Award Title: Improving violence risk assessment and intervention in first episode psychosis
Funder: Department of Health and Social Care

Abstract: Research questionHow can violence risk best be routinely assessed in Early Intervention in Psychosis (EIP) services, and what interventions should be provided for those at higher risk?BackgroundWhilst the majority of patients with severe mental illnesses are never violent, a range of psychiatric diagnoses confer a modestly but significantly increased risk. For psychotic illnesses such as schizophrenia, absolute risks are clinically relevant. Assessing and managing this is a core feature of psychiatric practice. Whilst forensic psychiatry services specialise in this, thresholds for their involvement are extremely high. The majority of frontline risk assessment is undertaken by general services.This is particularly relevant to EIP services. These community teams promote recovery in patients experiencing a first episode of psychosis- a high risk phase of illness for violence. Predicting who is at higher risk of future violence is challenging. Furthermore, whilst there are some promising approaches to violence reduction, evidence in psychiatric populations is limited. Better assessment of violence risk to guide allocation of individualised, evidence-based non-harmful interventions at this unique time-point is essential to reduce violent outcomes.A number of tools exist to structure risk assessment; however none are practically amenable to settings such as EIP services. Clinicians instead rely on unstructured clinical judgement. A simple, free tool (OxMIV) has been developed that offers both practicality of use and favourable performance. This could be an invaluable adjunct to clinical judgement in EIP services. The prediction model has been validated in Swedish patient registries, but more work is needed to understand its performance in UK populations and role in clinical practice. By analysing changes in practice brought about when patients are identified as high risk with OxMIV, clearer interventions for violence reduction can be developed and tested.Aims and objectivesThis project aims to (1) externally validate OxMIV's performance in patients presenting to EIP services, (2) qualitatively evaluate and refine its clinical use, and (3) model its impact including beginning to develop interventions to link it to.MethodsOffline evaluation using clinical documentation will test predictive accuracy compared to assessment as usual without impacting clinician behaviour, allowing for re-calibration. Qualitative methodology will establish consensus on the role of OxMIV in the clinical pathway. Experiences of first use by patients and clinicians will be explored including acceptability and feasibility. Informed by these stages, the tool will be used prospectively in clinical practice. As well as violent outcome data, changes in practice will be modelled in detail.Anticipated impact and disseminationBy evaluating OxMIV in this staged manner, this project will both potentially provide a clinically validated tool whose role in clinical work is well understood, and provide an evaluation framework applicable to other areas of psychiatry. It will also start to develop a complex intervention for violence risk reduction that can be tested on a larger scale. Improving the approach to violence risk in EIP services will benefit patients, services and wider society. Results will be disseminated through engaging patient groups and online, and be published in high-impact peer-reviewed medical journals.

Lay Abstract: BackgroundSchizophrenia and other 'psychoses' are severe mental illnesses which can profoundly affect how you feel, think and act. Receiving early specialist treatment can help increase the chances of making a full recovery and leading a fulfilling life. Community mental health teams called 'Early Intervention in Psychosis' (EIP) services help people with the first signs of psychotic illness recover.The majority of people that suffer with this type of illness never act violently, and only a small fraction of all violent crime is committed by people with severe mental illness. However, developing a psychotic illness does increase your chances of behaving violently for complex reasons. There are certain 'risk factors' that might increase the chances of this happening, such as if you have behaved violently previously or also have difficulties with drug use.One thing EIP services have to assess therefore is whether a patient might, due to having some of these risk factors, be at risk of behaving violently. Importantly this can guide what help someone might need to reduce the risk. Prediction can be difficult though. There are some tools to structure risk assessment, but these need lots of resource so are unhelpful for EIP services.Researchers have now developed a simpler tool,'OxMIV'. It uses information that is routinely asked about to estimate violence risk. One potential role for this is to support clinicians in EIP services. It has so far been tested using data about patients in Sweden. More work is needed to see if it is helpful in the UK and in clinical practice.As well as being difficult to assess, it is often unclear what should be done to reduce risks. Some approaches are probably helpful, like treating symptoms and reducing substance use, but evidence is limited. One way to improve this is to look in detail at what happens when clinicians use a tool such as OxMIV. By understanding what changes are made when someone is assessed as higher risk, we can develop clearer treatment options and test what helps. Aims of project- Test the accuracy of the 'OxMIV' tool in patients under EIP services. - Understand the challenges of using the tool in practice, and develop the best way to do so. - Observe the impact when the tool is brought into practice.Design and methodsThe tool must first be tested for accuracy in this new group of patients without changing clinician behaviour. Clinical documentation will be used to make a prediction with the tool and check for violent incidents. OxMIV will be compared to the judgement the clinician made at the time to see whether the tool would have helped, or if it needs adjusting.'Qualitative' methods will be employed to plan how the tool might best be used and to trial this with a sample of patients and clinicians, exploring experiences and problems through group discussions, interviews and surveys.The tool will then be introduced into an EIP service. Accuracy will be tested and changes in treatment modelled.Patient and public involvementPatient and family experience and views on the tool are integral to the project. Patients will be directly involved in the qualitative aspects of the study. One key aspect of the work is the acceptability of the tool for patients, and their experience of how clinicians share and discuss violence risk. DisseminationThe results of the study will be published in medical journals. They will be fed back to patient groups locally and nationally through the Royal College of Psychiatrists and charities. They will also be shared with the public in a variety of online formats.

Research Activity Codes: 2.5 RESEARCH DESIGN AND METHODOLOGIES (AETIOLOGY)
Health Categories: MENTAL HEALTH