Adolescent violence screening in the ED

Comparison of V-RISK-Y and V-RISK-10 for risk of violence: A one-year study from a psychiatric emergency department for adolescents

There has been a lack of short and simple screening instruments to assess the risk of violence in youth. Many acute youth departments have used the V-RISK-10, a risk screener for adults. V-RISK-Y is a risk screener based on the V-RISK-10 and adapted to youths. Our aim was to compare the predictive validity between V-RISK-Y and VRISK-10 in an emergency psychiatric adolescent ward. Target population were all 92 patients admitted within one year, and study population consisted of 49 (53 %) patients who had completed data. V-RISK-10 and V-RISK-Y were scored at admission and compared with recorded episodes of violence during the hospitalization. V-RISK-Y showed higher AUC values for recorded violence and some of the individual items also showed better results. Most differences were not significant, but results may still be of clinical interest.

Validation of a violence risk screening for youth in psychiatric inpatient care-a pilot study of V-RISK-Y

The reason for this study was the void of validated risk assessment screening tools for violence in adolescence psychiatry. Our aims were to test the predictive validity and feasibility of a pilot version of the Violence Risk Screening for Youth (V-RISK-Y). The V-RISK-Y was based on a violence risk screen for adults, the V-RISK-10, and adapted to adolescents, resulting in 12 risk items that are scored for (a) presence and (b) relevance for future violence. In this naturalistic, prospective observational study, the V-RISK-Y was scored at admission and compared with recorded episodes of violent acts and threats during hospital stay. The target population was all 92 patients admitted to the emergency department of adolescent psychiatry at Oslo University Hospital for 1 year, of which 67 patients were scored with the V-RISK-Y at admission and constituted the study sample. The predictive validity of the V-RISK-Y for violent behavior showed an AUC of 0.762 (p = 0.006). Staff approved the screener and found it to be equally or better usable than the V-RISK-10, which was previously used in the department. Still, a high proportion of raters failed to follow the scoring instructions of relevance scores, reducing feasibility. The results must be interpreted within the limits of a pilot study and low power. We conclude that results suggest changes of certain parts of the V-RISK-Y and provide a basis for testing a revised edition of the screener in a more comprehensive study, preferably with a multicenter design.

The strain theory of suicide

Suicide is a global public health problem, but very few theories have been developed for its etiology and effective prevention. Presented in this article is a comprehensive and parsimonious theory explaining the socio-psychological mechanism prior to suicidal behavior. Strain, resulting from conflicting and competing pressures in an individual’s life, is hypothesized to precede suicide. The strain theory of suicide (STS) proposes four sources of strain leading to suicide: (1) value strain from differential values; (2) aspiration strain from the discrepancy between aspiration and reality; (3) deprivation strain from the relative deprivation, including poverty; and (4) coping strain from deficient coping skills in the face of a crisis. This new model is built on previous notions of anomie (Durkheim, 1897/1951 ), strain theories of deviance (Merton, 1957 ) and crime (Agnew, 1992 ), although suicide is not a major target for explanation in those theories. Future research with rigorous quantitative data needs to be conducted to further test STS on a more comprehensive level.

Self-reported violent ideation and its link to interpersonal violence among offenders with mental disorders and general psychiatric patients

This study aims at comparing mentally disordered offenders and general psychiatric patients regarding violent ideation and at exploring its association with interpersonal violence. We recruited 200 detainees undergoing forensic psychiatric evaluation and 390 general psychiatric patients at discharge. At baseline, they were asked about violent ideation; at the 20-week follow-up, information about violent acts was gathered from crime conviction registry, interviews, and records. The lifetime prevalence of violent ideation was 32.5% for offenders and 35.6% for patients; the corresponding two-month prevalence was 22.5% and 21.0%, respectively. For the both samples combined, those with violent ideation in their lifetime were significantly more prone to commit violent acts during follow-up than those without such ideation, OR = 2.65. The same applied to the patient sample, OR = 3.41. In terms of positive predictive values, fewer than 25% of those with violent ideation committed violent acts. Contrary to our hypothesis, the prevalence of violent ideation did not differ significantly between offenders and patients. However, there was support for the hypothesized association between violent ideation and violent acts on a group level. On an individual level, the clinician should consider additional factors when assessing the risk for violent acts.

Evolutionary processes in suicide

Suicidal behavior contains several dynamic elements. Due to its complexity, empirical science may approach suicide through various avenues. One underutilized approach is taking an evolutionary perspective. Our review of the literature presents two evolutionary processes that may be implicated in suicidal behavior, namely eusocial behavior and antipredator response behaviors. Studies have indicated that aspects of suicidal behavior parallel self-sacrificial behavior in eusocial animals, and that systems similar to hyperarousal-shutdown systems involved in antipredator behaviors may be activated among suicidal individuals. Research on brain activity and decision-making processes among suicidal individuals also suggests that eusociality and antipredator response behaviors in suicide may not be mutually exclusive. These processes represent novel sources of information and potential solutions regarding suicide.

Pediatric suicide-related presentations: a systematic review of mental health care in the emergency department

STUDY OBJECTIVE

We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits.

METHODS

We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each study's primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome.

RESULTS

We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67).

CONCLUSION

Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

Mental health and emergency medicine: a research agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

Vulnerable Goth teens: the role of schools in this psychosocial high-risk culture

BACKGROUND

In recent years, a number of tragedies have been linked to the Goth culture. Most alarming have been the acts of violence, suicide, and self-harm found among teens. Teachers, parents, administrators, and fellow students are at a loss on how to relate to such students. They are unsure what role they might play in addressing some of the psychosocial issues they encounter. The purposes of this article are to describe characteristics of Goth teens, identify psychosocial risks for these teens, and describe roles school personnel can play.

METHODS

This article provides a review of the Goth culture, risk factors for Goth teens, and methods school personnel can use in identifying and addressing the psychosocial needs of this group.

RESULTS

The Goth culture attracts teens who are depressed, feel persecuted, have a distrust of society, or have suffered past abuse. They then surround themselves with people, music, Web sites, and activities that foster angry or depressed feelings. They have a higher prevalence of depression, self-harm, suicide, and violence than non-Goth teens.

CONCLUSIONS

School personnel are in a position to make a difference. By preparing themselves with knowledge, skills, materials, and referral sources, they can serve as liaisons. They have a specific role in advocating for the health and safety of students, identifying students who are at risk, disseminating new knowledge, and providing guidance in the management of the troubled teens.

Children's mental health emergencies-part 3: special situations: child maltreatment, violence, and response to disasters

OBJECTIVE

Children may be exposed to or even be the victims of a violent situation, or a disaster, and the likelihood of a child's exposure to a violent situation or a disaster is increasing.

METHODS

A review of the literature was done to address key mental health issues occurring with child maltreatment, violence in the home, community, in the emergency department, and disasters.

RESULTS

Although pediatric mental health issues regarding violence, disasters, and child maltreatment have often been overlooked or unrecognized, the consequences for the child in such situations can be devastating. However, recognition and appropriate treatment can favorably impact the child's recovery from exposure to such violent events or disasters.

CONCLUSIONS

Recognition and early intervention to address the mental health issues of children in violent situations or disasters can help ameliorate the negative psychological sequelae of such events. The importance of providing mental health and social services to children exposed to disasters was recognized by the Pediatric Institute of Medicine Report.

Screening for suicide risk in the pediatric emergency and acute care setting

PURPOSE OF REVIEW

This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings.

RECENT FINDINGS

For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings.

SUMMARY

Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.