Managing aggression and violence: the clinician's role in contemporary mental health care.

OBJECTIVE: From time to time misconceptions about violence risk assessment raise debate about the role mental health professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This paper will address some of the misconceptions about risk assessment in those with serious mental illness. METHODS: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowledge and discussion they have reviewed the literature to form their opinions. RESULTS: This paper reflects the authors' views. CONCLUSION: There is a modest yet statistical and clinically significant association between certain types of mental illness and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of case-specific factors to inform appropriate management interventions to reduce the identified risk.

Reducing impulsivity in repeat violent offenders: an open label trial of a selective serotonin reuptake inhibitor.

BACKGROUND: The association between serotonergic dysfunction and aggression has prompted the use of selective serotonin re-uptake inhibitors (SSRIs) as a means of controlling impulsive violent behaviour. The aim of the current study was to examine the feasibility of using an SSRI to treat impulsivity in a group of repeat violent offenders. METHODS: Potential participants were recruited from three magistrates' court complexes in the Sydney metropolitan area and all had histories of violent offending (at least one prior conviction for a violent offence). Those who scored highly on the Barratt Impulsivity Scale (BIS-11), passed medical and psychiatric evaluations and consented to treatment were prescribed sertraline (Zoloft) over a three month period. RESULTS: Thirty-four individuals commenced the trial, with 20 completing the three month intervention. Reductions were observed across a range of behavioural measures from baseline to 3 months: impulsivity (35%), irritability (45%), anger (63%), assault (51%), verbal-assault (40%), indirect-assault (63%), and depression (62%). All those who completed the three month trial requested to continue sertraline under the supervision of their own medical practitioner. CONCLUSION: Our findings suggest that treating impulsive violent individuals in the criminal justice system with an SSRI is a potential treatment opportunity for this population. An adequately powered randomized control trial of this intervention is warranted.