVC format estimated a pooled area under the curve at 0.83 (95% CI 0.78-0.87) in a subset of 15 studies.

DISCUSSION

The BVC combines high predictive validity and good clinical utility across a wide range of settings and cultures. It should continue to be incorporated into routine practice in mental health services focused on preventing violence and coercion.

IMPLICATIONS FOR PRACTICE

Development of collaborative approaches with service users involved in assessing their own risk of future violence.

Validity and reliability of the Persian version of Violence Risk Screening-10 Instrument (V-Risk-10) in admitted patients to the psychiatric ward

BACKGROUND

Violence Risk Screening Tool-10 (V-Risk-10) is one of the few instruments available for violence risk assessment in patients with a psychiatric diagnosis. The present study aimed to validate the Persian version of this instrument in patients admitted to the psychiatric ward.

MATERIALS AND METHODS

Eighty patients referred to a psychiatric hospital were enrolled in this cross-sectional methodological study. In the initial phase, seven senior psychiatry residents rated 20 cases independently at the time of their admission and total scale and subscale reliability were examined. Intraclass correlation coefficients were used to assess the inter-rater reliability. After initial confirmation of V-RISK-10 reliability, a senior psychiatry resident assessed 80 patients with V-RISK-10 in the emergency room. The incident of violent behaviors was recorded during the patients' admission period. The receiver operator characteristics curve (ROC-curve) analysis was used to measure the predictive accuracy of the instrument. The convergent validity was assessed by comparing V-RISK-10 scores between the three risk categories and the three outcome recommendations according to clinicians' overall clinical judgment.

RESULTS

A Cronbach's alpha coefficient was 0.99 for the total scale. During the research period, 47.5% of patients demonstrated various degrees of aggression and violent behavior. The ROC area under the curve was 0.89 (P < 0.001) with 87% sensitivity, 69% specificity, 72% positive predictive value, and 85% negative predictive value at the cutoff point of 8.5.

CONCLUSION

Results indicate that the Persian version of V-Risk-10 is a reliable and valid screening tool for violence risk in patients who are admitted into psychiatric wards.

Contributions of Multimethod Personality Assessment in Indirect Evaluation

Indirect assessment is a useful tool in forensic evaluation, especially in cases of threat assessment. To this end, we illustrated the ability to conceptualize a complicated case (i.e., Theodore John Kaczynski) using an indirect approach, with a particular emphasis upon dimensional frameworks of personality. Raters who were unrelated to Mr. Kaczynski's case and with expertise in relevant domains were asked to study information available in the public domain about Mr. Kaczynski and provide ratings using several assessment instruments. Our aim was not to provide a professional clinical opinion, but rather engage in scholarly discourse about the utility of instruments. Mr. Kaczynski was rated to demonstrate characteristics associated with lone actor terrorists. He showed an elevation on a measure of psychosis, and raters conceptualized trauma as an important aspect of his functioning. He demonstrated impairments in detachment and psychoticism (Criterion B of the AMPD) and interpersonal functioning (Criterion A of the AMPD). Clinical conceptualizations for Mr. Kaczynski emphasized schizotypal and paranoid personality disorders. This analysis of an infamous case about which considerable data are publicly available demonstrates the ease with which indirect and multimethod assessment can be applied and integrated in forensic assessment, using modern conceptualizations of personality pathology.

Short-term risk assessments in an acute psychiatric inpatient setting: A re-examination of the Brøset Violence Checklist using repeated measurements - Differentiating violence characteristics and gender

This study investigated the association between short-term risk assessment measured by the Brøset Violence Checklist (BVC) and imminent violence using repeated measurements and differentiating violence characteristics and gender. All patients admitted to an acute psychiatric ward during one year (N = 528) were included. Logistic regression and generalized linear mixed model (GLMM) analyses were conducted. Results confirmed BVC's suitability for both male and female inpatients throughout their hospitalization also when differentiating threats and physical violence, and adjusting for diagnostic subpopulations and circadian variability. Results point to modified interpretations of the BVC sum scores. Future research should adjust for repeated measurements.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

PURPOSE OF REVIEW

We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience.

RECENT FINDINGS

A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

Therapeutic Risk Management for Violence: Augmenting Clinical Risk Assessment With Structured Instruments

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and a personalized safety plan to mitigate/manage risk. This second column in the series describes the advantages of, and offers suggestions for, incorporating structured tools into violence risk assessment.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist.

Probability and loss: two sides of the risk assessment coin

Risk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.

Prediction of violent crime on discharge from secure psychiatric hospitals: A clinical prediction rule (FoVOx)

BACKGROUND

Current approaches to assess violence risk in secure hospitals are resource intensive, limited by accuracy and authorship bias and may have reached a performance ceiling. This study seeks to develop scalable predictive models for violent offending following discharge from secure psychiatric hospitals.

METHODS

We identified all patients discharged from secure hospitals in Sweden between January 1, 1992 and December 31, 2013. Using multiple Cox regression, pre-specified criminal, sociodemographic, and clinical risk factors were included in a model that was tested for discrimination and calibration in the prediction of violent crime at 12 and 24 months post-discharge. Risk cut-offs were pre-specified at 5% (low vs. medium) and 20% (medium vs. high).

