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A Novel Approach to Determining Violence Risk in Schizophrenia: Developing a Stepped Strategy in 13,806 Discharged Patients

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  • Jay P Singh
  • Martin Grann
  • Paul Lichtenstein
  • Niklas Långström
  • Seena Fazel

Abstract

Clinical guidelines recommend that violence risk be assessed in schizophrenia. Current approaches are resource-intensive as they employ detailed clinical assessments of dangerousness for most patients. An alternative approach would be to first screen out patients at very low risk of future violence prior to more costly and time-consuming assessments. In order to implement such a stepped strategy, we developed a simple tool to screen out individuals with schizophrenia at very low risk of violent offending. We merged high quality Swedish national registers containing information on psychiatric diagnoses, socio-demographic factors, and violent crime. A cohort of 13,806 individuals with hospital discharge diagnoses of schizophrenia was identified and followed for up to 33 years for violent crime. Cox regression was used to determine risk factors for violent crime and construct the screening tool, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Regression analyses resulted in a tool composed of five items: male sex, previous criminal conviction, young age at assessment, comorbid alcohol abuse, and comorbid drug abuse. At 5 years after discharge, the instrument had a negative predictive value of 0.99 (95% CI = 0.98–0.99), meaning that very few individuals who the tool screened out (n = 2,359 out of original sample of 6,903) were subsequently convicted of a violent offence. Screening out patients who are at very low risk of violence prior to more detailed clinical assessment may assist the risk assessment process in schizophrenia.

Suggested Citation

  • Jay P Singh & Martin Grann & Paul Lichtenstein & Niklas Långström & Seena Fazel, 2012. "A Novel Approach to Determining Violence Risk in Schizophrenia: Developing a Stepped Strategy in 13,806 Discharged Patients," PLOS ONE, Public Library of Science, vol. 7(2), pages 1-9, February.
  • Handle: RePEc:plo:pone00:0031727
    DOI: 10.1371/journal.pone.0031727
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    References listed on IDEAS

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    1. Sukanta Saha & David Chant & Joy Welham & John McGrath, 2005. "A Systematic Review of the Prevalence of Schizophrenia," PLOS Medicine, Public Library of Science, vol. 2(5), pages 1-1, May.
    2. G. V. Kass, 1980. "An Exploratory Technique for Investigating Large Quantities of Categorical Data," Journal of the Royal Statistical Society Series C, Royal Statistical Society, vol. 29(2), pages 119-127, June.
    3. Pilowsky, D.J. & Keyes, K.M. & Hasin, D.S., 2009. "Adverse childhood events and lifetime alcohol dependence," American Journal of Public Health, American Public Health Association, vol. 99(2), pages 258-263.
    4. Seena Fazel & Gautam Gulati & Louise Linsell & John R Geddes & Martin Grann, 2009. "Schizophrenia and Violence: Systematic Review and Meta-Analysis," PLOS Medicine, Public Library of Science, vol. 6(8), pages 1-15, August.
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