Interrater reliability of the violence risk assessment checklist for youth: a case vignette study.

BACKGROUND: Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions. METHODS: A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS: Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent. CONCLUSIONS: This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Comparison of V-RISK-Y and V-RISK-10 for risk of violence: A one-year study from a psychiatric emergency department for adolescents.

There has been a lack of short and simple screening instruments to assess the risk of violence in youth. Many acute youth departments have used the V-RISK-10, a risk screener for adults. V-RISK-Y is a risk screener based on the V-RISK-10 and adapted to youths. Our aim was to compare the predictive validity between V-RISK-Y and VRISK-10 in an emergency psychiatric adolescent ward. Target population were all 92 patients admitted within one year, and study population consisted of 49 (53 %) patients who had completed data. V-RISK-10 and V-RISK-Y were scored at admission and compared with recorded episodes of violence during the hospitalization. V-RISK-Y showed higher AUC values for recorded violence and some of the individual items also showed better results. Most differences were not significant, but results may still be of clinical interest.

Validation of a violence risk screening for youth in psychiatric inpatient care-a pilot study of V-RISK-Y.

The reason for this study was the void of validated risk assessment screening tools for violence in adolescence psychiatry. Our aims were to test the predictive validity and feasibility of a pilot version of the Violence Risk Screening for Youth (V-RISK-Y). The V-RISK-Y was based on a violence risk screen for adults, the V-RISK-10, and adapted to adolescents, resulting in 12 risk items that are scored for (a) presence and (b) relevance for future violence. In this naturalistic, prospective observational study, the V-RISK-Y was scored at admission and compared with recorded episodes of violent acts and threats during hospital stay. The target population was all 92 patients admitted to the emergency department of adolescent psychiatry at Oslo University Hospital for 1 year, of which 67 patients were scored with the V-RISK-Y at admission and constituted the study sample. The predictive validity of the V-RISK-Y for violent behavior showed an AUC of 0.762 (p = 0.006). Staff approved the screener and found it to be equally or better usable than the V-RISK-10, which was previously used in the department. Still, a high proportion of raters failed to follow the scoring instructions of relevance scores, reducing feasibility. The results must be interpreted within the limits of a pilot study and low power. We conclude that results suggest changes of certain parts of the V-RISK-Y and provide a basis for testing a revised edition of the screener in a more comprehensive study, preferably with a multicenter design.

The Safe pilot study: A prospective naturalistic study with repeated measures design to test the psychosis - violence link in and after discharge from forensic facilities.

The research evidence is very strong for high recidivism rates of violence after discharge from forensic facilities. Big data research has found that a substantial proportion of the forensic population with relapse into violence has a psychosis diagnosis and a criminal record. However, more research on the association between psychotic symptoms and violence may inform and enhance risk assessment, prevention, and treatment. We conducted a prospective naturalistic study with a repeated measures design in a sample of 22 psychotic patients during follow-up after discharge from forensic mental health facilities. We had three aims: to test the predictive validity of three psychotic symptom scales for violence, to analyze main and interaction effects between psychotic symptoms and previous criminal conviction, and to explore the feasibility and potential benefit of the repeated measures design for prospective follow-up research. Interpreted within the limitation of the small sample size, the results were promising for all scales, particularly for adjusted effects without interaction. Two scales remained significant when their interaction with criminal conviction was adjusted. This indicates that risk judgment of psychotic patients with criminal conviction can be improved by adding measurement of fluctuations in psychotic symptoms. The repeated measures design was instrumental in this research.

Mid-Pregnancy Insomnia and its Association with Perinatal Depressive Symptoms: A Prospective Cohort Study.

Objective/Background: Insomnia and depression are disorders that affect many perinatal women and that often are interrelated. The present study aimed to examine concurrent and prospective associations between mid-pregnancy insomnia and depression during mid-pregnancy and 8 weeks postpartum. Furthermore, differences in depression and in the sleep-related characteristics insomnia, chronotype, and sleep efficiency were explored between the two time points (mid-pregnancy versus 8 weeks postpartum), and between primiparous and multiparous participants.Participants/Methods: The study was part of the Norwegian population-based Depression and Anxiety in the Perinatal Period (DAPP) prospective cohort study. Among 539 women that were recruited for participation when receiving a routine ultrasound examination, we analyzed data from hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8. We used the Edinburgh Postnatal Depression Scale to measure depression. The Bergen Insomnia Scale, the reduced Horne-Östberg Morningness-Eveningness Questionnaire, and three questions from the Pittsburgh Sleep Quality Index were used to measure the sleep-related characteristics.Results: Mid-pregnancy insomnia was significantly associated with concurrent depression (p < .001), but not with postpartum depression (p = .288), in a linear mixed model with adjustment for several reproductive and psychosocial variables. Sleep efficiency was reduced from mid-pregnancy to postpartum (from 88% to 77%), and primiparous women reported less efficient sleep than multiparous women after childbirth.Conclusions: The results indicate that mid-pregnancy insomnia may be a marker for concurrent depression but not a predictor of postpartum depression. Future research should examine the extent to which treatment of insomnia from mid-pregnancy on reduces both perinatal insomnia and depression.

