Role of risk assessment in reducing homicides by people with mental illness

Cross-Sectional Survey of Mental Health Risk Factors and Comparison of the Monoamine oxidase A Gene DNA Methylation Level in Different Mental Health Conditions among Oilfield Workers in Xinjiang, China

The incidence of psychological problems among occupational groups is becoming increasingly more serious, and adverse psychological conditions will seriously affect the working ability of occupational groups and harm the health of their bodies. This study adopted a multi-stage stratified cluster sampling method to conduct a cross-sectional survey on the mental health of 3631 oil workers in Karamay, Xinjiang from March 2017 to June 2018. The mental health status of oil workers was evaluated using the Symptom Checklist-90, and mental health risk factors were evaluated. The correlation between the monoamine oxidase A (MAOA) gene and mental health was analyzed, and the DNA methylation level of the MAOA gene was compared between the normal group and the abnormal group. The results show the incidence of mental health problems among oil workers according to differences in age, nationality, type of work, length of service, professional title, shift work, and marital status. The evaluation of mental health risk factors revealed that shift work, occupational stress, and high payment/low return affect mental health. The somatization scores of different genotypes of rs6323 in the MAOA gene were statistically significant (p < 0.05), suggesting that the somatization scores of different genotypes of rs6323 were different. According to the average rank, the TT genotype group had the highest score, followed by the GT genotype group, and the GG genotype group had the lowest score. The level of DNA methylation in the abnormal group was lower than that in the normal group (p < 0.05). The results suggested that occupational mental health can be enhanced by improving shift work, reducing stress, and balancing effort and reward. This preliminary investigation suggests that methylation status can affect mental health, indicating that methylation level may be a predictor of mental health status.

The presence of alcohol consumption prior to homicide in Singapore

OBJECTIVE

To determine the prevalence of alcohol use disorders in people charged with homicide in Singapore. We also sought to determine which historical risk factors were associated with the use of alcohol 24 h prior to the homicide and with the presence of a severe mental illness at the material time of the offence.

METHODS

We extracted data from administrative records of all people charged with homicide in Singapore between 2007 and 2014. We used regression models to adjust for known confounding variables and explore the relationship between alcohol use and homicide.

RESULTS

Of 253 homicide offenders, 141 individuals (56%) meeting criteria for alcohol use disorders at the time of the offence. 121 offenders (48%) consumed alcohol within the 24 h preceding the homicide. Of the 149 that met criteria for a psychiatric diagnosis, 35 had a severe mental illness.

CONCLUSION

Alcohol use disorders are by far the most common disorder diagnosed in people charged with homicide in Singapore. Alcohol use is less common in homicide offenders with SMI.

Violence within mental health services: how to enhance risk management

This paper aims to present best practice in risk management within mental health services. Its purpose is to explore the prevalence of violence within mental health services, to examine the nature of risk, highlight lessons learned and guidance published on safer services, and to identify ways to enhance risk management in mental health care. We reflect on current health care practices in the UK, England and Wales, and Ireland and refer to research and practice from other jurisdictions internationally where it exists.

Violent incidents in a secure service for individuals with learning disabilities: Incident types, circumstances and staff responses

BACKGROUND

The issue of violence in secure services has long been recognized both in the UK and worldwide. However, there is currently scarce literature available about violence within learning disability (LD) secure settings.

METHODS

Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a 1-year period.

RESULTS

Physical assaults were the most frequent type of incident, and the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalized linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff.

CONCLUSIONS

These findings can inform staff training on violence prevention and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

External validity and anchoring heuristics: application of DUNDRUM-1 to secure service gatekeeping in South Wales

Aims and method Structured clinical judgement tools provide scope for the standardisation of forensic service gatekeeping and also allow identification of heuristics in this decision process. The DUNDRUM-1 triage tool was completed retrospectively for 121 first-time referrals to forensic services in South Wales. Fifty were admitted to medium security, 49 to low security and 22 remained in open conditions.

