Rates of violence in patients classified as high risk by structured risk assessment instruments

Abstract

BackgroundRates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies.AimsTo analyse the variation in rates of violence in individuals identified as high risk by SRAIs.MethodA systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity.ResultsInformation was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study.ConclusionsAfter controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.

Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation study

“…Current risk assessment instruments, however, have been limited by low-to-moderate accuracy, 6 poor reporting standards, 7 and inconsistent definitions of what constitutes high risk 8 . The tools have rarely been developed in individuals with psychosis 9 .…”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…A substantial body of epidemiological, cohort, and case-control studies has shown associations between the risk factors described in this guideline and medium-to long-term relative risk of aggression in populations (Coid et al 2006;Doyle and Dolan 2006;Doyle et al 2012;Elbogen and Johnson 2009;Elbogen et al 2006;Eriksson et al 2011;Falk et al 2014;Harford et al 2013;Swanson et al 1990;Ten Have et al 2014;Van Dorn et al 2012;Whittington et al 2013;Witt et al 2013). However, there is no evidence that assessment of any of these factors can predict aggression in an individual (Buchanan et al 2012;Fazel et al 2012;Large et al 2011b;Rossegger et al 2013;Singh et al 2011Singh et al , 2014Thomas et al 2005). Similarly, no study has supported the ability of a specific rating scale to predict aggression in an individual.…”

“…Although structured assessments of aggression risk have been developed and studied, none has sufficient predictive validity to identify individuals at high aggression risk in clinical settings (Buchanan et al 2012;Fazel et al 2012;Large et al 2011b;Rossegger et al 2013;Singh et al 2011Singh et al , 2014Thomas et al 2005). Accordingly, estimation of an individual patient's risk for aggression is ultimately a matter of clinician judgment that requires synthesizing the available information and deciding how to weigh the contributions of multiple factors, including those that may prevent the patient from acting on aggressive ideas.…”

The Nature of Violence: Origins and Prevention of Healthcare Violence

“…Over 10% -40% of mental health admissions are admitted to address aggression and violence issues [24,25]. Many patients arrive to medical and mental health facilities with existing aggression and violence issues as reasons for admission to mental health facilities.…”

“…Strong clinical admission assessment is one of the most vital interventions to prevent healthcare violence [25]. It is imperative that an efficient violence prevention plan include a risk assessment on admission as a critical part of a comprehensive mental health assessment.…”