Real-time Tool Assesses Violence Risk in Psych Patients

Pauline Anderson

May 19, 2016

ATLANTA ― Canadian researchers have incorporated real-time analytics to better determine the risk for violence in psychiatric patients.

The tool was developed for risk management in the forensic psychiatric setting but has been adapted for use in general psychiatry and in the community, said one of its developers, Gary Chaimowitz, MB, ChB, head of the Forensic Psychiatry Program and professor, Department of Psychiatry and Behavioral Neurosciences, Faculty of Health Sciences, McMaster University, in Hamilton, Ontario, Canada.

The tool assists in predicting, assessing, and managing risk for violence. "We think it's the best tool for this," Dr Chaimowitz told Medscape Medical News. "This is the first time in psychiatry, as far as I know, that we have been able to use analytics in our clinical activity."

Dr Chaimowitz discussed the new tool at a poster session here at the American Psychiatric Association (APA) 2016 Annual Meeting.

Major Clinical Issue

Psychiatrists are "very concerned" about aggression among psychiatric patients, said Dr Chaimowitz. "One of the problems is that unless you're actually measuring something, how on earth can you manage it?"

About 10 years ago, he and colleague Mini Mamak, EdD, developed a risk assessment tool that is "very sensitive" in picking up and monitoring levels of aggression among both inpatients and outpatients, said Dr Chaimowitz.

The tool, known as the Aggressive Incidence Scale, uses a 9-level scale to indicate progressively more aggressive behavior. Level 1 is being rude or argumentative, whereas level 9 could signal life-threatening situations, such as serious and violent assault, and should elicit medical attention.

"A lot gets said about violence, but nobody was actually rating it. We think this is the best rating tool out there," he said.

Although Dr Chaimowitz initially believed that the tool would be applicable only in the inpatient setting, "where you have 24/7 eyes on a patient," it is proving to be useful in various community settings as well. For example, a homeless women's shelter in Ottawa, Canada, is using it to evaluate risk.

"It provides you with a language, so if you were a community worker, you would be able to go to the clinicians who come to visit and say, 'Today we have six 6's and three 1's.' "

But the McMaster researchers went further and developed a structured professional judgment tool that represents the current state of the art in terms of risk assessment. It incorporates historical risk factors, including personality disorder, substance abuse, cognitive deficits, and others, and current evidence-based risk factors, including mood symptoms, psychiatric symptoms, stress management, and anger management.

Through use of all these information points, the psychiatrist can come up with a streamlined management plan.

The McMaster team has developed a forensic version of this tool as well as a version for general psychiatry and a version geared for use among youth and in the community.

The tool was developed for use by teams of experts, for example, social workers and occupational therapists, as well as psychiatrists. During a team meeting, the information is projected onto a screen so that members can easily discuss cases.

"Research shows that team-based risk assessment is better than individual assessment," commented Dr Chaimowitz.

Real-time Analytics

Now they have real-time analytics. Dr Chaimowitz and Dr Mamak worked with an analytics company to turn what they had been doing with word processing programs into database spreadsheets.

"What that means is that with a bit of coding, you can actually click on a mouse and see how a particular patient has done in the last month or the last year, and you can watch any change in any of the risk factors, any of the management factors."

The information can be displayed graphically, and it can be used by, for example, review boards or tribunals for the assessment of patients, he said.

"We think this is a breakthrough, because in forensic psychiatry ― and we believe also in all of psychiatry ― it's the first time that analytics has been used in real time as psychiatrists conduct their clinical activities," said Dr Chaimowitz.

He added that an "aggregator" that pulls together multiple reports allows for analysis of between-group risk factors. For example, researchers could determine how many people in a particular facility have both a mood disorder and schizophrenia, or how many patients with schizophrenia have a substance abuse problem. Or they could conduct intercenter analyses.

"You click on a mouse, and the information is all there," said Dr Chaimowitz. "This can turn research on its head. Instead of having to go back to your clinical data and extract the factors, you have the factors already entered into a database.

"We have gotten rid of that whole 'let's go back and look at the data, pull the variables out, and then conduct the research' approach. This is real-time, accessible data in psychiatry."

Such quick and simple assessment of risk factors should help facilitate planning of interventions, noted Dr Chaimowitz.

The tool is "open source," so anyone can learn to use it at no cost. Dr Chaimowitz and colleagues have already trained groups of forensic psychiatrists at various centers across Canada.

Impressive Tool

Medscape Medical News asked Katelyn Mullally, research assistant in the Forensic Psychiatry Program at St Joseph's Healthcare, Hamilton, who said she has "intimate knowledge of the tool," to comment on it.

"I can tell you that this tool is extremely intuitive and informative and will influence clinical practice by providing physicians with real-time analytics that will allow them a better understanding of their patients as individuals and their various units or entire program as a whole."

She praised the tool for facilitating a number of tasks.

"Using automatically generated patient- and group-level analytics, clinicians will be able to decipher exactly when a patient's behavior has deteriorated, allowing them to pinpoint ― with data to back it up ― the stressors that coincided with it, understand the exact breakdown of diagnoses on a given unit or within a larger program, examine which medications are being prescribed to which patients, and more."

All of this is done "with a click of a button" as the clinical team enters its regular reports. "It really is an impressive tool," she said.

Funding for this project was provided in part by an educational grant from Janssen Canada Inc.

American Psychiatric Association (APA) 2016 Annual Meeting: New Research, poster 11, presented May 15, 2016.

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