The first step in the validation of a new screen for violence risk in acute psychiatry: The inpatient context

Background

Instruments for evaluating the risk of violence towards others have mostly been developed for assessment of risk for recidivism into violent crime in forensic psychiatry. In general psychiatry there is a considerable need for specialised, brief and structured assessment tools to inform risk decisions.

Method

The study aimed to validate a brief structured clinical risk assessment screen of inpatient violence (V-RISK-10), a 10-item structured clinical checklist with a good vignette-based interrater reliability (ICC=0.87). In this study it was used for risk assessment of a one-year sample of patients (N = 1.017) admitted to two acute psychiatric units. Risk assessments at admission were compared to prospective records of aggressive and violent acts during the hospital stay.

Results

Results showed a base rate for aggression of 9%. The predictive validity of the V-RISK-10 was estimated by Receiver Operating Characteristics (ROC). It yielded an area under the curve (AUC) of 0.83, with sensitivity/specificity of 0.81/0.73 and corresponding positive and negative predictive values (PPV/NPV) of 0.24/0.97. The screen was easy-to-use and showed a short completion time.

Conclusion

Despite promising results further validation studies are required before the V-RISK-10 is adopted into routine clinical practise.     

Suicidal behaviour and intensity of psychiatric care in a region at high risk for suicide

BACKGROUND Suicidal behaviour represents a social and health-related issue of prime importance in both the general and psychiatric population. People with mental illness are at great risk of suicide, but indirect evidence suggests that the treatment of psychiatric disorders may prevent suicide. The aim of our study was to compare the risk of suicide in the population of psychiatric patients with that of the general population in Friuli Venezia-Giulia (FVG).

METHOD We analyzed the suicide rates, based on the official statistical database, relating to the resident population in FVG during the years 1998–1999. The sucide rates (per 100?000 subjects) were standardised by sex and age. The characteristics of suicidal behaviour in subjects who had been in contact with (Community Mental Health Centres) CMHC (n=65) were compared with that of suicidal subjects not in contact (n=237).

RESULTS There was an increase in the suicide phenomenon in the elderly population in FVG over the tested period. The rates were three times higher in males than in females. The rates of patients in contact with CMHC in 1998 and in 1999 were, respectively, 14 and 20 times higher than that of the general population. Most suicidal schizophrenics and 37% of the depressed patients have been previously hospitalised.

CONCLUSION The population of north-eastern Italy is at high risk of suicide compared to other regions. The mortality ratio of psychiatric subjects who commit suicide in our sample is elevated. Since Italian community-oriented services rely less on hospitalisation than in other countries, the fact that about 50% of suicidal psychiatric patients have been previously admitted in a psychiatric ward may indicate that previous hospitalisation is a hierarchic factor related to suicide.     

Influencing mental health policy: the MHA approach

The Mental Health Association was founded in 1909 as a citizen advocate organization for the mentally ill. Today it embraces more than a million members in nearly 850 chapters nationwide and conducts numerous programs designed to prevent mental illness, promote mental health, and improve mental health services. In recent years it has played an increasingly active role in influencing mental health policy at the federal level. This article focuses on the association's activities in the political arena.     

Triage in psychiatric emergency services in Copenhagen: results from a descriptive 1-year evaluation study

Inspired by the Australasian triage system, a regional psychiatric triage system was introduced in the psychiatric emergency units (PEUs) in Copenhagen in 2011. Our aim of the study is to determine the characteristics of the patient according to the defined triage criteria and check if this is in accordance with recommendations. A random 10% data sample was obtained throughout 2012 in three PEUs of Copenhagen. Triage category, demographic, social and clinically relevant variables were collected. A total of 929 contacts were registered. We found significant associations between triage category and several clinical parameters. Time of visit was correlated to diagnoses. The results indicate that use of the new triage system in emergency psychiatry has facilitated urgency categorization, reduced waiting time, and optimized clinical decisions. These goals are important clinical implications of the service in PEUs. The need for PEUs out-of-daytime (when all Community Mental Health Centers are closed) has also been demonstrated.     

Covert and Implicit Influences on the Interpretation of Violence Risk Instruments

Forensic mental health practitioners are frequently asked to estimate the risk of future violence. Legal decisions concerning the sentencing, management and disposition of offenders often rely on the advice of such testimony. The burgeoning use of violence risk instruments in these settings undoubtedly injects a level of scientific rigour into forensic evaluations for courts and tribunals. Yet scrutiny of the inherent limitations of both risk instruments and the inferences and formulations drawn from them are often veiled by the discipline's endorsement for such approaches. Misconceptions about the validity and dependability of present-day risk assessments and expert infallibility persist. The furtive influences that shape both the (mis)interpretation and miscommunication of risk instruments in legal settings necessitate discussion.     

