Developing Clinical Practice Guidelines for violence risk assessment in mental health triage : a systematic review

Background : On a global level, there is a growing trend to utilise mental health triage service systems as a way of providing consumers with access to 24 hour mental health care. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines. This presentation provides an overview of a Clinical Practice Guideline for violence risk assessment at point of entry to health services.
Aims : The objective of this study was to develop Clinical Practice Guidelines for violence risk assessment in mental health triage, and to pilot test the Clinical Guidelines in two major hospitals in Melbourne.
Method : The method employed in the study was a systematic review, as per the Australian National Health and Medical Research Council’s methodology for developing Clinical Guidelines. Research was conducted at the Royal Melbourne Hospital and the Alfred Hospital to establish the utility of the Guideline in practice.
Results : The systematic review established the highest level of evidence for violence risk assessment. Clinical Practice Guidelines for mental health triage were developed from these findings.
Conclusions : Evidence based Clinical Guidelines maximise the potential for creating safer outcomes for consumers, families/carers, and health care workers.

Characteristics of Mentally Disordered Youth Referred to a Forensic Satellite Clinic for Violence Risk Assessment: A Case Control Study

There is a lack of appropriate services to manage youth with comorbid mental health problems and violence risks. To address this gap, we implemented a forensic satellite clinic in a youth mental health service. This paper characterises offending histories among 45 young patients referred to the clinic, and compares them with matched clinical controls (n = 45). Levels of prior risk taking and aggression were prominent among referred patients. Forensic cases and controls did not differ on demographic and clinical variables, with the exception of psychiatric inpatient admissions, which were higher among referred patients. Group differences were observed for prior offending variables (e.g., physical aggression), which were significantly higher among referred patients than controls. Findings suggest that referrals were made to the clinic based on challenging and aggressive behaviour rather than specific clinical characteristics. The role of specialist assessment, treatment and management of violence risks in youth mental health services are discussed.

Violence risk assessment in psychiatric patients in China: a systematic review

Objectives: The aim of this study was to undertake a systematic review on violence risk assessment instruments used for psychiatric patients in China.

Methods: A systematic search was conducted from 1980 until 2014 to identify studies that used psychometric tools or structured instruments to assess aggression and violence risk. Information from primary studies was extracted, including demographic characteristics of the samples used, study design characteristics, and reliability and validity estimates.

Results: A total of 30 primary studies were identified that investigated aggression or violence; 6 reported on tools assessing aggression while an additional 24 studies reported on structured instruments designed to predict violence. Although measures of reliability were typically good, estimates of predictive validity were mostly in the range of poor to moderate, with only 1 study finding good validity. These estimates were typically lower than that found in previous work for Western samples.

Conclusion: There is currently little evidence to support the use of current violence risk assessment instruments in psychiatric patients in China. Developing more accurate and scalable approaches are research priorities.

An ABC approach to assessing the risk of violence at triage

There is evidence to suggest that the incidence of violent behaviour in the emergency department by patients toward staff is on the rise. As part of the process of determining urgency, triage nurses must assess the risk of violence at point of entry. The risk of violence, that is, behaviour that either involves a threat of physical or psychological harm to one's self or to others, is considered a critical predictor of urgency in mental health triage. A rapid violence risk assessment strategy will be described which can be utilised in emergency department triage.

Mental health-related risk factors for violence : using the evidence to guide mental health triage decision making

Mental health clinicians working in emergency crisis assessment teams or mental health triage roles are required to make rapid and accurate risk assessments. The assessment of violence risk at triage is particularly pertinent to the early identification and prevention of patient violence, and to enhancing the safety of clinical staff and the general public. To date, the evidence base for mental health triage violence risk assessment has been minimal. This study aimed to address this evidence gap by identifying best available evidence for mental health-related risk factors for patientinitiated violence.We conducted a systematic review based on the National Health and Medical Research Council of Australia’s methodology for systematic reviews. A total of 6847 studies were retrieved, of which 326 studies met the study inclusion criteria. Of these studies, 277 met inclusion criteria but failed the quality appraisal process, thus a total of 49 studies were included in the final review. The risk factors that achieved the highest evidence grading were predominantly related to dynamic clinical factors immediately observable in the patient’s general appearance, behaviour and speech. These factors included hostility/anger, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability.

