FUTURE VIOLENCE PREDICTION: research strategies for better risk assessment and care in schizophrenia

The new issue of The American Journal of Psychiatry (Impact Factor 13.655) shows important findings from a recent study by Alec Buchanan and colleagues and a valuable Editorial by Paul Appelbaum on the investigation of future violence in schizophrenia (Volume 176, Issue 9, September 2019).

Clinical, legal, and societal pressures to identify correlates of future violence motivate studies like the one by Buchanan et al., says Paul Appelbaum. The above-mentioned study was conceived to provide data on the correlates of future violent behavior in people meeting DSM-IV diagnostic criteria for schizophrenia. It describes a secondary analysis of data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, involving a total of 1,435 individuals followed for 18 months. Illness of involved individuals was on average long-standing and relatively unstable. At baseline, mean time since the first treatment with antipsychotic medication was 16.5 years (SD=10.9).

As a whole, 5.4% reported engaging in injurious violence during follow-up, and 8.3% reported engaging in exclusively noninjurious violence. Main findings on predictors of time to first injurious violence drew attention to baseline violence, recent violent victimization, childhood sexual abuse, severity of drug use, and poor medication adherence. Baseline symptoms of psychosis or depression did not appear relevant in the prediction.

However, current research strategies have intrinsic limitations.

How then can we move research on violence in schizophrenia forward? says Paul Appelbaum. In search of a new paradigm, prospective studies with violence as the primary outcome are needed. There are several methodological aspects we should handle in this new paradigm:

• Secondary analyses of data collected for other purposes are unlikely to make substantial contributions because they are not specifically designed to explore and predict violence in people with schizophrenia
• Violence should be the primary outcome. Outcome measures should be robust, preferably based on more than one method of ascertainment
• Appropriate sampling strategies should be considered to improve the understanding of violence among stable, community-dwelling patients with schizophrenia or persons newly discharged from an inpatient hospitalization
• Many contributions have gotten us to where we are today: do not disregard information on significant predictors from previous analyses

Whatever the degree of violence risk a person is thought to present, the tasks of clinical care should focus on providing the best available evidence-based treatment and necessary psychosocial support, stated Paul Appelbaum.

Link to relevant issue in The American Journal of Psychiatry:

https://ajp.psychiatryonline.org/toc/ajp/176/9

• Appelbaum PS. In Search of a New Paradigm for Research on Violence and Schizophrenia. Am J Psychiatry. 2019 Sep 1;176(9):677-679. doi: 10.1176/appi.ajp.2019.19070678.
• Buchanan A, Sint K, Swanson J, Rosenheck R. Correlates of Future Violence in People Being Treated for Schizophrenia. Am J Psychiatry. 2019 Sep 1;176(9):694-701. doi: 10.1176/appi.ajp.2019.18080909.