V-RISK-10: Validation of a screen for risk of violence after discharge from acute psychiatry

Background

Current violence risk assessment instruments are time-consuming and mainly developed for forensic psychiatry. A paucity of violence screens for acute psychiatry instigated the development and validation of the V-RISK-10. The aim of this prospective naturalistic study was to test the predictive validity of the V-RISK-10 as a screen of violence risk after discharge from two acute psychiatric wards.

Methods

Patients were screened with V-RISK-10 before discharge, and incidents of violence were recorded 3, 6, 9 and 12 months after discharge. A total of 381 of the 1017 patients that were screened completed the follow up.

Results

The ROC-AUC values for any violent behaviour were 0.80 and 0.75 (p < 0.001) for the 3 and 12 months follow-up periods, respectively, and significant for both genders. The most accurate risk estimates were obtained for severe violence. For persons without a known history of violence prior to the screening, AUCs were 0.74 (p = 0.004) and 0.68 (p = 0.002).

Conclusions

Results indicate that the V-RISK-10 is a valid and clinically useful screen for violence risk after discharge from acute psychiatry, and even significant for patients without a known previous history of violence.     

Sociopsychological Correlates of Teen-Age Pregnancy in the United States Virgin Islands

Consultation-liaison (C-L) and emergency psychiatry are two aspects of public psychiatry that experienced considerable development during the last decade in France. Major disparities still persist as regards endowment in professional resources and organization of C-L activity from one general hospital to another. Several emergent practices are described that underlie the role attributed to the C-L psychiatrist or psychologist as an expert in some systematic screening or assessment requests, as well as address the issue of combining, for some clinical situations, psychiatric and medical consultations. Substantial efforts have also been made for implementing C-L psychiatry outside the general hospital wards, notably in prisons. Psychiatric emergencies are, henceforth, integrated within emergency facilities of general hospitals. Several sociological changes or health policy decisions in France, such as the deinstitutionalization movement of the mentally ill, led to an increased numbers of patients at psychiatric emergency departments. Progress in crisis management, as well as opening of crisis units outside the hospital wards and some experimental mobile emergency units to operate at patients' homes, limit the number of psychiatric hospitalizations, whether they are with or without patient's consent, which is following a visit to the emergency department of a general hospital. Management of suicide attempts and prevention of recurrences remain a priority goal of emergency psychiatry, as are a better exploration of mixed medical and psychiatric situations and the implementation of facilities specially devoted to child and adolescent emergencies.     

Mentally disordered offenders in Sweden: differentiating recidivists from non-recidivists in a 10-year follow-up study

Background: Forensic psychiatric patients present a challenge as they manifest severe mental disorders together with criminal behaviour. There are well-known risk factors for criminal behaviour in the general population, yet knowledge of what predicts reconviction in the Swedish forensic population in the long-term perspective is still insufficient.

Aims: The study aims to (1) describe background and clinical characteristics of forensic psychiatric patients in a 10-year follow-up, (2) analyse risk factors associated with recidivism, and (3) test the predictive validity of risk factors for general and violent criminality.

Methods: Detailed information on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment from 1999–2005 (n?=?125) was collected. Court decisions were collected up until the end of 2008 (median follow-up time?=?6.2 years, range?=?0.6–9.7 years).

Results: Relapse in general crime (n?=?30) was predicted by low educational attainment, mental disorder in a first degree relative, and low age at first sentenced crime. Relapse in violent crime (n?=?16) was predicted by low educational attainment and low GAF scores. Patients with a restriction order were less likely to relapse in both crime categories.

Conclusions: Signs of childhood adversities together with early debut in criminality appeared as important risk factors for general and violent recidivism. Forensic psychiatric treatment combined with a restriction order was demonstrated as a protective factor against recidivism, suggesting that the risk of recidivism is strongly related to the level of supervision. Although the low number of recidivism cases is highly desirable, it unfortunately reduces the power of the analyses in this paper.     

