Psychiatric patients with severe mental illness and those who were admitted to the emergency department (ED) accompanied by police were more likely than their counterparts to be considered a high risk for violence or aggression, according to a study issued today in Psychiatric Services.
In emergency and acute psychiatry, routinely assessing each patient’s risk of violence or aggression may prevent the need for coercive or potentially traumatizing interventions, wrote Christoffer Dharma, M.Sc., of the University of Toronto, and colleagues. “Despite this well-intentioned goal, psychiatric assessments may be influenced by social determinants of health.”
Dharma and colleagues used electronic health record (EHR) data for 7,424 patients (58% male) who had 12,650 acute care stays at the Centre for Addiction and Mental Health in Toronto between May 2016 and May 2022. All patients were admitted through the ED and assessed for their risk of becoming violent or aggressive within the next 24 hours. Risk assessments were conducted by acute care nurses and based on the Dynamic Appraisal of Situational Aggression, which measures factors such as the patient’s impulsivity, irritability, unwillingness to follow directions, and negative attitude. The EHR data also included information on violent or aggressive incidents that occurred while the patient was in care.
In 76% of cases, the risk assessments were aligned with the incidents, most often when low-risk assessments were followed by no violent incidents during the patient’s stay. Risk assessment accuracy was much lower than the overall average for Black patients, patients brought to the ED by police, and patients in supported or unstable housing.
In the researchers’ adjusted analysis, however, patient race and/or housing status was not the strongest predictor of wrongly assessing high violence risk. Rather, it was psychiatric diagnosis, as patients with bipolar disorder, a neurodevelopmental disorder, or a neurocognitive disorder were approximately three times as likely to be assessed as high risk without a subsequent violent incident compared with their counterparts with a depressive or anxiety disorder. Patients who were accompanied by police were also twice as likely as their counterparts who admitted themselves to receive a high-risk assessment without a subsequent violent incident.
“The practice of clinicians using police apprehension as a cue for determining and potentially managing patient risk raises concern,” the authors wrote. “Our findings also indicate the roles of other [social determinants of health], such as housing status and psychiatric diagnosis type, that should be considered in future research on violence risk assessment and management.”
For related information, see the Psychiatric Services article “Race-Based Disparities in the Frequency and Duration of Restraint Use in a Psychiatric Inpatient Setting.”
(Image: Getty Images/iStock/JazzIRT)
Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.