RESULTS

DUNDRUM-1 total scores differed appropriately between different levels of security. However, regression revealed heuristic anchoring on the 'legal process' and 'immediacy of risk due to mental disorder' items. Clinical implications Patient placement was broadly aligned with DUNDRUM-1 recommendations. However, not all triage items informed gatekeeping decisions. It remains to be seen whether decisions anchored in this way are effective. Declaration of interest Dr Mark Freestone gave permission for AUC values from Freestone et al. (2015) to be presented here for comparison.

Feasibility of a structured risk assessment tool in general adult psychiatry admissions

AIMS AND METHOD

To assess the feasibility of using a structured risk assessment tool (Historical Clinical Risk 20-Item (HCR–20) Scale) in general adult psychiatry admissions and the characteristics of ‘high-risk’ patients. A notes review and interviews were used to conduct an HCR–20 assessment of 135 patients admitted to Murray Royal Hospital, Scotland.

RESULTS

Patients scoring higher on the HCR–20 were discharged earlier and more likely to have a diagnosis of personality disorder and a comorbid diagnosis.

CLINICAL IMPLICATIONS

It was possible to complete an HCR–20 assessment of over 80% of patients within 48 h of admission.

Assessing violence risk in general adult psychiatry

Aims and Method

We aimed to establish current practice in the risk assessment of harm to others within general adult psychiatry and review risk assessment documentation in use. Consultants working across 66 randomly selected trusts across England were surveyed. A qualitative analysis of risk assessment documentation was carried out.

Results

Data were obtained from 45 trusts (68%). Consultants reported that 30 (67%) of the trusts had standardised forms for risk assessment. Forty-one forms were subjected to content analysis. Wide variation was found in the methods used to identify risk factors and in approaches to quantifying risk.

Clinical Implications

Current risk assessment practice is highly variable, indicating a lack of consensus about suitable methods.

Confidence in the face of risk: the Risk Assessment and Management Self-Efficacy Study (RAMSES)

Aims and method To evaluate a comprehensive risk management programme. A Risk Assessment and Management Self-Efficacy Scale (RAMSES) was used to evaluate the impact of a clinical guideline and training course. Fifty-three psychological therapists were randomly allocated to training v. waiting list in a controlled, delayed-intervention design. Differences in mean self-efficacy scores between groups were examined using analysis of covariance (ANCOVA).

Results The RAMSES measure had adequate factor structure, internal consistency and construct validity. When adjusting for baseline scores and cluster design, the group exposed to training had a higher mean self-efficacy score than controls. Mean differences between groups were not significant after the control group received training, nor at 6 months’ follow-up.

Clinical implications Exposure to training and clinical guidelines can improve self-efficacy in risk assessment and management. An important advance put forward by this study is the specification of areas of competence in risk assessment and management, which can be measured using a psychometrically sound tool.

Civil commitment law, mental health services, and US homicide rates

PURPOSE

The study considers whether involuntary civil comment (ICC) statute provisions are associated with homicide rates. Do statutes based solely upon dangerousness criteria versus broader ICC-criteria-i.e. "need for treatment," "protection of health and safety," and family protection-have differential associations related to their goal of reducing the frequency of homicide?

METHOD

State-level data were obtained from online data bases and key-informant surveys. Ordinary-least-squares and Poisson regression were used to evaluate the association between statute characteristics, mental health system characteristics, and 2004 Homicide Rates after controlling for firearm-control-law restrictiveness and social-economic-demographic-geographic-and-political indicators historically related to homicide rate variation.

RESULTS

Poisson and OLS models, respectively, were significant: likelihood ratio χ(2) = 108.47, df = 10; p < 0.000 and Adj. R (2) = 0.72; df = 10, 25; F = 10.21; p < 0.000. Poisson results indicate that social-economic-demographic-geographic-and-political-indicators had the strongest association with state homicide rates (p < 0.000). Lower rates were associated with: broader ICC-criteria (p ≤ 0.01), fewer inpatient-bed access problems (p ≤ 0.03), and better mental health system ratings (p ≤ 0.04). OLS results indicate that social-economic-demographic-geographic-and-political indicators accounted for 25% of homicide rate variation. Broader ICC-criteria were associated with 1.42 less homicides per 100,000. Less access to psychiatric inpatient-beds and more poorly rated mental health systems were associated with increases in the homicide rates of 1.08 and 0.26 per 100,000, respectively.

