A Short Tool for Screening Violence Risk in Adults with Mental Illnesses.

CARTWRIGHT, JOEL KEITH A Short Tool for Screening Violence Risk in Adults with Mental Illnesses. (Under the direction of Dr. Sarah L. Desmarais.) Structured risk assessments improve the prediction of violence over unstructured approaches, and, consequently, many statutes and regulations require the use of such tools in mental health and correctional settings. However, these instruments are typically long, costly, and resource-intensive. Thus, a short, accurate, cost-effective, and easily administered screening tool has the potential to increase the efficiency of the violence risk assessment process by identifying those at low risk of violence who can be screened out of future indepth assessments. To that end, a short screening tool was recently developed by Singh and colleagues (2012) in a Swedish sample of adults diagnosed with schizophrenia using data drawn from national registries. The screening tool included five items: male sex, previous criminal conviction, below the age of 32, alcohol abuse, and drug abuse. Item ratings (0 = absence, 1 = presence) are summed and individuals scoring one or less are screened out from further risk assessment. Though results demonstrated good accuracy in screening out individuals who did not commit violence, there was a very high rate of false positives. Thus, whether the approach truly would improve efficiency is questionable. Moreover, generalizability was limited by the nature of the sample, relatively long follow-up periods, and reliance on administrative records. The current study evaluated the performance of the five-item screening tool developed by Singh and colleagues (2012) in predicting violence over 6-month and 12-month follow-up periods in a large, heterogeneous U.S. sample of adults with mental illnesses (Aim 1). Results were compared to those reported by Singh and colleagues, when possible. I additionally examined and compared the strength of association between the original five items, as well as other theoretically-supported items, with violence at 6-month and 12-month follow-up (Aim 2). Data were pooled from four longitudinal studies of adults with mental illnesses: (a) Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study (n = 1,460) (Stroup et al., 2003); (b) MacArthur Mental Disorder and Violence Risk (MacRisk) Study (n = 1,136) (Steadman, Mulvey, Monahan, et al., 1998); (c) Facilitated Psychiatric Advance Directive (F-PAD) Study (n = 469) (Swanson, Swartz, Elbogen, Van Dorn, & et al., 2006); (d) Schizophrenia Care and Assessment Program (SCAP) Study (n = 404) (Swanson, Swartz, & Elbogen, 2004). A total of 3,469 participants were included in the sample at baseline; 2,471 (71.2%) participants were available at 6-month follow-up, and 2,211 (63.7%) participants were available at 12-month follow-up. Results of Aim 1 analyses demonstrated that the five-item screening tool performed reasonably well at screening out individuals who did not commit violence during follow-up; however, the screening tool performed less well at identifying individuals who did commit violence during follow-up. For instance, though the proportion of true positives increased from the 6to 12-month follow-up (26.0% to 32.0%), the rate of false positives was high across both follow-up periods (i.e., 74.0% and 68.0%). Moreover, although those who were screened in were about twice as likely to engage in violence over 6-month follow-up, by 12month follow-up, there was very little difference in odds of engaging in violence between participants who were screened and screened out. Results of Aim 2 analyses, taken together, suggest that the original five items are not the most important predictors of violence among U.S. adults with mental illnesses. Instead, seven items accounted for the majority of variance in violence explained by the model: recent violence, age, recent victimization, primary diagnosis, inpatient service use, alcohol use, and suicidal behavior. Overall, findings do not support the application of the five-item screening tool in U.S. adults with mental illnesses and suggest that other items may be more appropriate for inclusion in a violence screening tool.