Understanding dynamic risk factors for violence

Recent years have seen a consensus emerge regarding the dynamic risk factors that are associated with future violence. These risk factors are now routinely assessed in structured violence risk assessment instruments. They provide a focus for treatment in structured group programmes. However, relatively little attention has been paid to risk-related theoretical issues, whether these dynamic risk factors are causally related or simply correlates of violent offending, or the extent to which they change as a consequence of treatment. More challenging is the lack of evidence to suggest that changes in these dynamic risk factors actually result in reductions in violent offending. In this paper we consider the meaning of the term dynamic risk, arguing that only those factors that, when changed, reduce the likelihood of violent recidivism, can be considered to be truly dynamic. We conclude that few of the violence risk factors commonly regarded as dynamic fulfil this requirement. There is a need to think more critically about assessment findings and treatment recommendations relating to dynamic risk, and conduct research that establishes, rather than assumes, that certain dynamic risk factors are directly related to violence. Some suggestions for advancing knowledge and practice are provided.

Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies

Background

Previous reviews on risk and protective factors for violence in psychosis have produced contrasting findings. There is therefore a need to clarify the direction and strength of association of risk and protective factors for violent outcomes in individuals with psychosis.

Method

We conducted a systematic review and meta-analysis using 6 electronic databases (CINAHL, EBSCO, EMBASE, Global Health, PsycINFO, PUBMED) and Google Scholar. Studies were identified that reported factors associated with violence in adults diagnosed, using DSM or ICD criteria, with schizophrenia and other psychoses. We considered non-English language studies and dissertations. Risk and protective factors were meta-analysed if reported in three or more primary studies. Meta-regression examined sources of heterogeneity. A novel meta-epidemiological approach was used to group similar risk factors into one of 10 domains. Sub-group analyses were then used to investigate whether risk domains differed for studies reporting severe violence (rather than aggression or hostility) and studies based in inpatient (rather than outpatient) settings.

Findings

There were 110 eligible studies reporting on 45,533 individuals, 8,439 (18.5%) of whom were violent. A total of 39,995 (87.8%) were diagnosed with schizophrenia, 209 (0.4%) were diagnosed with bipolar disorder, and 5,329 (11.8%) were diagnosed with other psychoses. Dynamic (or modifiable) risk factors included hostile behaviour, recent drug misuse, non-adherence with psychological therapies (p values<0.001), higher poor impulse control scores, recent substance misuse, recent alcohol misuse (p values<0.01), and non-adherence with medication (p value <0.05). We also examined a number of static factors, the strongest of which were criminal history factors. When restricting outcomes to severe violence, these associations did not change materially. In studies investigating inpatient violence, associations differed in strength but not direction.

Conclusion

Certain dynamic risk factors are strongly associated with increased violence risk in individuals with psychosis and their role in risk assessment and management warrants further examination.

Predicting risk of violence through a self-appraisal questionnaire

The Self-Appraisal Questionnaire (SAQ) is a self-report that predicts the risk of violence and recidivism and provides relevant information about treatment needs for incarcerated populations. The objective of the present study was to evaluate the concurrent and predictive validity of this self-report in Spanish offenders. The SAQ was administered to 276 offenders recruited from several prisons in Madrid (Spain). SAQ total scores presented high levels of internal consistency (alpha = .92). Correlations of the instrument with violence risk instruments were statistically significant and showed a moderate magnitude, indicating a reasonable degree of concurrent validity. The ROC analysis carried out on the SAQ total score revealed an AUC of .80, showing acceptable accuracy discriminating between violent and nonviolent recidivist groups. It is concluded that the SAQ total score is a reliable and valid measure to estimate violence and recidivism risk in Spanish offenders.

