Am J Psychiatry 1992; 149:207-212
Copyright © 1992 by American Psychiatric Association
The role of violence in decisions about hospitalization from the psychiatric emergency room
DE McNiel, RS Myers, HK Zeiner, HL Wolfe and C Hatcher
Department of Psychiatry, University of California, San Francisco.
OBJECTIVE: The authors evaluated the relationship between violent behavior
and decision making about hospitalization from the psychiatric emergency
room. METHOD: The medical charts of 321 patients evaluated in an urban
psychiatric emergency room during a 4-week period were reviewed
retrospectively. Violent behavior was defined as physical attacks on
persons or fear-inducing behavior before or during the evaluation in the
emergency room; and its value in predicting hospitalization decisions was
assessed with logistic regression analyses that also included 12
demographic, clinical, and contextual variables. RESULTS: A model
predicting hospitalization decisions was developed and cross-validated.
Although violent patients were more likely to be hospitalized than
nonviolent patients, clinical variables such as diagnosis and overall
severity of psychiatric impairment were more important than violent
behavior in predicting hospitalization decisions. CONCLUSIONS: Despite
legal pressures to focus on overt behaviors such as violence as a basis for
liability prevention and civil commitment, clinicians in this study did not
allocate inpatient resources to preventively detain persons unlikely to
benefit from treatment. Rather, they hospitalized the most severely
disturbed patients, with diagnoses such as schizophrenic and manic
disorders for which a widely accepted therapeutic armamentarium exists. The
results are consistent with clinical recommendations that in the evaluation
of the violent patient, attention needs to be given to the underlying
disorder, since violent behavior itself can result from diverse causes only
some of which require inpatient psychiatric treatment.