Characteristics associated with later self-harm hospitalization and/or suicide: A follow-up study of the HUNT-2 cohort, Norway.

BACKGROUND: To improve suicide and self-harm prevention in adults, better knowledge on preexisting characteristics and risk factors is of great importance. METHODS: This is a population-based case-control study; baseline measures were collected in the second wave of the North-Trøndelag Health Study (HUNT-2, 1995-1997) in Norway, and outcomes were observed for up to 19 years. Average follow up time was 4.9 years for self-harm and 6.8 years for suicides. Out of 93,898 eligible adult inhabitants aged 20 and above, a total of 65,229 (70%) participated in the study. The data were linked to the National Mortality Registry and hospital patient records in the three hospitals covering the HUNT-2 catchment area. RESULTS: Among the participants, 332 patients (68% women) were hospitalized because of self-harm (HSH), and 91 patients (32% women) were died by suicide (SU). A total of 10% of those who died by SU had previously been HSH. People in the HSH and SU groups were younger, reported more depression and anxiety symptoms, sleeping problems, higher use of alcohol and tobacco, poorer social network and more economic problems, compared to the rest of the HUNT-2 population. In addition, the HSH group reported more somatic health problems, higher use of health services, higher sick leave, and lower work participation than the SU group. LIMITATIONS: Younger adults (20-40 years) were under-represented in HUNT-2. Younger adults (20-40 years) were constituted 31.7% in HUNT-2, 50% in HSH and 33% in SU. Further, we did not identify less severe self-harm, not requiring hospitalization. Life changes, adverse events, and other possible triggers to self-harming behavior were not recorded. CONCLUSION: Psychological problems were long-term predictors of both HSH and SU. Somatic health problems and lower functional performance were more present in HSH-group compared to the SU-group.

Mid-pregnancy insomnia is associated with concurrent and postpartum maternal anxiety and obsessive-compulsive symptoms: A prospective cohort study.

BACKGROUND: Although many perinatal women are affected by anxiety, few studies have focused on perinatal anxiety and its potential triggers. The primary aim of this study was to examine concurrent and prospective associations between mid-pregnancy insomnia and perinatal anxiety. Furthermore, we compared psychosocial and reproductive characteristics between participants with and without mid-pregnancy insomnia and explored changes in the prevalence of obsessive-compulsive disorder (OCD) symptoms from mid-pregnancy to 8 weeks postpartum. METHODS: This study was part of the Norwegian Depression and Anxiety in the Perinatal Period (DAPP) prospective, population-based, cohort study. We analyzed hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8 (n = 530). The Bergen Insomnia Scale was used to measure insomnia and the Hopkins Symptom Checklist to measure anxiety. OCD symptoms were measured based on questions from the Mini-International Neuropsychiatric Interview. RESULTS: Mid-pregnancy insomnia was significantly associated with both concurrent and postpartum anxiety in a linear mixed model adjusted for several potential confounders. Participants with mid-pregnancy insomnia had significantly higher levels of perinatal anxiety and postpartum OCD symptoms than participants with normal mid-pregnancy sleep. OCD symptoms affected more women after delivery than before (6.4% vs. 3.8% p = 0.034). LIMITATIONS: Immigrants were underrepresented in our sample. CONCLUSION: Our results suggest that mid-pregnancy insomnia is a marker for concurrent anxiety and predictor of postpartum anxiety. Future research should examine whether insomnia treatment starting in mid-pregnancy reduces both perinatal insomnia and anxiety. Health providers should also be aware that postpartum women have an increased risk of developing OCD symptoms.

Insomnia late in pregnancy is associated with perinatal anxiety: A longitudinal cohort study.

