A violence risk screening tool, the V-RISK-10, shows promising results for both men and women in an acute psychiatric setting. This is the bottom line of a published article in International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | International Journal of Forensic Mental Health | 2016, Vol. 15, No. 2, 186-197
Gender Differences in the Predictive Validity of a Violence Risk Screening Tool: A Prospective Study in an Acute Psychiatric Ward
Bjørn Magne S. Erikson, Oslo University Hospital & University of Oslo
Stàl Bjørkly, University of Oslo & Molde University
Anne Færden, Oslo University Hospital
Christine Friestad, University of Oslo & Oslo University Hospital
Pål Hartvig, Oslo University Hospital
John Olav Roaldset, Alesund Hosptial & The Norwegian University of Science and Technology
In this one-year prospective, naturalistic study in an acute psychiatric facility, we explored gender differences between 230 men and 284 women regarding the predictive validity of the Violence risk screening-10 (V-RISK-10). Hospital staff recorded violent incidents during hospital stays (range 1– 176 days; median: 5.5 days) resulting in 50 men (22%) and 30 women (11%) being recorded for violence. The predictive validity was significant for both genders, with ROC-AUCs of .79 for males and .80 for females. Scoring at cut-off or beyond indicated a two-fold increased risk of becoming violent for men and a three-fold risk for women. A lower score indicated a five-fold decrease in risk for both genders. Estimates of explained variance for the prediction model were higher for men. Findings indicate gender differences for risk factors of violence and highlight the need of further research on this issue.
Gender; V-RISK; acute psychiatric ward; risk assessment; violence
Summary of the Research
“Some studies find gender differences in violence (Bowers et al., 2011; Dack, Ross, Papadopoulos, Stewart, & Bowers, 2013) while others do not (Cornaggia, Beghi, Pavone, & Barale, 2011). Findings indicate that mental health professionals tend to underestimate women’s violence potential, even within forensic settings (Skeem et al., 2005; Yourstone, Lindholm, Grann, & Svenson, 2008), which highlights the importance of the gender issue concerning violence risk.” (p. 186)
“One important step toward reducing inpatient violence in acute psychiatric wards is to improve the methods used to assess the risk for violence at the time of hospital admission so that appropriate preventive measures can then be implemented (Abderhalden et al., 2008; van de Sande et al., 2011). Most risk assessment tools have been developed within forensic settings. Thus, few existing tools aim explicitly at assessing risk of violence in acute psychiatric settings.” (p. 186)
It is important to develop tools for this purpose because acute psychiatry differs from forensic and long-term psychiatry in many ways. Acute psychiatric facilities are typically characterized by a high frequency of admissions and are obliged to accept all referred patients with acute psychiatric conditions. In addition, the length of stay is typically short, from days to a few weeks. Mean length of stay in the four prospective studies mentioned earlier ranged from 12 to 18 days (Abderhalden et al., 2007; Grassi et al., 2001; Hartvig et al., 2011; Mellesdal, 2003).” (p. 186)
“The Violence risk screening – 10 (V-RISK-10), consisting of 10 psychosocial risk factors for violence, has been developed for inpatient and outpatient violence risk assessment in acute psychiatry. A test of the V-RISK-10’s predictive validity in two acute psychiatric departments in Norway has shown a ROC-AUC value of .82 for the hospital stay (Hartvig et al., 2011).” (p. 187)
“To summarize, very few tools have been developed for inpatient violence risk assessment in acute psychiatry, and to our knowledge, there is a paucity of research that has specifically brought gender differences concerning the predictive validity of these tools into focus. Hence, the main objective of this prospective study was to investigate gender differences concerning the predictive validity of the V-RISK-10 in a one-year cohort of acute psychiatric inpatients. To accomplish this, we also specifically examined gender differences for each of the 10 items of the scale and controlled for gender differences in other sociodemographic and clinical variables having a possible impact on violence.” (p. 187)
“This was a naturalistic, prospective observational study at the acute psychiatric ward at Oslo University Hospital in Norway, which has a catchment area of nearly 226,000. The ward has 45 beds divided into five units and receives all emergency psychiatric admissions of adults over 18 years of age. Patients are first admitted to the Emergency Unit, which has seven beds, where they stay for a maximum of 3 days. They are then either dis-charged or transferred to one of four specialized units with a total of 38 beds. The target population were all voluntary and involuntary patients admitted one or more times between March 21, 2012, and March 20, 2013, yielding a total of 558 patients with 755 hospital stays.” (p. 187)
“The V-RISK-10 was recorded by the medical doctor or psychiatrist on duty as part of the admission procedure (see Baseline Measures). All patients were informed verbally and in writing about the project during their hospital stay and at discharge, including their right to decline or withdraw consent to participate.
