Prediction and prevention of aggressive incidents during outpatient crisis contacts

1. Prediction and prevention of aggressive incidents during outpatient crisis contacts Berry Penterman & Henk Nijman Psychiater Professor of forensic GGZ Oost-Brabant, psychology, Radboud The Netherlands University

2. The Checklist Risks Crisis team (CRC)

3. Risk assessment • Clinical judgment • Actuarial risk assessment • Structured clinical risk assessment

4. Clinical Judgment • Depends on the experience and knowledge of the rater • Not structured • Intuitive

5. Actuarial risk assessment • Use of objectively measured factors e.g. • gender • previous aggressive behaviour • Iterative Classification Tree (ICT) Developed by the MacArthur Foundation Network

6. Structured Clinical Risk Assessment • static factors, e.g. previous aggressive behaviour • dynamic factors, e.g. psychiatric condition • situational or contextual factors, e.g. neighborhood

7. Examples of Risk assessment Instruments The Historical, Clinical, and Riskindicators (HCR-20) Historische, Klinische en Toekomstige risico-indicatoren (HKT-30) Psychopathy Checklist – Revised (PCL-R)

8. Short term prediction • E.e, the Brøset–Violence–Checklist (BVC)Almvik, Woods & Rasmussen (2000) • Prediction of aggressive incidents within 24 hours in a closed psychiatric ward

9. Problems with prediction of aggression on crisis duty • No previous contacts with the patient • Minimal information from others, e.g. general practitioner

10. Is it possible to make valid predictions about the chance of aggression by using this minimal information?collected from others?

11. Excercise in completing the CRC And: Based on the time you completed the CRC…the risk of aggression is also elevated!!! Potentially dangerous individuals in vicinity of the patient (odds ratio = 8) Possibility of weapons in patient’s home (6) Possibility of imperative hallucinations(4,7) Antisocial personality (4) Prior compulsory admission(s) (4) Crisis was signalled by patients’s family / acquaintances (3,5) Crisis was signalled by the patient him / her self (3,3) Prior patient aggression (3,1) Possibility of paranoid delusions (2,8) Unpredictability due to drug or alcohol intoxication (2,7) Other patient related risk factors (when endorsed) (2,6) Under influence of alcohol or drugs (2,4) Crisis was signalled by the police (2,3) Problems in the patient’s system (2,2) Psychotic condition (1,6)

12. Methods The first study was during a 2 year – period from june 2003 to june 2005 (And a replication study took place in 2006 to 2009) Prior to every outreaching contact the checklist, called CRC, was completed If aggressive behaviour by a patient had taken place during the contact this incident was registered using the SOAS-R

13. Checklist of Risks Crisis team (CRC)

14. Results • In total the crisis team was asked for consultation 576 times • For 502 of the 576 consultations a CRC was completed. • In 51 of these 502 cases (10%), a SOAS-R was completed after the crisis visit

15. Figure 1. Who called in the crisis team? • * • * • * • *p < 0.05, two-tailed

16. Figure 2. First assessment of patient’s psychiatric condition • * • * • * • * • *p < 0.05, two-tailed

17. Figure 3. Risk increasing, patient related risk factors? • * • * • * • * • * • * • *p < 0.05, two-tailed

18. Figure 4. Risk increasing factors in the patient’s living environment? • * • * • * • *p < 0.05, two-tailed

19. Summary of univariate associations with aggression Potentially dangerous individuals in vicinity of the patient (odds ratio = 8) Possibility of weapons in patient’s home (6) Possibility of imperative hallucinations(4,7) Antisocial personality (4) Prior compulsory admission(s) (4) Crisis was signalled by patients’s family / acquaintances (3,5) Crisis was signalled by the patient him / her self (3,3) Prior patient aggression (3,1) Possibility of paranoid delusions (2,8) Unpredictability due to drug or alcohol intoxication (2,7) Other patient related risk factors (when endorsed) (2,6) Under influence of alcohol or drugs (2,4) Crisis was signalled by the police (2,3) Problems in the patient’s system (2,2) Psychotic condition (1,6)