RESULTS

We identified 2248 patients with 2933 discharges into community settings. We developed a 12-item model with good measures of calibration and discrimination (area under the curve=0.77 at 12 and 24 months). At 24 months post-discharge, using the 5% cut-off, sensitivity was 96% and specificity was 21%. Positive and negative predictive values were 19% and 97%, respectively. Using the 20% cut-off, sensitivity was 55%, specificity 83% and the positive and negative predictive values were 37% and 91%, respectively. The model was used to develop a free online tool (FoVOx).

INTERPRETATION

We have developed a prediction score in a Swedish cohort of patients discharged from secure hospitals that can assist in clinical decision-making. Scalable predictive models for violence risk are possible in specific patient groups and can free up clinical time for treatment and management. Further evaluation in other countries is needed.

FUNDING

Wellcome Trust (202836/Z/16/Z) and the Swedish Research Council. The funding sources had no involvement in writing of the manuscript or decision to submit or in data collection, analysis or interpretation or any aspect pertinent to the study.

Risk of violence among patients in psychiatric treatment: results from a national census

BACKGROUND

Adverse media coverage of isolated incidents affects the public perception of the risk of violent behavior among people with mental illness. However, the risk of violence is studied most frequently among inpatients, which falsely exaggerates the prevalence of people with mental illness because the majority of individuals receive treatment as outpatients.

AIM

To estimate the prevalence of the risk of violence among inpatients and outpatients in psychiatric treatment, as well as the associations with gender, age, socio-economic status and co-morbid substance use disorders in all major diagnostic categories.

METHODS

We conducted a national census of patients in specialist mental health services in Norway, which included 65% of all inpatients (N = 2,358) and 60% of all outpatients (N = 23,124).

RESULTS

The prevalence of the risk of violence was 32% among inpatients and 8% among outpatients, where 80% of the patients in specialist mental health services were outpatients. If we weight the prevalence rates accordingly, less than 2% of the patients in specialist mental health services had a high risk of violent behavior.

CONCLUSIONS

The stigma attached to those with mental illness is not consistent with the absence or low to modest risk of violent behavior in 98% of the patient group. Substance use disorders must be given priority in the treatment of all patient groups. Mental health care in general and interventions that target violent behavior in particular should address the problems and needs of these patients better, especially those who are unemployed, have a low level of education and have a background of being a refugee or an immigrant.

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

Several studies indicate an association between low levels of serum cholesterol and aggressive behaviour, but prospective studies are scarce. In this naturalistic prospective inpatient and post-discharge study from an acute psychiatric ward, we investigated total cholesterol (TC) and high-density lipoprotein (HDL) as risk markers of violence. From March 21, 2012, to March 20, 2013, 158 men and 204 women were included. TC and HDL were measured at admission. Violence was recorded during hospital stay and for the first 3 months post-discharge. Univariate and multivariate binary logistic regression were used to estimate associations between low TC and low HDL and violence. Results showed that HDL level was significantly inversely associated with violence during hospital stay for all patients. For men, but not for women, HDL level was significantly inversely associated with violence the first 3 months post-discharge. Results indicate that low HDL is a risk marker for inpatient and post-discharge violence in acute psychiatry and also suggest gender differences in HDL as a risk marker for violence.

Psychometric properties and predictive validity of a police version of a violence risk screen - A pilot study

The Violence Risk Screening - Police Version (V-RISK-POL) is a seven-item screening tool for use at police stations by police officers and law enforcement officials to assist in the process of decision making regarding release, restrictive measures or arrest for apprehended individuals where the risk of future violence must be considered. The screen is based on the V-RISK-10, originally developed for emergency psychiatry. We examined psychometric properties and the prospective predictive validity of future violent convictions for the V-RISK-POL in a sample of 111 persons arrested for suspicion of violent crimes. Seventeen persons were convicted for a new violent crime committed during the 24-40months follow-up. The V-RISK-POL demonstrated good internal consistency; Cronbach's alpha=0.81 (95% CI=0.75-0.86) and moderate predictive validity; the area under the curve of the receiving operator characteristics (AUC)=0.753 (95% CI=0.644-0.843). Further research on larger and more heterogeneous samples is necessary to examine whether the screen may be useful in the police context.

Comparison of patients who were violent, victimized and violent-victimized during the first year after discharge from emergency psychiatry

This prospective observational study included 345 (70%) of 489 patients discharged from an emergency psychiatric hospital during one year. Episodes of offending and victimization were recorded during first year after discharge. Forty-eight persons (14%) committed violent offenses only, 27 persons (8%) were violence victims only, and 42 persons (12%) were both offenders and victims. Significant differences in demographic and clinical variables were found between the three groups. The results pointed to two distinct groups of victims: one group with a robust offender-victim overlap and another group without offender-victim overlap. The latter group was difficult to distinguish from other discharged patients.

Triglycerides as a biological marker of repeated re-hospitalization resulting from deliberate self-harm in acute psychiatry patients: a prospective observational study

BACKGROUND

Biological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments.This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH.

METHODS

In this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge.

