Violence Risk Assessment & Management Information Toolkit

1. Violence Risk Assessment & Management Information Toolkit Dr Gregory Darryl / Dr Waldron Gerard

2. Structure • Epidemiology of violence and mental illness • Risk Assessment: • Clinical • Actuarial • Structured clinical • Risk Management • Further Study

3. Epidemiology of Violence and Mental Illness

4. Is it this bad?

5. Crime • There are various ways of measuring crime: • Household survey (e.g. British Crime Survey) • Arrest statistics • Rates of convictions

6. British Crime Survey 2012/13http://www.ons.gov.uk/ons/dcp171778_349849.pdf • 8.0 million crimes in past one year • c.f. police report 3.7 million offences • 21.5% chance of being a victim (39.7% in 1995)

7. BCS- Types of Offences

8. Trends in Violent Offences source: Crime Survey for England and Wales, Office for National Statistics

9. BCS- Violent offenceshttp://www.ons.gov.uk/ons/dcp171778_298904.pdf • Levels of violent crime estimated by the CSEW showed a statistically significant decrease of 13%in the year ending September 2013 compared with the previous year. This follows on from largefalls seen in the CSEW between 1995 and 2004/05, with current estimates at less than half the levelseen at the highest level reported, in 1995 • Highest perpetrator group- single men, 16-24 (86% violent offenders men; 52% aged between 16 and 24) • Highest victim group- see above • 2.3% risk of violence (3.8% men, 2.1% women, 11% gp above) • Men most likely victim violence from stranger (75%) • Women most likely victim of domestic violence (71%) • 47% of perpetrators alcohol; 23% drugs

10. Types of Violent Offences(2011/12)source:Focus on: Violent Crime and SexualOffences, 2011/12 http://www.ons.gov.uk/ons/dcp171778_298904.pdf

11. Why drop in crime? • Various theories e.g. • Post World War 2 baby boom- large numbers of young men during 1960s and 1970s who are now older • Removal of lead from petrol • Repopulation of inner cities • Hotspot policing • Technology, making acquisitive offending harder • Better trauma care, meaning fewer deaths from violence • For review see 'The International Crime Drop’, van Dijk, J et al, Palgrave Macmillan, London, 2012

12. Is there a link between psychosis and violence?

13. Research Base • Before 1990s there was a lack of evidence on the link between mental illness and violence • During the 1990s and 2000s a large number of different studies were undertaken, driven, in part by public anxiety

14. Bias • Studies in this area are difficult. Information biases are particularly problematic, concerning: • Psychiatric factors e.g. • Diagnosis • Definition of psychiatric patient • And offending / violence e.g. • Recording of crime • Selection bias (are people who are psychotic more likely to be arrested?) • Arrest statistics

15. Types of studies • Prison Surveys • Cross-Sectional Studies • Cohort studies • Discharge Follow-up • Meta-analysis

16. Prison Surveys • Prisons are a good place to look for those who’ve been violent! • These were the first studies to look at the link between violence and mental illness e.g. • Maden, Taylor, Brooke et al (1995); Taylor & Gunn (1984)

17. Gunn, Maden & Swinton (1991) • 5% of all convicted male prisoners in E&W; n=1796 • 45% psychiatric diagnosis • 90%= substance abuse, PD, sexual deviance, neurosis • 2% psychotic • 3% needed transfer to hospital

18. Cross-sectional Studies • Prison surveys gave some information but looked at an unusual group • Cross sectional studies aimed to measure mental illness and criminality at using data obtained at one moment in time e.g. • Epidemiological Catchment Area Survey- Swanson et al (1990)

19. Epidemiological Catchment Area Survey- Swanson et al (1990) • Method: • 10,000 people • 3 metropolitan areas in USA • DSM-III diagnosis

20. Epidemiological Catchment Area Survey- Swanson et al (1990) • Measures of violence (1 or more needed in past year): • “Did you ever hit or throw things at your partner?” • “Have you ever spanked or hit a child hard enough that he/she has bruises or had to stay in bed or had to see a doctor?” • “Since the age of 18, have you been in more than 1 fight that came to swapping blows, other than fights with your partner?” • “Have you ever used a weapon like a stick, knife or gun in a fight since you were 18?” • Have you ever gotten into physical fights while drinking?”

21. ECA- Results • Usual demographic correlates of violence e.g. young socially disadvantaged men had highest rate of violence • Rates of violence: • 2% in those with no disorder • 8% ‘pure schizophrenia’ • 25% alcoholism + no diagnosis • 35% alcoholism + another psychiatric diagnosis

22. ECA- Comments • No selection bias • Blunt measure of violence • Cross-sectional i.e. impossible to answer questions about causation

23. Cohort Studies • Looked at groups of individuals at different periods of time, often using large case registries and matching these with arrest or conviction data e.g. Linquist & Allbeck • Results gave some indication about causality • Large numbers of participants but possibility of selection bias (e.g. doesn’t consider those not arrested/ convicted, depending on data set used)

24. Lindqvist & Allbeck (1990) • 644 patients with schizophrenia • All patients discharged from hospital in Stockholm during 1971 • Followed up to 15 years on police registry • No difference in overall offending • 4x higher rate of violent offences among males with schizophrenia

25. Follow-up studies • Concentrated on patients discharged from psychiatric hospitals e.g. • Hodgins et al (1992) • Monahan et al (2002): MacArthur Violence Risk Assessment Study

26. Monahan et al (2002): MacArthur Violence Risk Assessment Study • Method: • 1,130 recently discharged patients • Follow up for 1 year • 3 urban centres in USA • Controls- community controls • Comprehensive measure of violence- interviewed discharge and 10 weekly; subject, collateral; and official records