Violent episodes on the ward were recorded by the nursing staff using the Staff Observation Aggression Scale-Revised (SOAS-R) (Nijman et al., 1999). The nursing staff were not blinded to the V-RISK-10 recordings. Further information about violent episodes, including any use of protocols of coercive measures, was gathered from hospital records by the researchers during the data collection period.” (p. 188)
“The explained variance (i.e., how much of the recorded violence that could be explained by the factors) of the V-RISK-10 and also of the V-RISK-10 plus other risk factors was lower for women than for men. Three of the other risk factors (psychosis, involuntarily admitted, and previously admitted) added significantly to the explained variance of violence for men, but not for women. These differences might be random, but they might also indicate the presence of possible risk factors for women which are not included in either the V-RISK- 10 or the other clinical and demographic variables con- trolled for in the study.” (p. 192)
“During hospital stays, 80 patients, 50 men (22%) and 30 women (11%), were recorded with violent behavior. The ROC-AUC analyses showed high predictive validity for the V-RISK-10, with AUCs of .80 for women, .79 for men, and .81 for the whole sample. The V- RISK-10 was significant for both men and women after controlling for other risk factors.” (p. 193)
“Results indicate good overall properties of the V- RISK-10 as a screening tool for both men and women. Despite this, only about 20% of the violence for men and 15% of the violence for women could be explained by the tool.” (p 194)
Translating Research into Practice
“High rates of false positive predictions are a clinical and ethical challenge. The V-RISK-10 is a screening tool, and its main purpose is to identify persons in need of further assessment of violence risk. A positive test could lead to more comprehensive risk assessment, treatment, and risk management, which hopefully could prevent violent episodes and change a true positive to a false positive. It should also be noted that in clinical practice, cut- offs are not applied, and the V-RISK-10 is used as part of structured clinical judgment.” (p. 195)
“The study’s results showed that the V-RISK-10, in general, seems to be equally useful for men and women. Still, there were some possible gender differences concerning risk factors for violence and properties of the tool that may be of clinical relevance provided that they can be replicated by future research.” (p. 195)
Other Interesting Tidbits for Researchers and Clinicians
“In addition to previous/current violence, lack of empathy remained the only significant risk factor for women. To our knowledge, no previous study has found lack of empathy as a significant female-specific predictor of violence in an acute psychiatric sample. Lack of empathy may play a mediating role in the relationship between violence and a variety of mental disorders, but the evidence for this association is still weak (Harris & Picchioni, 2013). One possible explanation for this finding is that dissocial personality disorder and psychopathic traits were underdiagnosed in the female patients.” (p. 194)
“Further research is needed in order to establish the importance of these findings with greater certainty so that the assessment and management of violence risk in acute psychiatry can be optimized for both male and female patients. Our findings indicate that only about one fifth of the violence could be
explained by the V-RISK-10. The fact that the proportion of explained variance was even lower for women suggests that further research may want to explore if there are risk factors unique for violence in women.” (p. 196)
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Authored by Kenny Gonzalez
Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.