Risk of Violence by Psychiatric Patients: Beyond the ‘Actuarial Versus Clinical’ Assessment Debate

Department of Psychiatry, Yale University, 34 Park St., New Haven, CT 06519, USA.
Psychiatric Services (Impact Factor: 2.41). 03/2008; 59(2):184-90. DOI: 10.1176/
Source: PubMed


Recently adopted statistical approaches improve researchers' ability to describe what is, and what is not, possible in the prediction of violence by psychiatric patients. At the base rates of violence routinely encountered in outpatient settings, current assessment methods would require hospital admission of large numbers of patients who are potential offenders in order to prevent the actual offending of a few. Suggestions that substantially greater accuracy is possible for short-term predictions, for particular symptom clusters, and for particular offenses have yet to be tested and confirmed. Further research may improve this state of affairs, for instance, by concentrating on particular patient groups. There are reasons to suspect that any improvement will be limited. Clinical practice, however, is likely to continue to require the assessment of a patient's potential for acting violently. Future research should aid such assessments by clarifying the mechanisms by which risk factors correlate with violence and by establishing the clinical usefulness of actuarial scales.

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    • "On the other hand, a strictly probabilistic risk assessment, based on objective risk factors and observations of large cohorts of similar patients as are considered in actuarial studies of risk can be seen as approximating a Frequentist position. While it is almost certainly true that this sort of assessment is statistically superior to clinical methods, the preference for clinical or actuarial risk assessment methods remains controversial (Buchanan, 2008). In reality, we probably cannot divorce prior beliefs from any risk assessment when faced with a particular patient. "

    Full-text · Article · Aug 2014
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    • "Unlike the PPV, the ROC method is unaffected by base rates. However, the base rate of violence in risk assessment remains important because of the difficulty of translating the AUC value into clinically meaningful information by itself.32 To elaborate, if a risk assessment instrument was used as a screening test, and those identified as likely to be violent remained in secure care, then, for any given period, the number of patients we require to be detained (number needed to detain, NND) in order to prevent one violent act can be calculated. "
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    ABSTRACT: Risk assessment differs from other medical interventions in that the welfare of the patient is not the immediate object of the intervention. However, improving the risk assessment process may reduce the chance of risk assessment itself being unjust. We explore the ethical arguments in relation to risk assessment as a medical intervention, drawing analogies, where applicable, with ethical arguments raised by general medical investigations. The article concludes by supporting the structured professional judgement approach as a method of risk assessment that is most consistent with the respect for principles of medical ethics. Recommendations are made for the future direction of risk assessment indicated by ethical theory.
    Full-text · Article · Apr 2014
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    • "There is only limited evidence that a history of violence predicts inpatient violence during the whole course of hospitalization, although it has been reported to be a good predictor of subsequent aggressive behavior (Bobes et al., 2009; Lanza, 1996; McNiel and Binder, 1989; Tardiff et al., 1997; Walsh et al., 2004). Criminological and forensic research has demonstrated some evidence that violence could be predicted by identifying particular types of offenses from the histories; however, few data are available for psychiatric samples (Buchanan, 2008). Moreover, it is necessary to focus on a particular group of psychiatric patients to study violence. "
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    ABSTRACT: A standard measure to assess and predict violence is important for psychiatric services. No prospective study has examined the history of violence and heterogeneity of violence in predicting specific types of violence among inpatient with schizophrenia. This study aimed to prospectively examine the accuracy of prediction of types of violence using the Chinese modified version of Violence Scale (VS-CM) among inpatients with schizophrenia based on their past history of violence and the real occurrence of violence during hospitalization. A prospective cohort study design. A total of 107 adult patients with schizophrenia spectrum disorders, consecutively admitted to an acute psychiatric ward of a university hospital in Taiwan, were recruited. In addition to data about demographics and clinical illness, count records of the history of violence within one month prior to admission by interview and the actual occurrence of violence during the whole course of hospitalization by participant observation were collected using the VS-CM. Multivariate logistic analysis and area under the Receiver Operating Characteristic curve (AUC) analysis were applied to examine the predictive ability of the VS-CM. A patient's history of violence assessed by the VS-CM predicted the actual occurrence of violence during hospitalization with the Odds Ratio of 17.5 (p=0.001). The predictive accuracy of the VS-CM had high sensitivity (97.0%), moderate positive predictive value (71.4%), and high negative predictive value (87.5%); however, the specificity was relatively low (35.0%). The AUC was 79.5% using the total scale of the VS-CM and 70.7-74.5% using the subscales in predicting corresponding types of violence. The VS-CM is a valid and reliable measure of potential violence. It can be applied to assess and predict specific types of violence among inpatient with schizophrenia.
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