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Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis.

ABSTRACT: BACKGROUND AND AIMS:Violent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings. METHODS:The nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of these tools in forensic psychiatric inpatient settings. Risk assessment instruments were separated into those designed for imminent (within 24?hours) violence prediction and those designed for longer-term prediction. A range of accuracy measures and descriptive variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2. Summary performance measures (sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, and area under the curve value) and HSROC curves were produced. In addition, meta-regression analyses investigated study and sample effects on tool performance. RESULTS:Fifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71-0.85) compared with longer-term tools (AUC 0.68; IQR: 0.62-0.75). Other performance measures indicated variable accuracy for imminent and longer-term tools. Meta-regression indicated that no study or sample-related characteristics were associated with between-study differences in AUCs. INTERPRETATION:The performance of current tools in predicting risk of violence beyond the first few days is variable, and the selection of which tool to use in clinical practice should consider accuracy estimates. For more imminent violence, however, there is evidence in support of brief scalable assessment tools.

SUBMITTER: Ramesh T

PROVIDER: S-EPMC6020743 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis.

Ramesh Taanvi T Igoumenou Artemis A Vazquez Montes Maria M Fazel Seena S

European psychiatry : the journal of the Association of European Psychiatrists 20180404

<h4>Background and aims</h4>Violent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings.<h4>Methods</h4>The nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of the ...[more]

PMID: 29626758

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Project description:BackgroundAlthough structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered.MethodsIn our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716.FindingsWe conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%).InterpretationCurrent violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support.FundingWellcome Trust.

Project description:ImportanceThe association of Lyme neuroborreliosis with the development of psychiatric disease is unknown and remains a subject of debate.ObjectiveTo investigate the risk of psychiatric disease, the percentage of psychiatric hospital inpatient and outpatient contacts, and the receipt of prescribed psychiatric medications among patients with Lyme neuroborreliosis compared with individuals in a matched comparison cohort.Design, setting, and participantsThis nationwide population-based matched cohort study included all residents of Denmark who received a positive result on an intrathecal antibody index test for Borrelia burgdorferi (patient cohort) between January 1, 1995, and December 31, 2015. Patients were matched by age and sex to a comparison cohort of individuals without Lyme neuroborreliosis from the general population of Denmark. Data were analyzed from February 2019 to March 2020.ExposuresDiagnosis of Lyme neuroborreliosis, defined as a positive result on an intrathecal antibody index test for B burgdorferi.Main outcomes and measuresThe 0- to 15-year hazard ratios for the assignment of psychiatric diagnostic codes, the difference in the percentage of psychiatric inpatient and outpatient hospital contacts, and the difference in the percentage of prescribed psychiatric medications received among the patient cohort vs the comparison cohort.ResultsAmong 2897 patients with Lyme neuroborreliosis (1646 men [56.8%]) and 28 970 individuals in the matched comparison cohort (16 460 men [56.8%]), the median age was 45.7 years (interquartile range [IQR], 11.5-62.0 years) for both groups. The risk of a psychiatric disease diagnosis and the percentage of hospital contacts for psychiatric disease were not higher among patients with Lyme neuroborreliosis compared with individuals in the comparison cohort. A higher percentage of patients with Lyme neuroborreliosis compared with individuals in the comparison cohort received anxiolytic (7.2% vs 4.7%; difference, 2.6%; 95% CI, 1.6%-3.5%), hypnotic and sedative (11.0% vs 5.3%; difference, 5.7%; 95% CI, 4.5%-6.8%), and antidepressant (11.4% vs 6.0%; difference, 5.4%; 95% CI, 4.3%-6.6%) medications within the first year after diagnosis, after which the receipt of psychiatric medication returned to the same level as the comparison cohort.Conclusions and relevanceIn this population-based matched cohort study, patients with Lyme neuroborreliosis did not have an increased risk of developing psychiatric diseases that required hospital care or treatment with prescription medication. The increased receipt of psychiatric medication among patients with Lyme neuroborreliosis within the first year after diagnosis, but not thereafter, suggests that most symptoms associated with the diagnosis subside within a short period.

Project description:Background: Forensic psychiatric care treats mentally disordered offenders who suffer mainly from psychotic disorders, although comorbidities such as personality disorders, neurodevelopmental disorders, and substance abuse are common. A large proportion of these patients have committed violent crimes. Their care is involuntary, and their caregivers' mission is complex: not only to rehabilitate the patient, but also to consider their risk for reoffending and their risk to society. The objective of this overview of systematic reviews is to identify, appraise, and summarize the existing knowledge in forensic psychiatric care and identify knowledge gaps that require further research. Methods: We undertook a systematic literature search for systematic reviews in five defined domains considered important in daily clinical practice within the forensic psychiatric care: (1) diagnostic assessment and risk assessments; (2) pharmacological treatment; (3) psychological interventions; (4) psychosocial interventions, rehabilitation, and habilitation; and (5) restraint interventions. The target population was mentally disordered offenders (forensic psychiatric patients aged >15 years). Each abstract and full text review was assessed by two of the authors. Relevant reviews then were assessed for bias, and those with moderate or low risk of bias were included. Results: Of 38 systematic reviews meeting the inclusion criteria, only four had a moderate risk of bias. Two aimed to incorporate as many aspects of forensic psychiatric care as possible, one investigated non-pharmacological interventions to reduce aggression in forensic psychiatric care, and one focused on women with intellectual disabilities in forensic care. However, most of the primary studies included in these reviews had high risks of bias, and therefore, no conclusions could be drawn. All of our identified domains must be considered knowledge gaps. Conclusion: We could not answer any of our research questions within the five domains because of the high risk of bias in the primary studies in the included systematic reviews. There is an urgent need for more research on forensic psychiatric care since all of our studied domains were considered knowledge gaps.

