Predicting community violence from patients discharged from acute mental health units in England

  • Michael Doyle
  • Stuart Carter
  • Jenny Shaw
  • Mairead Dolan
Original Paper



To investigate the validity of risk factors and established risk measures in predicting community violence in an acute mental health sample up to 20 weeks post-discharge.


Prospective cohort follow-up study conducted between January 2006 and August 2007. Baseline assessments were conducted while participants were inpatients. The measures were rated following interview with the participants, record review and speaking to someone who knows the person well (e.g. friend, relative, carer). Baseline measures were then compared with frequency and severity of violence in the community post-discharge at 20 weeks.


In the 20-week period post-discharge, 29 (25.4%) of the 114 participants were violent. All the risk measures and measures of impulsiveness and anger were predictive of violence where p < 0.05. The HCR-20 total, psychopathy and clinical factors were strongly correlated with the frequency of violence where p < 0.05.


The risk factors and risk measures that have been found to be predictive in forensic samples are also predictive in acute mental health samples, although the effects are not as large. Future research needs to be conducted with a larger sample to include investigation of differences in risk factors based on gender and social support. Services and clinicians need to consider how to integrate findings into useful frameworks to support decisions and contribute to managing risk. This should assist in identifying interventions aimed at preventing community violence.


Violence Risk assessment Acute psychiatry Community 



We are very grateful to Professor John Monahan from the University of Virginia, USA , for all his support and advice with this work. This study was supported by a grant from the Department of Health National Forensic Research and Development programme.

