Am J Psychiatry 1995; 152:901-906
Copyright © 1995 by American Psychiatric Association
Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence
DE McNiel and RL Binder
Department of Psychiatry, School of Medicine, University of California, San Francisco, USA.
OBJECTIVE: The authors evaluated characteristics of patients whom
clinicians accurately assessed as being at high or low risk for violence
and patients for whom clinicians overestimated or underestimated the risk.
METHOD: At admission, physicians estimated the probability that each of 226
psychiatric inpatients would physically attack someone during the first
week of hospitalization. Nurses rated assaultive behavior in the hospital
with the Overt Aggression Scale. Acute symptoms were rated with the Brief
Psychiatric Rating Scale. RESULTS: For the group as a whole, assessed
levels of risk were substantially related to later physical aggression
(sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed
that patients with psychotic disorders such as schizophrenia, organic
psychotic conditions, and mania were more likely to be accurately assessed
by clinicians as being at high risk (true positives) than to be true
negatives or false positives. A recent history of violence was associated
with higher estimated risk but did not distinguish true positives from
false positives. An admission mental status characterized by low levels of
hostility, uncooperativeness, and suspiciousness and high levels of
depression, guilt, and anxiety differentiated true negative patients from
others, but symptom profiles did not differ among true positives, false
positives, and false negatives. Clinical judgments emphasizing gender and
race/ethnicity were associated with predictive errors: nonwhite and male
patients tended to be false positives. CONCLUSIONS: While clinicians can
accurately classify the potential for violence in the majority of patients
at admission, systematic errors characterize inaccurate assessments of the
risk. Awareness of these patterns may help improve assessment of the risk
of violence in clinical practice.