Lessons from western Kosovo for the documentation of war crimes

Based upon experiences of the International Crisis Group's Humanitarian Law Documentation Project in Western Kosovo, the author advances a series of recommendations for effective intervention by aid workers in areas where considerable trauma has been inflicted upon civilians. In particular, she argues that in documenting war crimes, the primary responsibility of the interviewer is to the wellbeing of the witness. This includes not only emergency survival needs such as adequate shelter, food and clothing; it means taking care of their mental health needs. This should be done by training interviewers in recognising symptoms of mental disorders and providing immediate assistance for those who need it as well as ensuring that there are facilities available in the longer term to address the inevitable consequences of mass violence. For people documenting war crimes, it is not enough simply to go in, take a statement and leave. In order to be able to provide this type of assistance, the mental health needs of humanitarian workers themselves must also be addressed. There must be adequate facilities staffed by experienced people to help both local and international workers deal with the type of work they are doing. In both of these situations, the persons providing training and treatment must themselves be trained in post‐conflict situations and issues arising as a result of mass trauma If possible, it is best to tap into local mental health structures that already exist.     

Attitudes of psychiatric nursing personnel towards patients who have attempted suicide

The aim of this study was to examine the attitudes towards suicidal patients of a group of psychiatric nursing personnel (n=197) and to establish a baseline of attitudinal measures against which the effects of a subsequent educational programme can be assessed. A scale, known as the Understanding of Suicide Attempt Patient Scale (USP Scale) was developed for this purpose. The reliability of the scale was satisfactory, and its correlation with visual analogue scale (VAS) scores based on clinical vignettes suggests that it has validity. Women tended to be more sympathetic than men, and older personnel were more favourably disposed than the younger nurses. Differences between personnel working in different settings were found, which might be explained by differences in the frequency of contact with suicide-prone patients, more frequent exposure being associated with more positive attitudes.     

General hospital psychiatry from the perspective of medical economics

The purpose of this study was to investigate the efficacy of consultation-liaison (C-L) psychiatry from the perspective of medical economics, by comparing a part-time and full-time psychiatric department. One full-time (5 days per week) psychiatrist began work at a general hospital (GH-A), and one part-time (once per week) psychiatrist had been working at another general hospital (GH-B). Both general hospitals are teaching hospitals of the same size. The number of patients and the medical reimbursements were investigated each month and compared. This study demonstrated that the establishment of C-L psychiatry was economically profitable in contrast with what was the common belief among general hospital administrators. Also, the differences in the total number of patients (GH-A: GH-B = 500:35-50 patients/month) and the total reimbursement (GH-A: GH-B = 3 million: 2-300000 yen/month) was not explained by the number of working days (GH-A: GH-B = 5:1 day/week). The full-time model of C-L psychiatry has also indirect effects (i.e. educational and relieving effects) on the hospital staff. Promoting the establishment of C-L psychiatry requires many evidence-based studies that demonstrate the necessity for C-L psychiatry and can directly persuade hospital directors.     

Consultation-liaison psychiatry: A comparison of two service models for geriatric patients

In general hospitals the psychiatric morbidity in the old and frail is at least 40%. Two models for the provision of a psychiatric service to hospitalized geriatric patients were evaluated in order to identify which model most effectively fulfilled the aims of liaison psychiatry. At present, consultation type services predominate and there is some concern that an active liaison service could increase the referral rate of cases more appropriately dealt with by physicians. In this study an active liaison model was not associated with a marked increase in the referral rate, and when compared to a service with an emphasis on consultation, there was a higher degree of diagnostic accuracy by referring doctors in the liaison type model.     

Neuroanatomy of vulnerability to psychosis: a voxel-based meta-analysis

Background

Individual structural imaging studies in the pre-psychotic phases deliver contrasting findings and are unable to definitively characterize the neuroanatomical correlates of an increased liability to psychosis and to predict transition to psychosis.

Method

Ninenteen voxel-based morphometry (VBM) studies of subjects at enhanced risk for psychosis and healthy controls were included in an activation likelihood estimation (ALE) meta-analysis.

Results

The overall sample consisted of 701 controls and 896 high risk subjects. Subjects at high risk for psychosis showed reduced gray matter (GM) volume as compared to controls in the right superior temporal gyrus, left precuneus, left medial frontal gyrus, right middle frontal gyrus, bilateral parahippocampal/hippocampal regions and bilateral anterior cingulate. High risk subjects who later developed a psychotic episode showed baseline GM volume reductions in the right inferior frontal gyrus and in the right superior temporal gyrus.

Conclusions

GM volume reductions in temporo-parietal, bilateral prefrontal and limbic cortex are neuroanatomical correlates of an enhanced vulnerability to psychosis. Baseline GM reductions in superior temporal and inferior frontal areas are associated with later transition to psychosis.     

