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ANZJP Correspondence
Violence risk assessment has not been shown to reduce violence Matthew M Large1 and Christopher J Ryan2 1Department
of Mental Health Services, Prince of Wales Hospital, and the School of Psychiatry, University of New South Wales, Sydney, Australia 2Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia Corresponding author: Matthew M Large, Department of Mental Health Services, Prince of Wales Hospital, and with the School of Psychiatry, University of New South Wales, Sydney, NSW 1360, Australia. Email: [email protected] DOI: 10.1177/0004867414539570
To the Editor Among the thousands of papers about violence risk assessment only two studies have found any evidence for any reduction in violence as a result of redirecting treatment resources from low-risk to high-risk patients. These two studies, cited in a recent commentary (Roaldset, 2015), comprise the totality of the evidence base for the use of violence risk assessment in mental health. Abderhalden and colleagues (2008) asked nurses on four randomly allocated wards to conduct twice-daily
Suicide rates and mental health disorder prevention Paul Fitzgerald1,2 and Jayashri Kulkarni1,2 1Monash
Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School, Melbourne, Australia 2The Alfred, Melbourne, Australia Corresponding author: Paul Fitzgerald, Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School, Level 4, 607 St Kilda Road, Melbourne, VIC 3004, Australia. Email: [email protected] DOI: 10.1177/0004867414557682
violence risk assessments during days 1–3 of each admission. They found that with this intervention the number of severe aggressive events on these wards dropped by 41%. This was compared to five control wards where the drop was only 15%. Unfortunately, the randomisation process had resulted in the four experimental wards being those with much higher rates of pre-study violence. They were also four wards where each ward manager perceived aggression prior to the study as being a ‘big or very big problem’, while only two of the five control wards’ managers rated aggression to be this problematic. By the end of the study, the fall in the rates of aggression in the intervention wards only resulted in those wards achieving the rate already evident in the control wards. Given these features of the study it is very hard to confidently attribute the apparent improvement in the rates of aggression to the experimental intervention, rather than a Hawthorne effect or simply regression to mean. In the van de Sande study (2011), the two experimental wards rated every patient every day with two risk assessment scales and then used another two risk assessment scales weekly. Staff on the experimental wards also received ‘ongoing clinical supervision … provided by a clinical nurse specialist supported by a risk assessment expert panel’. At the end of
the intervention period, the two experimental wards did see a reduction in violent episodes compared to the two treatment-as-usual wards, though after correction for the number of patient days a fall in the number of violent patients did not reach statistical significance. These two studies represent the sum-total of the evidence for the harm-reducing effects of violence risk assessment. The results of these studies, taken together with the other problems of risk assessment that Roaldset (2015) acknowledges, suggest that violence risk assessments cannot lead to better clinical practice.
To the Editor
warrants considerable attention and should be the focus of ongoing research (Jorm and Malhi, 2013). However, Professor Jorm uses the example of suicide prevention as the main support for the argument that we have reached a time where public health measures can be shown to impact in a positive way on mental health at a population level. From the information provided in the article, however, it does not appear that there is sufficient evidence for an impact of the National Suicide Prevention Strategy on suicide rates: certainly not sufficient evidence on
In his interesting article published recently in the Journal (Jorm, 2014), Professor Jorm proposed that we should be developing a national strategy for the prevention of mental disorders based upon the observation that increases in mental health services have not resulted in an improvement in the mental health of the Australian population. The observation that alterations in mental health service provision do not seem to have translated into improved clinical outcomes is certainly disturbing, if not puzzling, and
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors declare that there is no conflict of interest.
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. Roaldset JO (2015) Risk assessment and clinical decision-making. Australian and New Zealand Journal of Psychiatry 49: 91. 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.