CONCLUSIONS

While social-economic-demographic-geographic-and-political indicators show the strongest association with homicide rate variation, the results show the importance and potentially preventive utility of broader ICC criteria, increased psychiatric inpatient-bed access, and better performing mental health systems as factors contributing to homicide rate variation.

Homicide of strangers by people with a psychotic illness

BACKGROUND

The homicide of strangers by people with psychosis, referred to here as "stranger homicides," are rare and tragic events that generate adverse publicity for mental health services and have resulted in significant changes in mental health policy and law.

AIM

To estimate the incidence of stranger homicides, using data from previously published studies, and to compare the characteristics of psychotic offenders who killed strangers with the characteristics of those who killed a close relative.

METHOD

Meta-analysis of the population-based studies of homicide by persons suffering from a psychosis in which the number of subjects who killed strangers was also reported. Characteristics of stranger homicide and family homicide offenders were examined in a multicenter case-control study of homicide during psychotic illness in four high-income countries.

RESULTS

A pooled estimate of 1 stranger homicide per 14.3 million people per year (95% confidence interval, 1 in 18.9 million to 1 in 11.5 million people per year) was calculated by meta-analysis of 7 studies. The characteristics of the 42 stranger homicide offenders from New South Wales [NSW], Quebec and Eastern Ontario, Finland, and the Netherlands were identified. Twenty seven (64%) of these had never previously received treatment with antipsychotic medication. The stranger homicide offenders were more likely to be homeless, have exhibited antisocial conduct, and had fewer negative symptoms than those who killed family members. The victims of stranger homicide were mostly adult males and the homicides rarely occurred in the victim's home or workplace.

CONCLUSIONS

Stranger homicide in psychosis is extremely rare and is even rarer for a patient who has received treatment with antipsychotic medication. A lack of distinguishing characteristics of stranger homicide offenders and an extremely low base rate of stranger-homicide suggests that risk assessment of patients known to have a psychotic illness will be of little assistance in the prevention of stranger homicides.

"Screen and intervene": governing risky brains

This article argues that a new diagram is emerging in the criminal justice system as it encounters developments in the neurosciences. This does not take the form that concerns many "neuroethicists" -- it does not entail a challenge to doctrines of free will and the notion of the autonomous legal subject -- but is developing around the themes of susceptibility, risk, pre-emption and precaution. I term this diagram "screen and intervene" and in this article I attempt to trace out this new configuration and consider some of the consequences.

Promoting positive risk management: evaluation of a risk management panel

The purpose of this study was to evaluate whether a National Health Service Trust risk management panel (RMP) service was effective in promoting positive risk management by supporting mental health clinicians/teams in their management of people with mental health problems who presented with high risk of harm to themselves or to others. Fifteen mental health workers completed a questionnaire regarding their experience of the RMP. Content analysis revealed several themes. The majority of participants found the RMP helpful because of the support provided by shared case discussion and collective responsibility for risk management offered by the RMP. Medical records of the 23 individuals referred into the RMP were also examined. Trends in diagnoses, risks and RMP recommendations were identified. This study points to the importance of the organization's role alongside the individual clinician's in positive risk management and in supporting people with mental health problems using the recovery model. Improvements in developing a RMP are suggested.

An axis for risk management in classificatory systems as a contribution to efficient clinical practice

Comprehensive clinical assessment and patient management plans have been enhanced by the development of multiaxial classificatory systems. Assessment of risk is an essential clinical task for which the conclusions are not currently reflected in the multiaxial diagnostic schemata. Developments in the understanding of risk and its management make possible consideration of its place in multiaxial systems. The structure and principles of a potentially workable axis, summarizing current knowledge of risk in the domains of suicide, self-neglect and violence to others, are described. Clinicians are more likely to use this axis than the multiple, emerging, risk assessment guidelines. Incorporating risk management would be a practical addition to presently available axes and be very widely clinically applicable.