RESULTS

High triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients).

CONCLUSION

The triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio-psychosocial approach appears promising, but further research is necessary to refine and validate this method.

Validation of the Violence Risk Screening-10 instrument among clients discharged from a psychiatric hospital in Beijing

The Violence Risk Screening-10 is one of the few instruments available for evaluating violence risk in mental health clients during and after hospitalization. This prospective study examined the applicability of this brief instrument with a sample of 289 clients in the 6 months after discharge from a general psychiatric hospital in Beijing. During the research period, 24 of the 289 clients demonstrated aggression. The receiver-operator characteristic curve yielded an area under the curve of 0.62. At the cut-off point of 4.5, its sensitivity/specificity was 79.2%/33.3%, and the corresponding positive/negative predictive value was 9.9%/94.5%. The predictive accuracy of this instrument was lower compared with the results of the original study, and was also less accurate than when it was administered while the clients were in the hospital. While promising in its utility for use beyond the hospital, it deserves further modification prior to its wide use across culturally-diverse China.

Can lipid analysis help identify repeatedly violent patients after discharge from acute psychiatry?

In this study of 196 patients discharged from an acute psychiatric ward, 11 patients (6%) were identified as exhibiting repeated violence and having frequent readmissions. Compared with non-violent patients and those with only one violent post-discharge episode, repeatedly violent patients were significantly characterised by male gender, higher rates of previous threats of violence, lack of empathy, more severe violence during follow-up, and lower high-density lipoprotein levels.

Measurement of predictive validity in violence risk assessment studies: a second-order systematic review

The objective of the present review was to examine how predictive validity is analyzed and reported in studies of instruments used to assess violence risk. We reviewed 47 predictive validity studies published between 1990 and 2011 of 25 instruments that were included in two recent systematic reviews. Although all studies reported receiver operating characteristic curve analyses and the area under the curve (AUC) performance indicator, this methodology was defined inconsistently and findings often were misinterpreted. In addition, there was between-study variation in benchmarks used to determine whether AUCs were small, moderate, or large in magnitude. Though virtually all of the included instruments were designed to produce categorical estimates of risk - through the use of either actuarial risk bins or structured professional judgments - only a minority of studies calculated performance indicators for these categorical estimates. In addition to AUCs, other performance indicators, such as correlation coefficients, were reported in 60% of studies, but were infrequently defined or interpreted. An investigation of sources of heterogeneity did not reveal significant variation in reporting practices as a function of risk assessment approach (actuarial vs. structured professional judgment), study authorship, geographic location, type of journal (general vs. specialized audience), sample size, or year of publication. Findings suggest a need for standardization of predictive validity reporting to improve comparison across studies and instruments.

A multifaceted model for risk assessment of violent behaviour in acutely admitted psychiatric patients

Violence risk assessment instruments are mainly based on historical and clinical risk factors. Biological factors have been related to violent behaviour but hardly used in risk assessment. A recent study indicated that both low total cholesterol (TC) and the patients' own estimates about their risk of future violent behaviour, the Self-report Risk Scale (SRS), significantly predicted violent behaviour during hospital stay and the first 3 months after discharge from an acute psychiatric department. Our aim was to investigate whether combining three methods, a screening instrument for risk of violence (V-RISK-10), low TC and the SRS, into one multifaceted risk assessment model may enhance predictive validity. This prospective naturalistic study involved 134 of all (489) acutely admitted patients to a general psychiatric hospital during 1 year. Low TC, SRS and V-RISK-10 at admission were prospectively compared with recorded violence during hospital stay and the first 3 months after discharge. The multifaceted risk assessment model yielded a significant increase in explained variance beyond that of the V-RISK-10. AUC values were higher, but differences were not significant. The biopsychosocial approach to violence risk assessment seems promising, but further studies are needed to test the feasibility and predictive validity of multifaceted models.

A novel approach to determining violence risk in schizophrenia: developing a stepped strategy in 13,806 discharged patients

Clinical guidelines recommend that violence risk be assessed in schizophrenia. Current approaches are resource-intensive as they employ detailed clinical assessments of dangerousness for most patients. An alternative approach would be to first screen out patients at very low risk of future violence prior to more costly and time-consuming assessments. In order to implement such a stepped strategy, we developed a simple tool to screen out individuals with schizophrenia at very low risk of violent offending. We merged high quality Swedish national registers containing information on psychiatric diagnoses, socio-demographic factors, and violent crime. A cohort of 13,806 individuals with hospital discharge diagnoses of schizophrenia was identified and followed for up to 33 years for violent crime. Cox regression was used to determine risk factors for violent crime and construct the screening tool, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Regression analyses resulted in a tool composed of five items: male sex, previous criminal conviction, young age at assessment, comorbid alcohol abuse, and comorbid drug abuse. At 5 years after discharge, the instrument had a negative predictive value of 0.99 (95% CI = 0.98-0.99), meaning that very few individuals who the tool screened out (n = 2,359 out of original sample of 6,903) were subsequently convicted of a violent offence. Screening out patients who are at very low risk of violence prior to more detailed clinical assessment may assist the risk assessment process in schizophrenia.