27. Monahan et al (2002): MacArthur Violence Risk Assessment Study • Results: rate of violence in first 20 weeks- • schizophrenia 9% • Bipolar disorder 15% • PD 25% • Substance misuse 29% • PCL-SV (measure of psychopathy) score was best predictor • Demographic factors, previous violence important

28. Monahan et al (2002): MacArthur Violence Risk Assessment Study • Comments: • Very good measure of violence • Managed care model in USA- symptoms remained at discharge? • Very large proportion of substance misuse • Risky patients (with delusions?) not discharged

29. MacArthur Violence Risk Assessment Study • Main findings (not to be taken at face value …) • Violence is common in mental health populations • Substance misuse is more important than mental illness as cause of violence (delusions do not predict higher rates of violence) • Psychopathy is a useful predictor of violence in general mental health populations • Violence in mental health populations is related to many of the same factors as in the general population

30. Meta-analyses Putting the results of different studies together e.g. Fazel at al

31. Fazel et al (2009) Violence: arrests; convictions; self report Schizophrenia / psychosis v general population 20 studies; 18,400 subjects OR of being violent in schizophrenia group 4.7 (1 -7) for men & 8.2 (4- 29) for women Co-morbid substance use +/- schizophrenia considerably increased risk No difference: Nordic v US; outcome measure used

32. Fazel et al (2009) Few longitudinal studies found when literature searched Substance abuse & SCZ- “unlikely to be a simple additive relationship” It was noted that over the previous 25 years: increase SU in schizophrenia but no increase violence (Wallace et al, 2004) Suggested that violence highest in a ‘sub-group: PD, social problems + schizophrenia’

33. So, evidence of some link between psychosis and violence • Individual patient with schizophrenia likely to convicted of a violent offence once every 100 years- (Lindqvist et al 1990) • Risk of violence in SCZ less than that of typical 16-24yr old lower social class man- (Swanson et al 1990)

34. Maden, 2004 • But: association between psychotic illness with PD/SUD and violence in the community similar magnitude to smoking and lung cancer (i.e. 20 x increase)

35. The population attributable risk attributable to schizophrenia is small: • 5.2% (Fazel and Grann, 2006) • Demographic factors more important than psychosis • Risk is highest to family members (60% of victims family members; 10% strangers)

36. Overall, violence is unusual in psychosis • And needs to be seen in context: • Patients with schizophrenia have a high risk of victimisation- 15- 35% suffer violence each year (Choe et al 2008) • High risk of suicide- 18% of those who commit suicide suffer with schizophrenia (NCISH, 2013) http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2013-14/NCISHAnnualReport201304July13.pdf • Podcast: “The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness” by Professor Louis Appelby http://www.psychiatrycpd.co.uk/default.aspx?page=16705

37. Why is there an association between violence and psychosis? • Common risk factors for both • Volavka et al (2008) suggest three major groups: • Those who act violently directly as a result of psychotic symptoms • Impulsive aggression due to impaired response inhibition • Aggression due to co-morbid personality disorder (often younger age of first criminality, association with substance use) • Individual formulation is key • Podcast : “Violence and schizophrenia: a realistic look at the risks, contributing factors and management” by Professor John Gunn http://www.psychiatrycpd.co.uk/default.aspx?page=2138

38. Homicides in England and Wales

39. What proportion of homicides are perpetrated by people with mental disorder?

40. Homicide • 542 homicides (circa 400 during 1960s) (1 per 100000) • 20-50 per year by those who are considered to be mentally disordered at the time of the offence

41. Victims of Homicide (England and Wales)

42. Homicide offenders who are mentally ill • Family, not strangers, most likely victims • 7% homicide-suicide (Large et al 2008)

43. Homicide in 1st episode psychosis: Nielssen & Large, 2010 • Meta-analysis of 10 studies • 38.5% homicides during 1st episode • 1.59 per 1000 patients • 0.11 per 1000 treated patients • 15.5% increase rate in 1st episode patients • RCPsych CPD module link: ‘Psychiatric aspects of homicide’ http://www.psychiatrycpd.co.uk/learningmodules/psychiatricaspectsofhomicid.aspx

44. Fire-setting • Mostly unrelated to mental illness • Highest rate in young social disadvantaged men • Rix, 1994- fire setters referred for psychiatric report:

45. Arson & psychosis Anwar et al, 2009 • Case control study, Sweden, 1690 convictions for arson • OR in men 22.6 (14.8-34.4) • OR in women 38.7 (20.4-73.5)

46. Symptoms of psychosis & violence • What about the relationship between specific psychotic symptoms and violence?

47. Daniel McNaughten

48. Daniel McNaughten, 1843 • “The Tories in my native city have compelled me to do this. They have accused me of crimes of which I am not guilty; they do everything in their power to harass and persecute me; in fact, they wish to murder me” • Killed Edward Drummond, private secretary to the Prime Minister, leading to present day test of legal insanity

49. Symptoms of psychosis & violence:delusions • But not everyone acts on their delusions!: • Bleuler (1924): • “They really do nothing to attain their goal: the Emperor and the Pope manure the fields; the Queen of Heaven irons the patients’ shirts or besmears herself and the table with saliva”

50. Delusions & violence • Who acts on delusions? • Wessely et al, 1993 • Method: • Retrospectively assessed • Patients admitted to psychiatric hospital • Variety of diagnoses • Actions- self report and informant • Link to delusion rated by expert