1,721,344 research outputs found
Evidence‐based child and adolescent mental health care: The role of high‐quality and transparently reported evidence synthesis studies
Full text linkUse of risk assessment instruments to predict violence in forensic inpatient settings: a systematic review and meta-analysis
Full text linkBACKGROUND & AIMS: Violent behaviour by psychiatric inpatients can have many negative consequences for the physical and mental health of both psychiatric staff and other inpatients. The problem is of particular concern on forensic psychiatric wards, where the prevalence of violence is higher than on other inpatient wards. In order to assess, manage and potentially prevent this type of violence, instruments have been developed with the aim of identifying individuals who are at increased risk of violence within a certain timeframe. This systematic review and meta-analysis aims to investigate the accuracy of these risk assessment tools for the prediction of violence on forensic inpatient wards.
METHODS: The nine most commonly used violence risk assessment instruments that have been used in inpatient settings were included. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to retrieve all studies examining the predictive accuracy of these tools in forensic inpatient settings. A range of accuracy estimates and descriptive study- and sample-related variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2 (a tool designed to assess methodological quality for systematic reviews of studies investigating diagnostic or prognostic accuracy). Summary performance measures and HSROC curves were produced and meta-regression analyses investigated study and sample effects on accuracy.
RESULTS: Fifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 samples, with 7,705 participants. Due to lack of sufficient data reporting, 35 samples (3,306 participants from 19 publications) could be included in the full meta-analysis of all performance measures. Risk assessment instruments were separated into those designed for imminent violence prediction and those designed for longer-term prediction (such as the HCR-20 and PCL-R). Imminent tools performed well for the screening out of low risk individuals, with a summary specificity of 0.99 (95% confidence interval [CI]: 0.80-1.00) and negative predictive value (NPV) of 0.99 (interquartile range [IQR]: 0.85-1.00). Identification of higher-risk patients was poorer, with a summary sensitivity of 0.59 (95% CI: 0.29-0.83) and a median positive predictive value (PPV) of 0.36 (IQR: 0.10-0.93). For longer-term tools, the summary accuracy estimates were as follows: sensitivity = 0.75 (95% CI: 0.65-0.83); specificity = 0.56 (95% CI: 0.46-0.66); PPV = 0.56 (IQR: 0.30-0.75); and NPV = 0.75 (IQR: 0.58-0.95). As an overall measure of accuracy, the median area under the curve (AUC) value for the wider group of 78 samples indicated better performance for imminent tools â AUC = 0.83 (IQR: 0.71-0.85) â compared with longer-term tools with an AUC of 0.68 (IQR: 0.62-0.75). Meta-regression analyses indicated that no study- or sample-related variables were associated with between-study differences in AUCs.
DISCUSSION & CONCLUSIONS: This is a systematic review and meta-analysis of the predictive accuracy of violence risk assessment instruments for forensic inpatient violence. Imminent risk assessment instruments, including the Brøset Violence Checklist (BVC) and the Dynamic Appraisal of Situational Aggression (DASA), were found to be more accurate for the prediction of inpatient violence in forensic wards than those designed for longer-term prediction, such as the HCR-20 and VRAG.</p
Forensic risk assessment: a metareview, novel meta-analysis, and empirical study developing a violence screening tool for schizophrenia
Full text linkMental health professionals are routinely called upon to assess the violence risk of their patients. An increasingly common method for conducting such assessments is the use of structured risk assessment tools. The aim of this thesis was to investigate the utility of such instruments: to identify and explore current uncertainties concerning their applicability and to design a novel measure that could be used as part of a stepped strategy to risk assessment. Though a number of risk assessment tools have been developed and there is a considerable literature concerning their psychometric properties, uncertainty remains regarding their effective use. In order to identify key contemporary uncertainties, a metareview of the forensic assessment literature was conducted. The metareview found that previous systematic reviews and meta-analyses of the risk assessment literature have come to conflicting conclusions on a number of issues, including the comparative predictive validity of risk assessment tools, the efficacy of actuarial tools versus clinical judgement, and the influence of demographic factors and study design characteristics on predictive accuracy. These uncertainties were then investigated in a comprehensive meta-analysis of nine commonly used risk measures. The meta-analysis concluded that there were significant differences between the predictive validity of the risk assessment tools, with instruments designed for more specific purposes performing better than those designed for more general use. Tools performed best when administered to samples demographically similar to their calibration sample. Actuarial instruments and structured clinical judgement were found to perform comparably. The final study presented in this thesis explored the feasibility of a stepped approach to risk assessment in which individuals at very low risk of future violence are screened out prior to resource-intensive clinically based assessment. High-quality national registers were used to construct a simple tool to identify patients with schizophrenia at very low risk of violent conviction after being discharged from hospital. The tool was found to produce high rates of sensitivity as well as high negative predictive values at 1, 2, and 5 years follow.up. In light of the findings of these three studies, risk assessment procedures and guidelines by mental health services and criminal justice systems may need review
