A better understanding of forensic psychiatry care pathways and treatment patterns has been hampered by several matters. These include a lack of a clear common definition of violence and standardization of assessment tools, the inability to fully grasp the links between mental disorders, comorbidities and violence, the heterogeneity of key diagnostic groups, and the use of small samples and thus underpowered studies. Shedding light on all these factors, and the link between them, is therefore useful and important for research, clinical practice, public health, and policy debate.
A recent review by Whiting and colleagues, published in October in The Lancet Psychiatry, summarized existing evidence on the association between different mental disorders and violence. Assessing high quality designs and replicated findings, as well as clinical practice guidelines, the authors have highlighted how, whilst absolute rates of serious violence were shown to be low among individuals with mental illness, such rates are up to 6–10% in personality disorders and schizophrenia spectrum disorders (SSDs), and over 10% in substance misuse.
Going into detail, individuals suffering from SSDs appear to be particularly prone to violent behaviours before illness onset or first diagnosis, or in the 1–3 years after first contact with clinical services, with persecutory delusions as a possible disorder-specific explanation for such behaviors and subsequently a target for interventions. Personality disorders – pre-eminently antisocial personality disorder – were shown to have a three-times increased risk of perpetrating violence. Being a heterogeneous category, personality disorders could benefit from a more trait-based approach to understanding and managing their association with violence. Comorbid substance misuse (including alcohol) was proven to be the strongest risk factor for violence of psychiatric diagnoses and, together with past criminality, appears to be strongly predictive of future violence in many individual disorders, thus needing peculiar attention by clinical services.
Besides specific findings, this review aims at providing useful information to translate epidemiological knowledge more readily into general clinical practice. Thus, the use of prediction models appears to be a valid support to clinical judgement. Epidemiological-based methods have allowed for modelling of the potential population effect of preventing violence perpetration in people with mental illness, and the consequences of prevention at an individual level for victims, patients, their carers, and clinical services. To enhance patient care, clinicians working in general psychiatric settings require clear practice guidelines for the assessment and the management of violence risks beyond those related to behavioural disturbances during acute illness. This could be achieved by using clinically feasible prediction models and tools.
By improving the consistency, the accuracy, the efficiency, and the transparency of risk assessment, clinically feasible assessment tools may allow a more stratified approach to violence risk in psychiatry, in which interventions are targeted at those likely to derive the greatest absolute reduction in risk.
Standardised and clinically feasible approaches to the assessment and management of violence risk in general psychiatric settings need to be developed, and clinical practice guidelines require updating to benefit from the available epidemiological evidence.
The article full text is available at:
Whiting D, Lichtenstein P, Fazel S. Violence and mental disorders: a structured review of associations by individual diagnoses, risk factors, and risk assessment. Lancet Psychiatry. 2020 Oct 20:S2215-0366(20)30262-5. doi: 10.1016/S2215-0366(20)30262-5. Epub ahead of print. PMID: 33096045.