Project description:To identify instruments or components of instruments that aim to measure aspects of a caring culture-shared beliefs, norms and values that direct professionals and managers to act caring in hospitals, and to evaluate their psychometric properties.Systematic review.PubMed, CINAHL, EMBASE, PsychInfo, Web of Science and the International bibliography of the Social Sciences.Peer-reviewed articles describing (components of) instruments measuring aspects of a caring culture in a hospital setting. Studies had to report psychometric data regarding the reliability or validity of the instrument. Potentially useful instruments that were identified after the title and abstract scan were assessed on relevance by an expert panel (n=12) using the RAND-modified Delphi procedure.Of the 6399 references identified, 75 were examined in detail. 7 studies each covering a unique instrument met our inclusion criteria. On average, 24% of the instrument's items were considered relevant for measuring aspects of the hospital's caring culture. Studies showed moderate-to-high validity and reliability scores. Validity was addressed for 6 of the 7 instruments. Face, content (90%) and construct (60%) validity were the most frequently reported psychometric properties described. One study (14%) reported discriminant validity of the instrument. Reliability data were available for all of the instruments. Internal consistency was the most frequently reported psychometric property for the instruments and demonstrated by: a Cronbach's ? coefficient (80%), subscale intercorrelations (60%), and item-total correlations (40%).The ultimate standard for measuring a caring culture in hospitals does not exist. Existing instruments provide partial coverage and lack information on discriminant validity, responsiveness and feasibility. Characteristics of the instruments included in this review could provide useful input for the design of a reliable and valid instrument for measuring a caring culture in hospitals.

Project description:Various financial and non-financial conflicts of interests have been shown to influence the reporting of research findings, particularly in clinical medicine. In this study, we examine whether this extends to prognostic instruments designed to assess violence risk. Such instruments have increasingly become a routine part of clinical practice in mental health and criminal justice settings. The present meta-analysis investigated whether an authorship effect exists in the violence risk assessment literature by comparing predictive accuracy outcomes in studies where the individuals who designed these instruments were study authors with independent investigations. A systematic search from 1966 to 2011 was conducted using PsycINFO, EMBASE, MEDLINE, and US National Criminal Justice Reference Service Abstracts to identify predictive validity studies for the nine most commonly used risk assessment tools. Tabular data from 83 studies comprising 104 samples was collected, information on two-thirds of which was received directly from study authors for the review. Random effects subgroup analysis and metaregression were used to explore evidence of an authorship effect. We found a substantial and statistically significant authorship effect. Overall, studies authored by tool designers reported predictive validity findings around two times higher those of investigations reported by independent authors (DOR=6.22 [95% CI=4.68-8.26] in designers' studies vs. DOR=3.08 [95% CI=2.45-3.88] in independent studies). As there was evidence of an authorship effect, we also examined disclosure rates. None of the 25 studies where tool designers or translators were also study authors published a conflict of interest statement to that effect, despite a number of journals requiring that potential conflicts be disclosed. The field of risk assessment would benefit from routine disclosure and registration of research studies. The extent to which similar conflict of interests exists in those developing risk assessment guidelines and providing expert testimony needs clarification.

Project description:BackgroundViolence is a major concern and is prevalent across several mental disorders. The use of substances has been associated with an exacerbation of psychiatric symptoms as well as with violence. Compared to other substances such as alcohol and cocaine, existing literature on the cannabis-violence relationship has been more limited, with most studies being conducted in the general population, and has shown controversial results. Evidence has suggested a stronger relationship when examining the effects of the persistency of cannabis use on future violent behaviors. Though, while cannabis use is highly prevalent amid psychiatric patients, far less literature on the subject has been conducted in this population. Hence, the present prospective study aims to investigate the persistency of cannabis use in psychiatric patients.MethodThe sample comprised of 1,136 recently discharged psychiatric patients provided by the MacArthur Risk Assessment Study. A multi-wave (five-assessment) follow-up design was employed to allow temporal sequencing between substance use and violent behaviors. Generalized estimating equations (GEE) were used to examine the effect of persistency of cannabis use on violence, while controlling for potential confounding factors. Potential bidirectional association was also investigated using the same statistical approach.ResultsOur results suggest a unidirectional association between cannabis use and violence. GEE model revealed that the continuity of cannabis use across more than one time wave was associated with increased risks of future violent behavior. Patients who reported having used cannabis at each follow-up periods were 2.44 times more likely to display violent behaviors (OR = 2.44, 95% CI: 1.06-5.63, p < 0.05).ConclusionThese findings are particularly relevant as they suggest that the longer individuals report having used cannabis after a psychiatric discharge, the more likely they are of being violent in the following time waves. These results add to our understanding of the negative consequences of chronic cannabis use amid psychiatric patients.

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Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis.

Publications

Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis.

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