Childhood trauma and executive functioning in violent and criminal samples
Full text linkViolent and criminal behaviours have significant economic and psychological costs to society that contribute to substantial pain and suffering. It is important to understand the processes involved in such behaviours in order to implement preventative strategies and interventions. The first paper is a meta-analytic review exploring the association between childhood trauma and violent outcomes in prospective studies. A systematic search yielded 18 eligible papers, all of which defined childhood trauma in terms of child maltreatment and witnessing domestic violence. Overall, childhood trauma was found to increase the risk of violent outcomes with a random-effects odds ratio of 1.8 (95% CI 1.4-2.4) and substantial heterogeneity ( I2 = 92%). It is concluded that childhood trauma is associated with violent outcomes, and the clinical and forensic implications are discussed together with recommendations for future research. The second paper presents a quantitative study investigating aspects of executive functioning in older probationers. Executive dysfunction is considered to have a role in offending behaviour but to date no studies have specifically examined the executive functioning of older probationers. Thirty-two males aged fifty years and over were recruited and completed the Verbal Fluency and Stroop tests to assess mental flexibility and response inhibition. They also completed measures of mental health, substance use and cognitive impairment. In comparison to normative data older probationers did not present with deficits in executive functioning although they did display high rates of mental health and substance use difficulties. These preliminary findings can be used to guide future research with older probationers. The study strengths and limitations, service implications, and suggestions for future research are discussed
Risk factors for violence and suicide in the general population: an umbrella review
Full text linkBACKGROUND: Violence and suicide account for an estimated 1.4 million global annual deaths. There is a large volume of literature examining single risk factors or small groups of related risk factors for violence, and separately for suicide. This thesis is an umbrella review that created an overview of this literature and compared risk factors across multiple risk categories for both violence and suicide, assessed overlap and estimated the impact of risk factors at a population level. METHODS: A systematic search was conducted to identify reviews analysing risk factors for violence and suicide in the general population. Effect sizes were extracted and synthesized. Population attributable fractions were calculated where possible. Quality analyses were performed on reviews eligible for inclusion. RESULTS: Twenty-two meta-analyses reporting on violence risk factors and 12 metaanalyses reporting on suicide risk factors were eligible for quantitative analysis. A further 37 reviews were included in a qualitative analysis. The strongest associations and most distinct overlap were found between neuropsychiatric risk factors for both violence and suicide, with particularly strong effect sizes found for neuropsychiatric risk factors and suicide. The neuropsychiatric risk factors which had the largest impact at a population level were substance abuse for violence (14.8%) and depression for suicide (27.9%). DISCUSSION & CONCLUSION: This review demonstrated that neuropsychiatric risk factors for violence and suicide often have stronger associations with both outcomes than other types of risk factors, such as socio-demographic and childhood-related factors. This suggests that neuropsychiatric risk factors are of upmost importance in clinical risk assessment and as targets for intervention for violence and suicide reduction. Nevertheless, neuropsychiatric risk factors were found to account for only a small proportion of violence at a population level and appeared to have a stronger impact on suicide. Risk assessment for violence and suicide is complex and will always be imperfect. Further research is required to elucidate the areas of uncertainty found by this review
Violence in severe mental illness: risk factors, risk assessment, and prevention
Full text linkIndividuals with severe mental illness are at increased risk of violence compared with the general population. Risk factors for violence need clarification as a basis for risk assessment, and to inform evidence-based risk management. The aim of this thesis is to examine the risk factors for violence in schizophrenia-spectrum disorders, create a simple, scalable risk assessment tool to predict violence in forensic psychiatric populations, and review the evidence for violence prevention interventions in psychiatry.