Dangerousness and mental health policy

Mental health policy development in the UK has become increasingly dominated by the assumed need to prevent violence and alleviate public concerns about the dangers of the mentally ill living in the community. Risk management has become the expected focus of contemporary mental health services, and responsibility has increasingly been devolved to individual service professionals when systems fail to prevent violence. This paper analyses the development of mental health legislation and its impact on services users and mental health professionals at the micro level of service delivery. Historical precedence, media influence and public opinion are explored, and the reification of risk is questioned in practical and ethical terms. The government's newest proposals for compulsory treatment in the community are discussed in terms of practical efficacy and therapeutic impact. Dangerousness is far from being an objectively observable phenomenon arising from clinical pathology, but is a formulation of what is partially knowable through social analysis and unknowable by virtue of its situation in individual psychic motivation. Risk assessment can therefore never be completely accurate, and the solution of a 'better safe than sorry' approach to mental health policy is ethically and pragmatically flawed.

Risk and safety assessment in child welfare: instrument comparisons

The assessment of risk is a critical part of child welfare agency practice. This review of the research literature on different instruments for assessing risk and safety in child welfare focuses on instrument reliability, validity, outcomes, and use with children and families of color. The findings suggest that the current actuarial instruments have stronger predictive validity than consensus-based instruments. This review was limited by the variability in definitions and measures across studies, the relatively small number of studies examining risk assessment instruments, and the lack of studies on case decision points other than the initial investigation.

Mentally abnormal homicide in New Zealand as defined by legal and clinical criteria: a national study

BACKGROUND

Homicides by people with mental illness have been studied using either clinical or legal categorization of the homicide as abnormal. No previous study has employed both definitions in the same population.

METHOD

A retrospective study of all homicides in New Zealand between 1988 and 2000 considered mentally abnormal homicide using a legal definition (when the courts deemed a contribution of mental illness was present) and a clinical definition (defined as the presence of a discharge diagnosis from inpatient mental health treatment) of 'mentally abnormal'. Rates, characteristics and time trends were investigated.

RESULTS

Of the 844 cases, 7.1% met legal criteria for being mentally abnormal, while 7.7% had ever received a diagnosis for a psychotic illness, and a further 14.5% had been admitted to a psychiatric hospital for any other reason. The majority (60%) of perpetrators with a psychotic diagnosis received a mental health disposition from the court. Of these, 60% were first diagnosed with their psychotic illness prior to the homicide, while 28% were first diagnosed at the time of the offence and a further 12% after imprisonment. Of all those who received a psychotic diagnosis, 89% had post-conviction admissions or a mental health disposition.

CONCLUSION

Legal and clinical definitions of mentally abnormal homicide detect similar rates of mentally abnormal homicide, but illustrate somewhat different dimensions of the relationship between mental illness and homicide.

An anxious profession in an age of fear

This paper proposes that some practices and trends in mental health care may be considered as defensive responses to collective anxiety and fear. On a larger scale similar dynamics occur around fear of terrorism. Collectively and individually we are pulled by the defensive forces and dynamics associated with anxiety. This can in part explain the polarization that occurs around issues of definition and response to mental illness. Fear and anxiety push services towards simplistic viewpoints and futile practices. The capacity to view things from the perspective of others, embracing explanatory and therapeutic pluralism and adopting a humble attitude, may be helpful in enabling anxiety to be channelled productively.

Application of risk assessment for violence methods to general adult psychiatry: a selective literature review

OBJECTIVE

General adult psychiatrists are required to assess risk of violence as frequently as forensic psychiatrists. Yet most of the literature on risk assessment has originated from forensic settings, has been written by forensic psychiatrists, is applicable to forensic patients but may not apply to general psychiatric settings. Because the patient population and the nature of risk assessed may differ between the two settings, there is a need to consider the relevance of systems of assessment of risk of violence specific to the context of general adult psychiatry.