The impact of school connectedness on violent behavior, transport risk taking behavior and associated injuries in adolescence

Adolescents engage in many risk-taking behaviors that have the potential to lead to injury. The school environment has a significant role in shaping adolescent behavior, and this study aimed to provide additional information about the benefits associated with connectedness to school. Early adolescents aged 13 to 15 years (N = 509, 49% boys) were surveyed about school connectedness, engagement in transport and violence risk-taking, and injury experiences. Significant relations were found between school connectedness and reduced engagement in both transport and violence risk-taking, as well as fewer associated injuries. This study has implications for the area of risk-taking and injury prevention, as it suggests the potential for reducing adolescents' injury through school based interventions targeting school connectedness.

Traversing the space between threats and violence: A review of threat assessment guidelines

While the majority of violent threats – defined as an expression of intent to do harm or act out violently against someone or something – do not progress to actual violence, a small proportion of threateners do go on to enact violence. Most researchers argue that violence risk assessments are inadequate for assessing threats of violence, which raises the question: how should a threat assessment (TA) be conducted? To begin to understand available frameworks for assessing threats, a systematic review of TA research literature was conducted. Most TA literature pertains to a specific domain (schools, public figure threats, workplaces) and target audience (clinicians, school personnel, law enforcement). TA guidelines are typically based on literature reviews with some based on empirical measures and others having no strong evidential basis. The most common concepts in TA are exploration of the threatener's mental health, the motivation for the threat and the presence of any plans. Rather than advocating for the development of a protocol for conducting TA, this article outlines the common areas of inquiry in assessing threats and highlights the limitations of current TA guidelines.

Comportements sexuels à risque, VIH/ITS et violence dans les milieux prostitutionnels de St-Marc et Gonaïves, Haïti

Les clients de TS sont considérés comme un groupe à risque de VIH et aussi agiraient comme un « pont de transmission » entre les TS et les femmes de la population générale. En dépit de leurs comportements sexuels à risque, les clients de TS ont été rarement étudiés. En conséquence, les objectifs spécifiques de cette thèse étaient : 1) estimer la prévalence du VIH, de la syphilis, du VHS-2 (virus de l’herpès simplex et 2) des facteurs de risque associés chez les clients de TS en Haïti, 2) examiner les déterminants de l’intention d’utilisation du condom, et 3) estimer la prévalence des comportements de violence et ses conséquences. Pour ce faire, une enquête transversale a été effectuée en 2006 auprès de 378 clients fréquentant les milieux de prostitution de St-Marc et de Gonaïves, en Haïti. Un questionnaire structuré ainsi que des échantillons de sang séché sur papier filtre ont été utilisés pour la collecte de données comportementales et biologiques. Notre premier article a montré une prévalence élevée du VIH et des ITS chez les clients. Ces hommes avaient plusieurs partenaires sexuelles avec lesquelles l’utilisation du condom variait. Les clients qui avaient déjà consommé de la marijuana, pratiquaient le vaudou, avaient des antécédents d’ITS ou étaient infectés par le VHS-2, avaient plus de chances d’être positifs au VIH. Le fait d’habiter Gonaïves, de ne pas être protestant, d’être employé et d’avoir déjà essayé la marijuana était associé à l’infection à la syphilis. Tandis que les clients plus vieux, ceux résidants à Gonaïves ainsi que ceux pratiquant le vaudou étaient plus souvent infectés par le VHS-2. Dans notre second article, nous avons démontré que les normes subjectives, le contrôle comportemental perçu et les attitudes étaient des déterminants importants de l’intention d’utilisation du condom. Les clients qui avaient des antécédents d’ITS ou avaient utilisé le condom lors de la dernière relation sexuelle avec la TS étaient aussi plus susceptibles d’avoir l’intention d’en faire usage dans le futur. Les résultats du dernier article ont montré que la prévalence des comportements de violence envers les partenaires intimes était élevée. De plus, la violence émotionnelle et physique était associée à l’utilisation inconstante du condom avec les différentes partenaires sexuelles. En conclusion, cette étude suggère que les clients de TS agiraient comme un pont de transmission facilitant la propagation du VIH/ITS dans la population générale en Haïti et que la violence semblerait également jouer un rôle dans la transmission de ces infections. Nos résultats soulignent le besoin d’interventions en prévention du VIH et des ITS ciblant cette population vulnérable, incluant la problématique de la violence.