20. Based on the time the CRC app is used, an extra warning will be given when the crisis takes place in the evening or night

21. Structured clinical assessment of the aggression risk on the VAS scale • Average VAS score in case of no aggression: 21.9 mm • Average VAS score in case of aggression: 53.7 mm [t(497) = 7.7, p < 0.05, tweezijdig] Area Under the Curve (AUC) = 0.83 (but in 2 later replication studies, the AUC-values were 0.73 and 0.74)

22. Output

23. Output (in a worst case scenario) And: Based on the time you completed the CRC…the risk of aggression is also elevated!!! Potentially dangerous individuals in vicinity of the patient (odds ratio = 8) Possibility of weapons in patient’s home (6) Possibility of imperative hallucinations(4,7) Antisocial personality (4) Prior compulsory admission(s) (4) Crisis was signalled by patients’s family / acquaintances (3,5) Crisis was signalled by the patient him / her self (3,3) Prior patient aggression (3,1) Possibility of paranoid delusions (2,8) Unpredictability due to drug or alcohol intoxication (2,7) Other patient related risk factors (when endorsed) (2,6) Under influence of alcohol or drugs (2,4) Crisis was signalled by the police (2,3) Problems in the patient’s system (2,2) Psychotic condition (1,6)

24. Precautionary measures taken to prevent dangerous situations • The most prevalent precautionary measures taken by the crisis team members were: • Request for advice from backup staff (18%), • Request for additional information about the patient(16%), • Seeing the patient with a colleague (14%) • Having the patient come or be brought to another location (12%). • In 6% of the cases, police assistance was requested. In those cases, the probability that the patient would indeed behave aggressively was significantly higher [X2(1) = 34.4, p < 0.05]. • When it was decided to go see the patient with a colleague the probability of aggression occurring was also significantly higher [X2(1) = 12.0, p < 0.05].

25. And: In 3 cases (0.5%), the staff member made the decision not to go see the patient because of an anticipated dangerous situation.

26. Conclusions • The results indicate that the CRC is useful to assess risks of aggressive behavior during crisis visit • For this reason, the CRC can also be valuable to take precautionary measures (e.g., call in assistance of the police) to prevent dangerous situations

27. The validity of acute assessments of psychiatricconditions made by psychiatric emergency staff The staff of the psychiatric emergency service who make the initial diagnosis are pressed for time and have only limited information. The aim of this study was to find out what differences there are between the crisis team’s initial diagnosis of the psychiatric condition of the patient in crisis and the later diagnosis made after more extensive psychiatric tests are carried out following the regular intake procedure.

28. Sample and methods The study was based om 129 patients who, in the period of 2009 and 2010, were not known to mental health service and had not had any previous contact with the psychiatric emergency service. The first assessment of a patient’s psychiatric condition made by a member of the psychiatric emergency service was compared with the later diagnosis made by a professional psychiatrist after the regular intake procedure. We investigated the degree of agreement between the two diagnoses using Cohen’s kappa so that we could test the validity of the initial screening of the patient’s condition.

29. Sensitivity, specificity and the proportion overall predicted correctly of the psychiatric condition as evaluated by the psychiatric emergency staff member Cohen’s kappa 0,81 0,55 0,43 0,39 0,60 0,31

30. Conclusions We found that the staff of the psychiatric emergency team was able to achieve a result that was better than could be expected on the basis of chance. The Cohen’s kappas varied between 0.81 for psychotic disorders to 0.31 for borderline personality disorders. Borderline personality disorders and depressions tended to be overestimated by the psychiatric emergency staff.

31. discussie Vragen en/ of commentaar op de gepresenteerde resultaten. In your own experience, do you recognize the warning signals and risk factors that were found to be associated with increased risk of aggression? Do you use other factors or have recommendations that could be used to improve the assessment of aggression risks?

32. Dank voor uw aandacht ! Voor meer informatie mbt de CRC or the CRC app: e-mail naar ejm.penterman@ggzoostbrabant.nl