Predictive validity of the HCR-20 for inpatient self-harm.

BACKGROUND: Few instruments have been developed to assess the risk of self-harm by psychiatric patients and the evidence for their predictive validity is limited. Given that individuals who self-harm may also engage in other-directed aggression, and that the behaviour can be a precursor to violence, we tested whether, and for which groups, the commonly used violence risk assessment HCR-20 demonstrated predictive validity for self-harm. PROCEDURES: A pseudo-prospective cohort study (N=504) was conducted in a UK secure/forensic mental health setting using routinely collected data. HCR-20 assessments were completed by the clinical team and incidents of self-harm during the 3months following assessment were coded from patient records. FINDINGS: The HCR-20 total score, H10 and R5 subscales, and SJ for violence significantly predicted self-harm; however, AUC values did not demonstrate large effect sizes (range .345 to .749). Personality disorder and impulsivity were the strongest predictors of self-harm, but the R5 scale contained the greatest proportion of relevant items. Predictive efficacy was superior for women compared with men and for those with schizophrenia or personality disorder compared with organic and developmental disorders. CONCLUSIONS: The HCR-20 appears to be a significant predictor of self-harm. It may be possible to supplement HCR-20 ratings with case specific knowledge and additional known risk factors for self-harm to make a valuable summary judgement about the behaviour and thus minimise the need for multiple assessment tools.

Differential predictive validity of the Historical, Clinical and Risk Management Scales (HCR-20) for inpatient aggression.

The Historical, Clinical and Risk Management Scales (HCR-20) may be a better predictor of inpatient aggression for selected demographic and clinical groups but homogeneity of study samples has prevented definitive conclusions. The aim of this study, therefore, was to test the predictive validity of the HCR-20 as a function of gender, diagnosis, age, and ethnicity while controlling for potential covariates. A pseudo-prospective cohort study (n=505) was conducted in a UK secure/forensic mental health setting using routinely collected data. The HCR-20 predicted aggression better for women than men, and for people with schizophrenia and/or personality disorder than for other diagnostic groups. In women, the presence of the risk management items (R5) was important while men׳s aggression was best predicted solely by current clinical features from the C5 scale. R5 items were better than C5 items for predicting aggression in people with organic and developmental diagnoses. Our data provide additional information on which HCR-20 raters can formulate overall summary judgements about risk for inpatient aggression based on important demographic and clinical characteristics.

Off-licence prescribing and regulation in psychiatry: current challenges require a new model of governance.

The growing worldwide use of pharmaceuticals is managed in some countries by a regulatory system which sharply divides legal use into licensed and unlicensed categories. We examine how for the range of psychotropics this simultaneously restricts the possible benefits to patients, prescribers and producers in some domains, while failing to manage the risks in others. A more flexible system, which shares at an earlier stage experience and evidence on benefits and risks in patients, previously marginalized on the grounds of age, diagnosis or comorbidity, would aid the development of safer, more effective 'real-world prescribing'. Practical recommendations are made for a new model of research and prescribing governance, to enable more effective repurposing of these treatments.

Governance, choice and the global market for mental health.

The provision of health services to vulnerable members of the population should be regarded as one of the prime duties of government. However, it will be apparent to any reader of International Psychiatry that access to effective mental healthcare varies widely across the world, an impression powerfully reinforced for those who have the chance to visit and work in countries facing different developmental challenges. On World Mental Health Day 2010, the Secretary-General of the United Nations called for this shortfall to be remedied (United Nations, 2010). With the globalisation of knowledge and culture affecting every facet of life across national boundaries, it is worth reviewing how such changes could influence the development of mental healthcare across the planet.

Patients' complaints at a large psychiatric hospital: can they lead to better patient services?

PURPOSE: Little is known about complaints made by psychiatric patients. The aim of this study is to analyse complaints made by, or behalf of, inpatients at a large independent psychiatric hospital. DESIGN/METHODOLOGY/APPROACH: The hospital's complaints register was used to identify and study complaints made during 2006. A descriptive analysis was performed. FINDINGS: Of the 392 complaints, 39 per cent related to staff behaviour, 26 per cent to clinical matters, 18 per cent to the behaviour of other patients and the remaining 16 per cent to the physical environment and facilities. Action as a result of complaints was mainly taken at unit level but in 9 per cent of cases organisation-wide improvements were made, for example to enrich patient treatment programmes, rectify staff shortages and improve the quality of meals. RESEARCH LIMITATIONS/IMPLICATIONS: The study took place in a specialist hospital and so the findings cannot be generalised to the wider NHS. Important differences exist between complaints made in psychiatric as opposed to general hospital settings. PRACTICAL IMPLICATIONS: Complaints are a valuable source of organisational learning for mental health services. ORIGINALITY/VALUE: Given the paucity of literature on complaints in psychiatry, this study describes some in detail the nature of patients' complaints and one organisation's actions to improve patient services as a result of these complaints.

Characteristics of low IQ arsonists at psychiatric assessment.

We conducted a retrospective study of arsonists referred for psychiatric assessment and found that 88/202 (43.6%) had an IQ of 85 or below. The low IQ group showed more evidence of childhood temperamental disturbance, and a later pattern of internal problems rather than external factors expressing themselves as fire-setting. This study highlights the likelihood of lifelong, temperamental problems being apparent in childhood, and being predictive and possibly causative of fire setting in people with a low IQ. Better understanding of the distinct characteristics of lower IQ arsonists is essential for improved prevention, treatment and management.

Interpretation and knowledge of human rights in mental health practice.

The Human Rights Act is sometimes misunderstood as being an obstruction to the provision of safe and effective mental health care, allowing patients to cry 'human rights abuse' too easily. In reality, however, little is known about how human rights are protected and promoted in psychiatric care. This article provides an overview, for nurses, of how human rights are currently understood to be protected in mental health care and steps that could improve the protection of rights. Additionally, an overview of the relevant case law is presented to enable nurses to understand how human rights law is ever-evolving, how cases may be interpreted, and the implications that this has for mental health nursing practice.

Gender differences amongst adult arsonists at psychiatric assessment.

Reports of gender differences amongst arsonists at psychiatric assessment are not uncommon, however some are based on relatively small samples. A new retrospective study highlighting gender differences could help to confirm or refute the current state of knowledge. The aim of the current study was to examine gender differences amongst a sample of 167 adult arsonists (129 males and 38 females). Information was collected from clinical records on sociodemographic, family background and childhood factors; adult adjustment; fire setting history; motives; features of pyromania and other offending, from the case notes of a group of arsonists referred to the West Midlands Psychiatry Service over a 24-year period. Female arsonists were older than males and more likely to have a psychiatric diagnosis. Women more frequently had a history of sexual abuse, while men had a more varied criminal background and more substance abuse problems. Our findings largely support previous research, and are discussed in this context, whilst also bringing attention to a more recently developed theory (Action System Model). Significant gender differences amongst arsonists indicates that different emphases in the treatment of male and female arsonists may be advisable, though a reliable evidence base for treatment has yet to be established.