Australian & New Zealand Journal of Psychiatry, 49(1)
92 which to base major changes in mental health policy and funding allocation. The problem with Professor Jorm’s conclusion is apparent from Figure 3 in his article. Although there has been a significant reduction in male suicide rates since the institution of the National Suicide Prevention Strategy, there have been at least two equivalent reductions in suicide rates: one in the 1960s and one from 1930 through to the mid-1940s. These have been of similar to greater magnitude. Clearly, suicide rates at a population level can be affected by a range of sociocultural factors as well as potentially by clinical factors such as the widespread use of antidepressant medications that has occurred on a similar timeline to the fall in suicide rates seen over the last 15 to 20 years. In this context, the statement that there is a ‘striking’ coincidence between the reduction in suicide rates seen and the institution of the
ANZJP Correspondence National Suicide Prevention Strategy seems rather questionable and certainly not an observation on which it would seem prudent to base substantial changes in mental health policy. This by no means suggests that we should not consider the role of mental health prevention approaches (Whiteford et al., 2013). However, we need to look harder to establish evidence that they are effective to ensure any substantial redistribution in mental health funding is done in a manner that follows, rather than precedes, the gathering of evidence. Funding Jayashri Kulkarni has received grant support for research from: The Stanley Medical Research Institute (Washington, USA), The National Health and Medical Research Council of Australia, AstraZeneca, Mayne Pharma, Servier, Eli Lilly, Janssen-Cilag, Neurosciences Australia, and the Department of Human Services (Victoria, Australia). She has
Australian & New Zealand Journal of Psychiatry, 49(1)
received honoraria as a speaker for Janssen-Cilag, Lundbeck, AstraZeneca and Bristol-Myers Squibb, and is an advisory board member for Janssen-Cilag, Lundbeck, Roche and Pfizer.
Declaration of interest PF is supported by a NHMRC Practitioner Fellowship (606907). PF has received equipment for research from MagVenture A/S, Medtronic Ltd, Cervel Neurotech and Brainsway Ltd, and funding for research from Cervel Neurotech.
References Jorm AF (2014) Why hasn’t the mental health of Australians improved? The need for a national prevention strategy. Australian and New Zealand Journal of Psychiatry 48: 795–801. Jorm AF and Malhi GS (2013) Evidence-based mental health services reform in Australia: Where to next? Australian and New Zealand Journal of Psychiatry 47: 693–695. Whiteford H, Harris M and Diminic S (2013) Mental health service system improvement: Translating evidence into policy. Australian and New Zealand Journal of Psychiatry 47: 703–706.
ANZJP Correspondence
Violence risk assessment has not been shown to reduce violence Matthew M Large1 and Christopher J Ryan2 1Department
of Mental Health Services, Prince of Wales Hospital, and the School of Psychiatry, University of New South Wales, Sydney, Australia 2Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia Corresponding author: Matthew M Large, Department of Mental Health Services, Prince of Wales Hospital, and with the School of Psychiatry, University of New South Wales, Sydney, NSW 1360, Australia. Email: [email protected] DOI: 10.1177/0004867414539570
To the Editor Among the thousands of papers about violence risk assessment only two studies have found any evidence for any reduction in violence as a result of redirecting treatment resources from low-risk to high-risk patients. These two studies, cited in a recent commentary (Roaldset, 2015), comprise the totality of the evidence base for the use of violence risk assessment in mental health. Abderhalden and colleagues (2008) asked nurses on four randomly allocated wards to conduct twice-daily
Suicide rates and mental health disorder prevention Paul Fitzgerald1,2 and Jayashri Kulkarni1,2 1Monash
Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School, Melbourne, Australia 2The Alfred, Melbourne, Australia Corresponding author: Paul Fitzgerald, Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School, Level 4, 607 St Kilda Road, Melbourne, VIC 3004, Australia. Email: [email protected] DOI: 10.1177/0004867414557682
violence risk assessments during days 1–3 of each admission. They found that with this intervention the number of severe aggressive events on these wards dropped by 41%. This was compared to five control wards where the drop was only 15%. Unfortunately, the randomisation process had resulted in the four experimental wards being those with much higher rates of pre-study violence. They were also four wards where each ward manager perceived aggression prior to the study as being a ‘big or very big problem’, while only two of the five control wards’ managers rated aggression to be this problematic. By the end of the study, the fall in the rates of aggression in the intervention wards only resulted in those wards achieving the rate already evident in the control wards. Given these features of the study it is very hard to confidently attribute the apparent improvement in the rates of aggression to the experimental intervention, rather than a Hawthorne effect or simply regression to mean. In the van de Sande study (2011), the two experimental wards rated every patient every day with two risk assessment scales and then used another two risk assessment scales weekly. Staff on the experimental wards also received ‘ongoing clinical supervision … provided by a clinical nurse specialist supported by a risk assessment expert panel’. At the end of
the intervention period, the two experimental wards did see a reduction in violent episodes compared to the two treatment-as-usual wards, though after correction for the number of patient days a fall in the number of violent patients did not reach statistical significance. These two studies represent the sum-total of the evidence for the harm-reducing effects of violence risk assessment. The results of these studies, taken together with the other problems of risk assessment that Roaldset (2015) acknowledges, suggest that violence risk assessments cannot lead to better clinical practice.
