90
ANZJP Correspondence
flashbacks of sexual abuse between ages 5–8 years. Two weeks after starting the paroxetine she reported irritability and panic attacks. On the day of the assault, the smell of aftershave cologne from a visitor reminded her of the cologne used by the perpetrator. She later described that she was triggered, ‘saw red’ and ‘pushed the person in front of her and just wanted to get away’. Management included risperidone one-half mgs tid prn for anxiety and valproic acid for emotional regulation. The dosage of paroxetine was tapered to 15 mg daily. Patient B is a 45-year-old bookkeeper who was started on sertraline 200 mg after a 3 month history of anxiety, insomnia, nightmares, and intrusive memories of sexual abuse
between the ages of 5–9 years. Three weeks after starting the sertraline she reported panic attacks, increased insomnia and intense suicidal thoughts. She planned suicide by driving her car into a cement wall and stopped in the middle of her attempt, while driving, after receiving a cell phone call from her daughter. There was no previous history of suicide attempts. After hospitalization, initial pharmacological management included olanzapine 10 mg qhs to decrease her activation. She was later started on lamotrigine for emotional regulation, and sertraline 150 mg. Hyperarousal symptoms in PTSD patients (e.g. increasing insomnia, panic attacks, irritability) should be monitored carefully and managed before treatment with antidepressants is initiated.
Declaration of interest
Risk assessment and clinical decision-making John Olav Roaldset
to prevent violent behavior in both inpatients and outpatients, and not just observe if it happens. Good risk assessment and good treatment/management could lead to the prevention of violence, and a good risk assessment could then become a wrong risk prediction. Some of the false positive predictions might be ‘iatrogenic’ due to good risk management. The better the risk management, the more ‘iatrogenic’ false positive predictions there are, and the lower the accuracy for risk assessments and predictions. Studies of the accuracy of risk predictions may not be the best way to evaluate risk assessment instruments. Pre-post studies explore whether implementation of a risk instrument might lead to diminished violence or restraints. In a semi-randomized cluster trial of 14 acute departments (the departments were randomized) in Switzerland, Abderhalden et al. (2008) found a 41% reduction of violent episodes and a 27% reduction in the use of restraints after implementing a short-time risk assessment instrument (Brøset Violence Checklist – BVC) in seven of the wards, compared with the seven wards giving ‘treatment as usual’. In a randomized cluster trial, van de Sande et al. (2011) found a
similar reduction in inpatient violence and time spent in seclusion after implementation of BVC in two wards compared with two wards giving ‘treatment as usual’. The most important aspect, and more important than predictive accuracy, is whether risk assessments lead to decreased violence. Large et al. (2014) seem to have overlooked the pre-post studies, which also should be emphasized when the use or usefulness of risk assessments are discussed.
Ålesund Hospital, Åsetranda, Ålesund, Norway Corresponding author: John Olav Roaldset, Ålesund Hospital, Åsetranda, Ålesund 6026, Norway. Email: [email protected] DOI: 10.1177/0004867414540009
To the Editor In a recent commentary, Large et al. (2014) argue that violence risk assessments do not lead to a better clinical praxis, but rather the opposite. The main arguments are that a categorical application of risk assessments might lead to: (i) a large group of false positive predictions which could allocate resources from treatment to unnecessary restrictions or reports; (ii) non-treatment among lowrisk patients as a result of low-risk categorization, which could lead to violent episodes; and (iii) accuracy being insufficient. Their basis was systematic reviews of the literature, consisting mainly of risk prediction studies. One problem with risk prediction studies in psychiatric settings is that for obvious ethical reasons staff and other involved personnel have
Australian & New Zealand Journal of Psychiatry, 49(1)
The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Jeffreys M (2009) Clinician’s Guide to Medications for PTSD. National Center for PTSD. U.S Department of Veterans Affairs; 2009. Available at: www.ptsd.va.gov/professional/ pages/clinicians-guide-to-medicationsfor-ptsd. asp (accessed 5 April 2014). Shin HJ, Rosen CS, Greenbaum MA, et al. (2012) Longitudinal correlates of aggressive behavior in help-seeking US veterans with PTSD. Journal of Traumatic Stress 25: 649–656. Tondo L, Vazquez G and Baldessarini RJ (2010) Mania associated with antidepressant treatment: Comprehensive meta-analytic review. Acta Psychiatrica Scandinavica 121: 404–414.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflict of interest, the author alone is responsible for the content and writing of this paper.
References Abderhalden C, Needham I, Dassen T, et al. (2008) Structured risk assessment and violence in acute psychiatric wards: Randomised controlled trial. British Journal of Psychiatry 193: 44–50. Large MM, Ryan CJ, Callaghan S, et al. (2014) Can violence risk assessment really assist in clinical decision-making? Australian and New Zealand Journal of Psychiatry 48: 286–288. Van de Sande R, Nijman HL, Noorthoorn EO, et al. (2011) Aggression and seclusion on acute psychiatric wards: Effect of short-term risk assessment. British Journal of Psychiatry 199: 473–478.
