Dale E. McNiel

Utility of decision support tools for assessing acute risk of violence

The authors evaluated the utility of 3 decision support tools for assessing acute risk of violence in patients undergoing behavioral emergencies that warranted hospitalization. Information available at the time of admission to a short-term psychiatric unit was coded from the medical charts of 100 patients using the Historical, Clinical, Risk Management-20 (HCR-20), the Hare Psychopathy Checklist-Screening Version (PCL-SV), and the McNiel-Binder Violence Screening Checklist (VSC). Nurses rated violence that later occurred during hospitalization with the Overt Aggression Scale. Scores on all 3 instruments were associated with the likelihood of violence. The strongest predictive relationships were obtained for indices of clinical risk factors rather than historical risk factors. The results suggest that decision support tools, particularly those that emphasize clinical risk factors, have the potential to improve decision making about violence risk in the context of behavioral emergencies.

Screening for Risk of Inpatient Violence Validation of an Actuarial Tool

A screening checklist for assessing the risk of violence at the time of psychiatric hospitalization was developed. Checklist items and a cutoff point for low versus high risk of violence were selected based on a previous study of statistical prediction of violence. Application of the checklist to a new sample of 338 patients admitted to a university-based inpatient unit revealed promising results in identifying patients who later displayed aggressive behavior in the hospital, as indicated by its positive predictive value (59.0%), negative predictive value (70.6%), sensitivity (57.2%), specificity (70.0%), total predictive value (65.4%), and likelihood ratio (1.97). The results suggest the potential value of incorporating actuarial methods in the evaluation of violence risk.

Violence risk communication: Implications for research, policy, and practice

Abstract Risk communication of violence involves information provided by an assessor to a decision-maker regarding the likelihood that a violent act will be committed by an individual who is being evaluated. It has received relatively little conceptual and empirical attention, in contrast to the increased focus on violence risk factors, outcomes and prediction accuracy seen in research during the last decade. In this article, we offer a number of theoretical and practical justifications for studying risk communication: (a) the significant demand for risk assessment, (b) the likely increase in this demand in the future, (c) the identification of risk communication as conceptually important, (d) the absence of available empirical research, (e) the importance of risk communication as a link between risk assessment and decision-making, (f), the favorable impact of good risk communication on better-informed legal decision-making, and (g) the serious consequences of risk-relevant decisions. After reviewing the ...

Smoking and tardive dyskinesia

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Impact of Clinical Training on Violence Risk Assessment

ajp.psychiatryonline.org With this article, the Journal inaugurates a new feature for our readers. Education in Psychiatry, like Treatment in Psychiatry, begins with a case vignette to illustrate an important problem in clinical psychiatry. However, the goal of Education in Psychiatry is to present and evaluate methods to teach students, trainees, and other psychiatrists how to treat patients with these problems.

Violence, civil commitment, and hospitalization

The frequency of violent behavior and civil commitment leading to hospitalization of psychiatric patients was examined comparing the years 1973 and 1983. For each year, 150 patients were randomly selected among admissions to a locked acute psychiatric unit in a university setting. Medical charts were reviewed for descriptions of violent behavior, demographic information, and legal status. While the rate of preadmission violence did not change significantly between 1973 and 1983, there was a threefold increase in the proportion of patients admitted involuntarily as a danger to others. Possible explanations of the inconsistent application of civil commitment statutes are discussed.

Relevance of interrater agreement to violence risk assessment.

This study considered whether assessments of violence risk in which 2 clinicians reach similar conclusions are more accurate than the conclusions of either clinician alone when their assessments disagree. One hundred ten physicians and 44 nurses estimated the probability of physical assault of 478 patients admitted to a short-term locked psychiatric inpatient unit. The level of assessed risk showed a substantial correspondence with the likelihood of later violence when the physician and nurse ratings were highly concordant. As the extent of agreement between the physician and nurse ratings decreased, the strength of the association between the risk assessments and the occurrence of violence decreased accordingly.

Recent victimization increases risk for violence in justice-involved persons with mental illness.

A large body of research has examined relationships between distal experiences of victimization and the likelihood of engaging in violence later in life. Less is known about the influence of recent violent victimization on risk for violence perpetration. To our knowledge, this is the first study to examine prospectively whether recent victimization in adulthood increases the risk of future violence. Specifically, the present study assessed the incremental validity of recent violent victimization in the prediction of future violence in a sample of justice-involved adults with serious mental illness. The study examined (a) whether recent experiences of violent victimization (i.e., within 6 months of the baseline assessment) predicted a greater likelihood of perpetrating violence in the next year, and (b) whether inclusion of recent victimization enhanced the predictive validity of a model of violence risk in a sample of justice-involved adults with severe mental illness (N = 167). Hierarchical logistic regression analyses indicated that exposure to recent violent victimization at the baseline assessment predicted a greater likelihood of engaging in violent behavior during the year follow-up period. Additionally, recent exposure to violence at the baseline assessment continued to explain a significant amount of variance in a model of future violence perpetration above the variance accounted for by well-established violence risk factors. Taken together, the findings suggest that recent victimization is important to consider in understanding and evaluating risk of violence by persons with mental disorders who are involved in the criminal justice system.

A Method for Evaluating Competency in Assessment and Management of Suicide Risk

ObjectiveAlthough health professionals increasingly are expected to be able to assess and manage patients’ risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI—S), and evaluates its use in an objective structured clinical examination (OSCE).MethodsThe authors developed the CAI—S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI—S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI—S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI—S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments.ResultsThe CAI—S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI—S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision.ConclusionThe findings support the usefulness of the CAI—S for evaluating competency in suicide risk-assessment and management.

Functions of non-suicidal self-injury in adolescents and young adults with Borderline Personality Disorder symptoms.

Rates of deliberate non-suicidal self-injury (NSSI) increase during adolescence and young adulthood, particularly in clinical samples, making these important developmental stages for understanding the functions of NSSI. Borderline Personality Disorder (BPD) symptoms also begin to emerge in adolescence, though little research has examined relationships between BPD symptoms and the functions of NSSI in youth, the primary goal of the present study. Adolescents and young adults recruited from an outpatient psychotherapy clinic (N=36) endorsed a range of NSSI functions on the Inventory of Statements about Self-Injury (Klonsky and Glenn, 2009). Participants engaged in NSSI to serve intrapersonal functions (e.g., regulate affect, punish oneself) more frequently than interpersonal functions (e.g., bond with peers, establish autonomy). As predicted, linear regression analyses indicated that BPD affective dysregulation symptoms were associated with the intrapersonal but not the interpersonal functions of NSSI. In contrast, BPD interpersonal dysfunction symptoms were differentially associated with the interpersonal rather than intrapersonal functions of NSSI. These preliminary data indicate that clusters of BPD symptoms show unique relationships with functions of NSSI in treatment-seeking adolescents and young adults, relationships that can be used to target specific functions of NSSI in treatment planning.