To the Editor
warrants considerable attention and should be the focus of ongoing research (Jorm and Malhi, 2013). However, Professor Jorm uses the example of suicide prevention as the main support for the argument that we have reached a time where public health measures can be shown to impact in a positive way on mental health at a population level. From the information provided in the article, however, it does not appear that there is sufficient evidence for an impact of the National Suicide Prevention Strategy on suicide rates: certainly not sufficient evidence on
In his interesting article published recently in the Journal (Jorm, 2014), Professor Jorm proposed that we should be developing a national strategy for the prevention of mental disorders based upon the observation that increases in mental health services have not resulted in an improvement in the mental health of the Australian population. The observation that alterations in mental health service provision do not seem to have translated into improved clinical outcomes is certainly disturbing, if not puzzling, and
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The authors declare that there is no conflict of interest.
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. Roaldset JO (2015) Risk assessment and clinical decision-making. Australian and New Zealand Journal of Psychiatry 49: 91. 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.
Australian & New Zealand Journal of Psychiatry, 49(1)
92 which to base major changes in mental health policy and funding allocation. The problem with Professor Jorm’s conclusion is apparent from Figure 3 in his article. Although there has been a significant reduction in male suicide rates since the institution of the National Suicide Prevention Strategy, there have been at least two equivalent reductions in suicide rates: one in the 1960s and one from 1930 through to the mid-1940s. These have been of similar to greater magnitude. Clearly, suicide rates at a population level can be affected by a range of sociocultural factors as well as potentially by clinical factors such as the widespread use of antidepressant medications that has occurred on a similar timeline to the fall in suicide rates seen over the last 15 to 20 years. In this context, the statement that there is a ‘striking’ coincidence between the reduction in suicide rates seen and the institution of the
ANZJP Correspondence National Suicide Prevention Strategy seems rather questionable and certainly not an observation on which it would seem prudent to base substantial changes in mental health policy. This by no means suggests that we should not consider the role of mental health prevention approaches (Whiteford et al., 2013). However, we need to look harder to establish evidence that they are effective to ensure any substantial redistribution in mental health funding is done in a manner that follows, rather than precedes, the gathering of evidence. Funding Jayashri Kulkarni has received grant support for research from: The Stanley Medical Research Institute (Washington, USA), The National Health and Medical Research Council of Australia, AstraZeneca, Mayne Pharma, Servier, Eli Lilly, Janssen-Cilag, Neurosciences Australia, and the Department of Human Services (Victoria, Australia). She has
Australian & New Zealand Journal of Psychiatry, 49(1)
received honoraria as a speaker for Janssen-Cilag, Lundbeck, AstraZeneca and Bristol-Myers Squibb, and is an advisory board member for Janssen-Cilag, Lundbeck, Roche and Pfizer.
Declaration of interest PF is supported by a NHMRC Practitioner Fellowship (606907). PF has received equipment for research from MagVenture A/S, Medtronic Ltd, Cervel Neurotech and Brainsway Ltd, and funding for research from Cervel Neurotech.
References Jorm AF (2014) Why hasn’t the mental health of Australians improved? The need for a national prevention strategy. Australian and New Zealand Journal of Psychiatry 48: 795–801. Jorm AF and Malhi GS (2013) Evidence-based mental health services reform in Australia: Where to next? Australian and New Zealand Journal of Psychiatry 47: 693–695. Whiteford H, Harris M and Diminic S (2013) Mental health service system improvement: Translating evidence into policy. Australian and New Zealand Journal of Psychiatry 47: 703–706.