BACKGROUND: Postpartum anxiety (PPA) affects a substantial number of women. Despite increasing recognition of PPA, few studies have focused on perinatal anxiety and potential PPA triggers. Here we aimed to estimate the prevalence of perinatal anxiety disorders, and to explore the association between insomnia during late pregnancy and anxiety before and after childbirth. METHODS: This study was part of the large population-based Akershus Birth Cohort. We analyzed data from the hospital's birth records and questionnaire responses from pregnancy weeks 17 and 32 and postpartum week 8 (n = 1563). Perinatal anxiety symptoms were measured using the Hopkins Symptom Check List. Anxiety disorder measurements were based on questions from the Mini-International Neuropsychiatric Interview. Insomnia was measured using the Bergen Insomnia Scale. RESULTS: Among perinatal women, 10% reported symptoms of at least one anxiety disorder. The observed prevalence of obsessive-compulsive disorder was higher after delivery (4.2%) than during pregnancy (2.5%). Multiple regression analysis, with adjustment for several psychosocial and reproductive variables, indicated that insomnia during pregnancy was significantly associated with postpartum anxiety symptoms. However, this association was markedly weakened when depression variables were included in the analysis, indicating that gestational insomnia may also be a marker for a mood disorder. LIMITATIONS: Immigrant and single women were underrepresented in our sample. CONCLUSIONS: Our results suggest that anxiety disorders are prevalent during the perinatal period. Moreover, insomnia during pregnancy is associated with perinatal anxiety. Health professionals should be aware that women with gestational insomnia may have an increased risk of mood and anxiety disorders.

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry.

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit.

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

Low cholesterol level as a risk marker of inpatient and post-discharge violence in acute psychiatry - A prospective study with a focus on gender differences.

Several studies indicate an association between low levels of serum cholesterol and aggressive behaviour, but prospective studies are scarce. In this naturalistic prospective inpatient and post-discharge study from an acute psychiatric ward, we investigated total cholesterol (TC) and high-density lipoprotein (HDL) as risk markers of violence. From March 21, 2012, to March 20, 2013, 158 men and 204 women were included. TC and HDL were measured at admission. Violence was recorded during hospital stay and for the first 3 months post-discharge. Univariate and multivariate binary logistic regression were used to estimate associations between low TC and low HDL and violence. Results showed that HDL level was significantly inversely associated with violence during hospital stay for all patients. For men, but not for women, HDL level was significantly inversely associated with violence the first 3 months post-discharge. Results indicate that low HDL is a risk marker for inpatient and post-discharge violence in acute psychiatry and also suggest gender differences in HDL as a risk marker for violence.

Comparison of patients who were violent, victimized and violent-victimized during the first year after discharge from emergency psychiatry.

This prospective observational study included 345 (70%) of 489 patients discharged from an emergency psychiatric hospital during one year. Episodes of offending and victimization were recorded during first year after discharge. Forty-eight persons (14%) committed violent offenses only, 27 persons (8%) were violence victims only, and 42 persons (12%) were both offenders and victims. Significant differences in demographic and clinical variables were found between the three groups. The results pointed to two distinct groups of victims: one group with a robust offender-victim overlap and another group without offender-victim overlap. The latter group was difficult to distinguish from other discharged patients.

Can lipid analysis help identify repeatedly violent patients after discharge from acute psychiatry?

In this study of 196 patients discharged from an acute psychiatric ward, 11 patients (6%) were identified as exhibiting repeated violence and having frequent readmissions. Compared with non-violent patients and those with only one violent post-discharge episode, repeatedly violent patients were significantly characterised by male gender, higher rates of previous threats of violence, lack of empathy, more severe violence during follow-up, and lower high-density lipoprotein levels.

A multifaceted model for risk assessment of violent behaviour in acutely admitted psychiatric patients.

Violence risk assessment instruments are mainly based on historical and clinical risk factors. Biological factors have been related to violent behaviour but hardly used in risk assessment. A recent study indicated that both low total cholesterol (TC) and the patients' own estimates about their risk of future violent behaviour, the Self-report Risk Scale (SRS), significantly predicted violent behaviour during hospital stay and the first 3 months after discharge from an acute psychiatric department. Our aim was to investigate whether combining three methods, a screening instrument for risk of violence (V-RISK-10), low TC and the SRS, into one multifaceted risk assessment model may enhance predictive validity. This prospective naturalistic study involved 134 of all (489) acutely admitted patients to a general psychiatric hospital during 1 year. Low TC, SRS and V-RISK-10 at admission were prospectively compared with recorded violence during hospital stay and the first 3 months after discharge. The multifaceted risk assessment model yielded a significant increase in explained variance beyond that of the V-RISK-10. AUC values were higher, but differences were not significant. The biopsychosocial approach to violence risk assessment seems promising, but further studies are needed to test the feasibility and predictive validity of multifaceted models.