The first study reports risk factors for violence in a Swedish total population cohort of patients with schizophrenia-spectrum disorders (n=24,297), using register data. Substance use disorders, previous criminality, and self-harm were strong predictors of violence in patients, but also in unaffected sibling and general population controls.
The second study used pre-specified criminal, sociodemographic, and clinical risk factors to derive a clinical prediction rule for violent crime within 12 and 24 months of discharge from forensic psychiatric hospitals in Sweden (n=2,248). The model was used to develop a 12-item online tool (FoVOx) with good measures of calibration and discrimination (area under the curve = 0.77 at 12 and 24 months).
The third study reports an umbrella review of violence prevention interventions in psychiatry, through searches in ten bibliographic databases, and assesses the strength of evidence for each review using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Out of five included reviews, only one received a GRADE rating of âmoderateâ, and reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with mental illness.
Given the lack of intervention research in violence prevention in psychiatry, and considering the shared risk factors between populations, interventions from non-psychiatric populations may need to be relied upon. Research recommendations include the validation of FoVOx, and routine inclusion of violence outcomes in primary research.
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Patient outcomes following discharge from secure hospitals
Full text linkBackground: Despite limited evidence for service benefit, the demand for forensic psychiatric beds is growing. Some studies have reported rates of serious adverse outcomes post-discharge, however, the role of psychiatric diagnosis as a determinant of these outcomes needs to be clarified to ensure patients are managed in the most appropriate way.
Aims: The first aim of this thesis is to summarize evidence on key adverse outcomes, and to provide comparative information for public health and policy. The second aim of this thesis is to elucidate the role of diagnosis and comorbidity in the risk of some adverse outcomes.
Methods: The first study is a systematic review and a meta-analysis of investigations that followed patients discharged from secure hospitals, and reported data on key adverse outcomes after discharge. The second is a historical cohort study of forensic patients discharged from Swedish secure hospitals between 1972 and 2009, which examines the role of psychiatric diagnosis in risk of some adverse outcomes.
Results: Thirty-six studies from 10 countries were included. Mortality rates were lower in studies from England and Wales (crude rate=1,239, 95% CI 932-1,547) compared to other countries (2,331; 1,738-2,925). Readmission rates were higher in samples with a bigger proportion of patients with a diagnosis of mental illness (β=105.57, [se(β)]=54.90, p=0.070) as opposed to personality disorder (β=-181.45, [se(β)]=90.59, p=0.070). Reoffending rates were lower in more recent studies (β=-101.15, [se(β)]=43.34, p=0.026). Compared with different cohorts of discharged prisoners matched on gender, age, and type of offence, reoffending rates were lower for the forensic psychiatric samples (UK prevalence ratios 1.4-7.7 in UK studies)
In the Swedish study, substance use was associated with increased risk of death (HR=1.783, 95% CI=1.556-2.044, p<.000) and violent offending (HR=1.980, 95% CI=1.740-2.254, p<.000). Schizophrenia increased the risk of readmission. Bipolar disorder (HR=1.461, 95% CI=1.196-1.785, p<.000 and personality disorder (HR=1.496, 95% CI=1.345-1.663, p<.000) were associated with increased risk of violent offending.
