Hostname: page-component-7c8c6479df-hgkh8 Total loading time: 0 Render date: 2024-03-29T01:56:21.289Z Has data issue: false hasContentIssue false

Five simple questions to predict violence in psychiatric patients

Published online by Cambridge University Press:  02 January 2018

Mark Taylor
Affiliation:
Consultant Psychiatrist, Ballenden House, NHS Lothian, Edinburgh, email: marktaylor2@nhs.net
Adam Groves
Affiliation:
University of Edinburgh, UK
Fiona McCusker
Affiliation:
University of Edinburgh, UK
Natalie Lee
Affiliation:
University of Edinburgh, UK
Johanna Bradley
Affiliation:
University of Edinburgh, UK
Gianluca Alonzi
Affiliation:
University of Edinburgh, UK
Claire Murphy
Affiliation:
University of Edinburgh, UK
Rebecca Miles
Affiliation:
University of Edinburgh, UK
Samantha Ellis
Affiliation:
University of Edinburgh, UK
Ellie Richardson
Affiliation:
University of Edinburgh, UK
Rights & Permissions [Opens in a new window]

Abstract

Type
Columns
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2012

Forensic psychiatry is principally concerned with assessing and managing the risk to others (usually of violence) by people with a mental disorder. A variety of lengthy risk assessment instruments help consolidate this expertise, but these instruments do not find favour in day-to-day psychiatry.

Based on the work of Fazel and colleagues, Reference Fazel, Långström, Hjern, Grann and Lichtenstein1,Reference Singh and Fazel2 we set out to determine whether five ‘yes or no’ questions (male gender; less than 32 years old; previous criminal convictions; and comorbid alcohol misuse and drug misuse) could predict later actual physical violence to others. We analysed case notes on consecutively discharged patients from a medium secure forensic unit (52 patients, 46 male); an out-patient addictions service (51 patients; 26 male); and a crisis resolution and home treatment service (25 patients, 17 male), in a ‘pseudo-prospective’ method for a record of physical violence after applying these five questions as a screen to the case records 5 years earlier, from January 2006. Records with insufficient detail or length of history were excluded, and the screen was viewed as a positive predictor if three or more questions were answered ‘yes’.

We found 30 (of 128) patients were violent in the 5 years studied, with 83% being predicted as violent by our screen (sensitivity), and a false negative rate of 17%. The positive predictive value was poor at 38% but the negative predictive value (i.e. that a negative prediction was correct) was impressive at 92%. The factors predicting later violence were being male (93%); having a history of violence (80%, not a ‘Fazel’ question); a history of drug misuse (77%); a prior criminal conviction (70%); a history of alcohol misuse (60%); poor treatment adherence (52%, not a ‘Fazel’ question); and being less than 32 years old (50%). A history of self-harm was only seen in 20% of those who were violent later.

The rates of 5-year violence in the three separate groups were 35% in the forensic sample, 6% in addictions, and 36% in the acute community crisis resolution home treatment group. We acknowledge the preponderance of males in our sample will skew the results, given it is a screening question.

Our results raise two interesting points. First, that these five simple questions might aid clinical decision-making concerning which patients will not pose a risk of later violence, but does not elucidate prediction on who will become violent. This screen might therefore be useful as part of a stepped approach in a busy clinical environment when considering who to refer for more in-depth assessment. Second, as Turner & Salter have already noted, Reference Turner and Salter3 we conclude it is hard to define who is ‘a forensic patient’ when we compare patterns across our three samples.

References

1 Fazel, S, Långström, N, Hjern, A, Grann, M, Lichtenstein, P. Schizophrenia, substance abuse, and violent crime. JAMA 2009; 301: 2016–23.Google Scholar
3 Singh, JP, Fazel, S.Developing a violence screening instrument for patients with schizophrenia’. Paper presented at the XXXII International Congress on Law and Mental Health, Berlin, Germany, July 2011.Google Scholar
3 Turner, T, Salter, M. Forensic psychiatry and general psychiatry: re-examining the relationship. Psychiatrist 2008; 32: 26.Google Scholar
Submit a response

eLetters

No eLetters have been published for this article.