Patients' own statements of their future risk for violent and self-harm behaviour: a prospective inpatient and post-discharge follow-up study in an acute psychiatric unit.

Recently patients' responsibility for and ownership of their own treatment have been emphasised. A literature search on patients'' structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The present prospective naturalistic study comprised all involuntary and voluntary acutely admitted patients (n=489) to a psychiatric hospital during one year. Patients' self-reported risks of violence and self-harm at admission and at discharge were compared with episodes recorded during hospital stay and 3 months post-discharge. Patients' predictions were significant concerning violent, suicidal and self-injurious behaviour, with AUC values of 0.73 (95%CI=0.61-0.85), 0.92 (95%CI=0.88-0.96) and 0.82 (95%CI=0.67-0.98) for hospital stay, and 0.67 (95%CI=0.58-0.76), 0.63 (95%CI=0.55-0.72) and 0.66 (95%CI=0.57-0.76) after 3 months, respectively. Moderate or higher risk predictions remained significant in multivariate analysis, and risk of violence even after gender stratification. Self-harm predictions were significant for women. Moderate or higher risk scores remained significant predictors of violence one year post-discharge. Controlling for readmissions the results remained the same. Low sensitivity limits the clinical value, but relatively high positive predictive values might be clinically important. Still future research is recommended to explore if self prediction is a valid adjuvant method to established risk assessment procedures.

Psychometric examination and normative data for the narcissistic personality inventory 29 item version.

The Narcissistic Personality Inventory (NPI) is commonly used in empirical studies of narcissism. Few population-based studies have been published. Our aim was to do a confirmatory factor analysis (CFA) of the NPI 29 item version with a four-factor structure, in two population-based samples and in a patient sample, and present normative population-based data. The NPI-29 was filled in by 324 respondents from the Norwegian population, 231 from the Swedish population and 167 Norwegian psychiatric patients. The four-factor structure of the NPI-29 with Leadership/Power, Exhibitionism/Self-admiration, Superiority/Arrogance and Uniqueness/Entitlement was reproduced in these samples. The CFA models showed good fit indices in all samples. Mean scores on the NPI-29 and four subscales hardly differed between the samples. For the NPI-29 total score and factors, few significant differences were observed. CFA of the samples supported the factor structure of the NPI-29 formerly identified by principal component analysis of the Swedish population sample.

Narcissism in patients admitted to psychiatric acute wards: its relation to violence, suicidality and other psychopathology.

BACKGROUND: The objective was to examine various aspects of narcissism in patients admitted to acute psychiatric wards and to compare their level of narcissism to that of an age- and gender-matched sample from the general population (NORM). METHODS: This cross-sectional study interviewed 186 eligible acute psychiatric patients with the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment of Functioning (GAF). The patients filled in the Narcissistic Personality Inventory-21 item version (NPI-21), The Hospital Anxiety and Depression Scale (HADS) and the Rosenberg Self-Esteem Scale. High and low narcissism was defined by the median of the total NPI-21 score. An age- and gender-matched control sample from the general population also scored the NPI-21 (NORM). RESULTS: Being male, involuntary admitted, having diagnosis of schizophrenia, higher self-esteem, and severe violence were significantly associated with high narcissism, and so were also low levels of suicidality, depression, anxiety and GAF scores. Severe violence and high self-esteem were significantly associated with high narcissism in multivariable analyses. The NPI-21 and its subscales showed test-retest correlations >/=0.83, while the BPRS and the HADS showed lower correlations, confirming the trait character of the NPI-21. Depression and suicidality were negatively associated with the NPI-21 total score and all its subscales, while positive association was observed with grandiosity. No significant differences were observed between patients and NORM on the NPI-21 total score or any of the NPI subscales. CONCLUSION: Narcissism in the psychiatric patients was significantly associated with violence, suicidality and other symptoms relevant for management and treatment planning. Due to its trait character, use of the NPI-21 in acute psychiatric patients can give important clinical information. The similar level of narcissism found in patients and NORM is in need of further examination.