A long-term follow-up study of adolescent psychiatric in-patients. Part II. Predictors of delinquency

A total of 932 adolescent psychiatric in-patients were followed up 15-33 years after hospitalization by record linkage to the National Register of Criminality. On the basis of the hospital records the patients were rediagnosed according to DSM-IV and scored on data postulated to be predictors of later delinquency. The factors were investigated by Kaplan-Meyer survival analysis and Cox regression. Cox analysis showed that, in males, main diagnosis (relative risk (RR)=2.9, 95% confidence interval (CI)=2.0-4.2), verbal abuse at home (RR=1.5, CI=1.1-2.0), disciplinary problems at school (RR=1.7, CI=1.2-2.5), and violating ward rules during hospitalization (RR=1.6, CI=1.2-2.2) were strong and independent predictors of delinquency. In females, main diagnosis (RR=2.6, CI=1.6-4.2), concurrent psychoactive substance use disorder (RR=2.9, CI=1.9-4.2), verbal abuse at home (RR=1.5, CI=1.0-2.1), and disciplinary problems at school (RR=1.6, CI=1.1-2.5) were strong and independent predictors of delinquency. Among males who violated ward rules and received a diagnosis of disruptive behaviour disorder, psychoactive substance use disorder or personality disorder at index hospitalization, as many as 77.6% had a criminal record at follow-up.     

A long-term follow-up study of adolescent psychiatric in-patients. Part I. Predictors of early death

A total of 1095 adolescent psychiatric in-patients were followed up 15-33 years after hospitalization by record linkage to the National Registry of Causes of Death. On the basis of hospital records all patients were rediagnosed according to DSM-IV and scored on data postulated to be predictors of early death. The factors were investigated by Kaplan-Meyer survival analysis and Cox regression. Cox regression showed that male sex (relative risk (RR)=2.7, 95% confidence interval (CI)=1.9-3.9), psychoactive substance use disorder (RR=2.9, CI=2.0-4.0), short hospital stay (RR=3.1, CI=1.9-5.5) and poor impulse control (RR=1.6, CI=1.1-2.2) remained strong and independent predictors of death. Patients with psychoactive substance use disorder had different predictors of death (male sex, short hospital stay, poor impulse control, poor parental relationship, and low socio-economic status) than did patients without this disorder (male sex, somatic disorder at hospitalization, more than one hospitalization). In our patient population it seemed possible to identify a subgroup of adolescent psychiatric in-patients with an extremely high mortality (about 40%), namely males with psychoactive substance use disorder and poor impulse control.     

A long-term follow-up study of adolescent psychiatric in-patients. Part III. Predictors of disability

A total of 1095 adolescent psychiatric in-patients were followed up 15-33 years after hospitalization by record linkage to the National Register of Disability Benefits. On the basis of hospital records, all patients were rediagnosed according to DSM-IV and scored on data postulated to have predictive power with regard to disability. The factors were investigated by Kaplan-Meyer survival analysis and Cox regression. A psychotic or organic disorder, low score on DSM-IV Axis V (GAF) and the use of psychotropic medication at hospitalization were among the strong predictors of later disability, as were low IQ, poor achievement at school, somatic disorders, and self-harming behaviour (all P < 0.01). Cox analysis showed that, of these, the following factors remained strong and independent predictors of disability: psychotic and organic disorders (relative risk (RR)=3.1, 95% confidence interval (CI)=2.4-4.0), IQ < 90 (RR=1.8, CI=1.5-2.3); and GAF < 30 (RR=1.9, CI=1.5-2.4). Former adolescent psychiatric in-patients with a psychotic or organic disorder had a very high risk of later disability (71-81%), whereas those with other psychiatric diagnoses, and with IQ > or = 90 and GAF > or = 30 at hospitalization, had a relatively low risk of disability (22-29%).     

Children of parents with obsessive-compulsive disorder -- a 2-year follow-up study

OBJECTIVE: To examine the association between parental obsessive-compulsive disorder (OCD) and emotional and behavioural disorders in offspring. METHOD: Demographic, clinical, and diagnostic data were collected from parents with OCD, control subjects, and their respective offspring. Offspring were reassessed at a 2-year follow-up. RESULTS: Probands with OCD and controls were relatively well matched for age, gender, race, educational rating, and marital status. Offspring of OCD probands were at greater risk than offspring of controls for dimensionally measured anxiety, depression, somatization, and social problems. OCD offspring were significantly more likely than control offspring to have lifetime overanxious disorder, separation anxiety disorder, OCD, or 'any anxiety disorder'. Female gender in the parent with OCD, evidence of family dysfunction, and high symptom levels in offspring were predictive of broadly defined OCD at follow-up. CONCLUSION: Children having a parent with OCD are more likely than control offspring to have social, emotional, and behavioural disorders.