Conclusions: Treatment and post-discharge support strategies should take into account primary and comorbid diagnosis. Services should provide better overall care to improve patients' general health aiming to reduce premature mortality. Better health could also improve social functioning of these patients reducing readmissions and post-discharge offending in the long-term.</p
Risk factors for violence in psychosis: meta-analysis and Cox regression analyses investigating the association of established and novel risk factors for violence
Full text linkCurrent treatment practice guidelines in a number of countries mandate the assessment of violence risk in all patients diagnosed with schizophrenia. Although more than 100 different instruments have been developed to facilitate the assessment of violence risk, few have been specifically validated for use in those with schizophrenia. Recent work instead suggests that these instruments are typically associated with lower predictive validity in samples with schizophrenia when compared to that achieved in diagnostically heterogeneous samples, leading to concerns that these instruments omit risk factors that may be specific to the prediction of violence risk in this population. The present thesis therefore aimed to investigate the predictive validity of a number of risk factors for violence in those with schizophrenia. Firstly, to identify key risk factors for violence, a meta-analysis was undertaken, finding that although a number of criminal history risk factors are strongly associated with violence risk, nonetheless a number of risk factors rarely assessed by existing violence risk assessment instruments were significantly associated with violence in those with schizophrenia; most notably a history of attempted suicide. Results of this review also suggested that although the criminal history domain is most strongly associated with violence risk, nonetheless, there is considerable variability in the magnitude of association for the individual risk factors. Study two therefore aimed to investigate this variability and found that a history of violence was most strongly associated with subsequent violence. Study three aimed to identify whether suicidal behaviour, which has rarely been considered risk factors for violence in previous work, incrementally contributes to the prediction of violence. A simple risk model composed of young age, comorbid substance use disorder, previous violence, and a history of suicidal threats, explained as much predictive validity, as measured by the area under the receiver operating characteristic curve, as established risk assessment instruments such as the HCR–20, LSI–R, PCL–R, and VRAG. Current risk assessment approaches may therefore need revision in light of these findings
Adverse events of common psychiatric medications: an umbrella review
Full text linkBACKGROUND: Psychiatric medications were the second most prescribed therapeutic class in the United States in 2015 with 547 million prescriptions. Adverse events of medications are very common, can be distressing to patients and are often underreported in the primary studies. The purpose of this thesis is to systematically review the scientific literature to estimate the prevalence and burden of adverse events among the most common psychiatric medications.
METHODS: The 23 most commonly prescribed psychiatric medications in the United States as well as eight psychiatric medications from the World Health Organization's Essential Medicine List were included. A systematic and comprehensive search was conducted to retrieve all published and unpublished systematic reviews with meta-analyses to assess adverse events of individual psychiatric medications (this process of collecting secondary publications and not primary studies is called "umbrella review"). Seven databases (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, Medline, PreMedline, PsycINFO and PubMed) were searched between 1946 and 2016. Prevalence rates and effect estimates were extracted by two independent reviewers and summarised. A quality analysis was performed on included reviews using the AMSTAR (assessing the methodological quality of systematic reviews) tool and all were rated as medium or high quality reviews.
RESULTS: 69 systematic reviews and meta-analyses published were eligible for data extraction, quality appraisal and quantitative synthesis. Antipsychotic medications (60%) accounted for the majority of the findings, followed by antidepressants (16%), stimulants (13%), mood stabilisers (8%) and anxiolytics (3%). The strongest associations were between amitriptyline and sexual dysfunction (N=442, odds ratio [OR] 16.6; 95% Confidence Intervals [CI] 4.6 to 60.6), aripiprazole and somnolence (N=569, OR 25.8; 95% CI 1.3 to 112.3) and olanzapine and weight gain (N=249, OR 32.0; 95% CI 1.7 to 98.4). Overall, neurological adverse events were reported most frequently for antidepressant, antipsychotic and anxiolytic medication classes. Patient characteristics, particularly age and diagnosis, explained differences in adverse events across and within medication classes.
DISCUSSION & CONCLUSION:
To my knowledge, this is the first umbrella review on the tolerability profiles of 31 common psychiatric medications worldwide. Many medications were linked to adverse events through a weak or moderate strength of association and additional factors contributed to the variability in adverse outcome reporting aside from patient characteristics. Findings from this review need to be examined with the efficacy profiles of the medications and the clinical circumstances of the individual patients. </p
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