Application of Risk Assessment for Violence Methods to General Adult Psychiatry: A Selective Literature Review

Abstract

Objective: General adult psychiatrists are required to assess risk of violence as frequently as forensic psychiatrists. Yet most of the literature on risk assessment has originated from forensic settings, has been written by forensic psychiatrists, is applicable to forensic patients but may not apply to general psychiatric settings. Because the patient population and the nature of risk assessed may differ between the two settings, there is a need to consider the relevance of systems of assessment of risk of violence specific to the context of general adult psychiatry. Methods: We searched the literature on the way risk has been conceptualized in different disciplines using Medline database from 1993 to 2003. Keywords used were violence and risk management and risk assessment. Additional papers were identified from cross-references and personal knowledge of authors. Results: Seven hundred and nine key papers were identified. We identified three common key concepts that define risk: Uncertainty, weighing up the likelihood of different outcomes arising and, the possibility of benefits as well as harm due to risk assessment. The impact of safety culture – the collection of beliefs, norms, attitudes, roles and practices while making daily activities and management decisions – on psychiatric thinking is examined. We review the two main methods of risk assessment from forensic psychiatric literature (actuarial and clinical) with a view to examine their utility in general adult psychiatric context. Conclusions: In order to develop a system of risk assessment relevant to general adult psychiatry, we note the benefits of shifting from risk prediction to assessment, management and reduction of risk, the need to merge actuarial and clinical approaches, communication of risk and finally the need to involve patients in the process of risk assessment.