ANZJP Correspondence
flashbacks of sexual abuse between ages 5–8 years. Two weeks after starting the paroxetine she reported irritability and panic attacks. On the day of the assault, the smell of aftershave cologne from a visitor reminded her of the cologne used by the perpetrator. She later described that she was triggered, ‘saw red’ and ‘pushed the person in front of her and just wanted to get away’. Management included risperidone one-half mgs tid prn for anxiety and valproic acid for emotional regulation. The dosage of paroxetine was tapered to 15 mg daily. Patient B is a 45-year-old bookkeeper who was started on sertraline 200 mg after a 3 month history of anxiety, insomnia, nightmares, and intrusive memories of sexual abuse
between the ages of 5–9 years. Three weeks after starting the sertraline she reported panic attacks, increased insomnia and intense suicidal thoughts. She planned suicide by driving her car into a cement wall and stopped in the middle of her attempt, while driving, after receiving a cell phone call from her daughter. There was no previous history of suicide attempts. After hospitalization, initial pharmacological management included olanzapine 10 mg qhs to decrease her activation. She was later started on lamotrigine for emotional regulation, and sertraline 150 mg. Hyperarousal symptoms in PTSD patients (e.g. increasing insomnia, panic attacks, irritability) should be monitored carefully and managed before treatment with antidepressants is initiated.
Declaration of interest
Risk assessment and clinical decision-making John Olav Roaldset
to prevent violent behavior in both inpatients and outpatients, and not just observe if it happens. Good risk assessment and good treatment/management could lead to the prevention of violence, and a good risk assessment could then become a wrong risk prediction. Some of the false positive predictions might be ‘iatrogenic’ due to good risk management. The better the risk management, the more ‘iatrogenic’ false positive predictions there are, and the lower the accuracy for risk assessments and predictions. Studies of the accuracy of risk predictions may not be the best way to evaluate risk assessment instruments. Pre-post studies explore whether implementation of a risk instrument might lead to diminished violence or restraints. In a semi-randomized cluster trial of 14 acute departments (the departments were randomized) in Switzerland, Abderhalden et al. (2008) found a 41% reduction of violent episodes and a 27% reduction in the use of restraints after implementing a short-time risk assessment instrument (Brøset Violence Checklist – BVC) in seven of the wards, compared with the seven wards giving ‘treatment as usual’. In a randomized cluster trial, van de Sande et al. (2011) found a
similar reduction in inpatient violence and time spent in seclusion after implementation of BVC in two wards compared with two wards giving ‘treatment as usual’. The most important aspect, and more important than predictive accuracy, is whether risk assessments lead to decreased violence. Large et al. (2014) seem to have overlooked the pre-post studies, which also should be emphasized when the use or usefulness of risk assessments are discussed.
Ålesund Hospital, Åsetranda, Ålesund, Norway Corresponding author: John Olav Roaldset, Ålesund Hospital, Åsetranda, Ålesund 6026, Norway. Email: [email protected] DOI: 10.1177/0004867414540009
To the Editor In a recent commentary, Large et al. (2014) argue that violence risk assessments do not lead to a better clinical praxis, but rather the opposite. The main arguments are that a categorical application of risk assessments might lead to: (i) a large group of false positive predictions which could allocate resources from treatment to unnecessary restrictions or reports; (ii) non-treatment among lowrisk patients as a result of low-risk categorization, which could lead to violent episodes; and (iii) accuracy being insufficient. Their basis was systematic reviews of the literature, consisting mainly of risk prediction studies. One problem with risk prediction studies in psychiatric settings is that for obvious ethical reasons staff and other involved personnel have
Australian & New Zealand Journal of Psychiatry, 49(1)
The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Jeffreys M (2009) Clinician’s Guide to Medications for PTSD. National Center for PTSD. U.S Department of Veterans Affairs; 2009. Available at: www.ptsd.va.gov/professional/ pages/clinicians-guide-to-medicationsfor-ptsd. asp (accessed 5 April 2014). Shin HJ, Rosen CS, Greenbaum MA, et al. (2012) Longitudinal correlates of aggressive behavior in help-seeking US veterans with PTSD. Journal of Traumatic Stress 25: 649–656. Tondo L, Vazquez G and Baldessarini RJ (2010) Mania associated with antidepressant treatment: Comprehensive meta-analytic review. Acta Psychiatrica Scandinavica 121: 404–414.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflict of interest, the author alone is responsible for the content and writing of this paper.
References Abderhalden C, Needham I, Dassen T, et al. (2008) Structured risk assessment and violence in acute psychiatric wards: Randomised controlled trial. British Journal of Psychiatry 193: 44–50. Large MM, Ryan CJ, Callaghan S, et al. (2014) Can violence risk assessment really assist in clinical decision-making? Australian and New Zealand Journal of Psychiatry 48: 286–288. Van de Sande R, Nijman HL, Noorthoorn EO, et al. (2011) Aggression and seclusion on acute psychiatric wards: Effect of short-term risk assessment. British Journal of Psychiatry 199: 473–478.