METHODS

We searched the literature on the way risk has been conceptualized in different disciplines using Medline database from 1993 to 2003. Keywords used were violence and risk management and risk assessment. Additional papers were identified from cross-references and personal knowledge of authors.

RESULTS

Seven hundred and nine key papers were identified. We identified three common key concepts that define risk: Uncertainty, weighing up the likelihood of different outcomes arising and, the possibility of benefits as well as harm due to risk assessment. The impact of safety culture - the collection of beliefs, norms, attitudes, roles and practices while making daily activities and management decisions - on psychiatric thinking is examined. We review the two main methods of risk assessment from forensic psychiatric literature (actuarial and clinical) with a view to examine their utility in general adult psychiatric context.

CONCLUSIONS

In order to develop a system of risk assessment relevant to general adult psychiatry, we note the benefits of shifting from risk prediction to assessment, management and reduction of risk, the need to merge actuarial and clinical approaches, communication of risk and finally the need to involve patients in the process of risk assessment.

Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries

OBJECTIVE

To establish whether reinstitutionalisation is occurring in mental health care and, if so, with what variations between western European countries.

DESIGN

Comparison of data on changes in service provision.

SETTING

Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s--England, Germany, Italy, the Netherlands, Spain, and Sweden.

OUTCOME MEASURES

Changes in the number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 and 2002-3.

RESULTS

Forensic beds and places in supported housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds has been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. The general prison population has substantially increased in all countries.

CONCLUSIONS

Reinstitutionalisation is taking place in European countries with different traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.

Improving safety in medicine: a systems approach

The statutory inquiries after homicides by people with mental illness have been replaced by a system of mandatory reporting to the newly established National Patient Safety Agency (Department of Health, 2001a: p. 24). This reflects a radical change in the way that adverse events or ‘near misses' in medicine are to be investigated. Drawing on lessons from engineering on improving safety in aviation and the nuclear power industry, the Department of Health has moved from an individual to a system-centred approach. Whereas the traditional investigation generally stopped when human error was identified, the systems approach takes error as a symptom, not a cause, and asks why it happened, and what were the factors operating on the individual that contributed to the negative outcome (Department of Health, 2000). This approach to investigations could potentially lead to far more constructive solutions than those offered by the current system of inquiries after homicides.

Inquiries into homicides and serious violence perpetrated by psychiatric patients in New Zealand: need for consistency of method and result analysis

BACKGROUND

The violent action of mentally ill people is a source of considerable public and professional concern. At times such incidents are subject to inquiry. In England and Wales, homicides by people suffering from mental illness are subject to mandatory external inquiry. Further, the Royal College of Psychiatrists coordinates a confidential research study into homicide and suicide by people in contact with mental health services. Inquiries have raised concern regarding widespread problems in mental health service delivery. Within New Zealand, similar concerns have been raised, but inquiries have been irregular and not of consistent methodology. The paper aims to review 10 years of inquiries into violent incidents to describe their methods, structure and findings.

METHOD

All inquiries into violent actions perpetrated by patients in contact with mental health services between 1988 and 1998 and held by the Ministry of Health were reviewed. The nature of the inquiry, the incident, findings and recommendations were summarized. For each inquiry, an assessment was made as to whether the incident was predictable or preventable.

RESULTS

There were 11 incidents leading to 13 inquiries, six of homicide, two of rape, one of the release of a dangerous patient and two in which a patient was shot by police. Two internal inquiries were followed by external inquiries. All inquiries found deficiencies of varying severity, the degree of deficiency being greater with external inquiries. Consistent criticisms related to skill, resource, coordination and communication failures. Two of the 11 inquiries found the incident to be 'predictable', and eight to have been 'preventable'.

CONCLUSIONS

The problems in New Zealand are similar to those noted in England and Wales. Small numbers of inquiries make firm conclusions difficult, but the authors feel that a mandatory process of independent review of serious incidents is wise.