Conflict of interest



  1. 1.
    Reed J (1997) Risk assessment and clinical risk management: the lessons from recent inquiries. Br J Psychiatry 170(supp. 32):4–7Google Scholar
  2. 2.
    Royal College of Psychiatrists (2008) Rethinking risk to others in mental health services. Final report of scoping group. CR150, June, RCP, LondonGoogle Scholar
  3. 3.
    Angermeyer MC, Cooper B, Link BG (1998) Mental disorder and violence: results of epidemiological studies in the era of de-institutionalization. Soc Psychiatry Psychiatr Epidemiol 33:S1–S6PubMedCrossRefGoogle Scholar
  4. 4.
    Doyle M, Dolan M (2006) Predicting community violence from patients discharged from mental health services. Br J Psychiatry 189:520–526PubMedCrossRefGoogle Scholar
  5. 5.
    Coid JW, Hickey N, Yang M (2007) Comparison of outcomes following after-care from forensic and general adult psychiatric services. Br J Psychiatry 190:509–514PubMedCrossRefGoogle Scholar
  6. 6.
    Hodgins S (2009) Editorial: the interface between general and forensic psychiatric services. Eur Psychiatry 24(6):354–355Google Scholar
  7. 7.
    Coid J, Hickey N, Kahtan N, Zhang T, Yang M (2007) Patients discharged from medium secure forensic psychiatry services: reconvictions and risk factors. Br J Psychiatry 190:223–229PubMedCrossRefGoogle Scholar
  8. 8.
    Coid J, Yang M, Ullrich S, Zhang T, Sizmur S, Roberts C, Farrington D, Rogers R (2009) Gender differences in structured risk assessments: comparing the accuracy of five instruments. J Consult Clin Psychol 77(2):337–348PubMedCrossRefGoogle Scholar
  9. 9.
    Gray N, Fitzgerald S, Taylor J, MacCulloch M, Snowden R (2007) Predicting future reconviction in offenders with intellectual disabilities: the predictive efficacy of VRAG, PCL-SV and the HCR-20. Psychol Assess 19(4):474–479PubMedCrossRefGoogle Scholar
  10. 10.
    Webster C, Harris G, Rice M, Cormier C, Quinsey V (1994) The violence prediction scheme: assessing dangerousness in high risk men. University of Toronto, Centre of Criminology, TorontoGoogle Scholar
  11. 11.
    Webster CD, Douglas K, Eaves D, Hart S (1997) HCR-20: assessing risk for violence—version 2. Simon Fraser University, British Columbia, CanadaGoogle Scholar
  12. 12.
    Hart S, Cox D, Hare R (1995) The hare PCL: SV: Psychopathy Checklist: Screening Version. Multi-Health Systems Incorporated, New YorkGoogle Scholar
  13. 13.
    Klassen D, O’Connor WA (1989) Assessing the risk of violence in released mental patients: a cross-validation study. J Consult Clin Psychol 1:75–81Google Scholar
  14. 14.
    Douglas KS, Ogloff JRP, Nicholls TL, Grant I (1999) Assessing risk for violence among psychiatric patients: the HCR-20 risk assessment scheme and the Psychopathy Checklist: Screening Version. J Consult Clin Psychol 67:917–930PubMedCrossRefGoogle Scholar
  15. 15.
    Nicholls TN, Ogloff JRP, Douglas KS (2004) Assessing risk for violence among male and female psychiatric patients: the HCR-20, PCL:SV and VSC. Behav Sci Law 22:127–158PubMedCrossRefGoogle Scholar
  16. 16.
    Monahan J, Steadman H (eds) (1994) Violence and mental disorder: developments in risk assessment. University of Chicago Press, ChicagoGoogle Scholar
  17. 17.
    Monahan J, Steadman HJ, Appelbaum PS, Robbins PC, Mulvey EP, Silver E, Roth LH, Grisso T (2000) Developing a clinically useful actuarial tool for assessing violence risk. Br J Psychiatry 176:312–319PubMedCrossRefGoogle Scholar
  18. 18.
    Mulvey EP, Shaw E, Lidz CW (1994) Why use multiple sources in research on patient violence in the community? Crim Behav Mental Health 4:253–258Google Scholar
  19. 19.
    Monahan J (1988) Risk assessment of violence among the mentally disordered: generating useful knowledge. Int J Law Psychiatry 11:249–257PubMedCrossRefGoogle Scholar
  20. 20.
    Monahan J (2006) A jurisprudence of risk assessment: forecasting harm among prisoners, predators and patients. Virg Law Rev 92(3):391–435Google Scholar
  21. 21.
    Wong S, Gordon A (2006) The validity and reliability of the violence risk scale: a treatment friendly violence risk assessment tool. Psychol Pub Policy Law 12:279–309CrossRefGoogle Scholar
  22. 22.
    Novaco RW (2003) The Novaco anger scale and provocation inventory (NAS-PI). Western Psychological Services, Los AngelesGoogle Scholar
  23. 23.
    Barratt E (1994) Impulsiveness and aggression. In: Monahan J, Steadman H (eds) Violence and mental disorder: developments in risk assessment. University of Chicago Press, Chicago, pp 61–80Google Scholar
  24. 24.
    Kay SR, Opler LA, Fizbein A, Ramirez P, White L (2000) The positive and negative syndrome scale: users manual. Multi-Health Systems, New York, USAGoogle Scholar
  25. 25.
    Pokorny A, Miller B, Kaplan H (1972) The brief mast: a shortened version of the Michigan alcoholism screening test. Am J Psychiatry 129(3):342–345PubMedGoogle Scholar
  26. 26.
    Skinner H (1982) The drug abuse screening test. Addict Behav 7:363–371PubMedCrossRefGoogle Scholar
  27. 27.
    Monahan J, Steadman HJ, Silver E, Appelbaum PS, Robbins PC, Mulvey EP et al (2001) Rethinking risk assessment: the MacArthur study of mental disorder and violence. Oxford University Press, New YorkGoogle Scholar
  28. 28.
    Monahan J, Steadman H, Robbins P, Appelbaum P, Banks S, Grisso T, Heilbrun K, Mulvey E, Roth L, Silver E (2005) An actuarial model of violence risk assessment for persons with mental disorders. Psychiatr Serv 56:810–815PubMedCrossRefGoogle Scholar
  29. 29.
    Widiger TA, Trull TJ (1994) Personality disorders and violence. In: Monahan J, Steadman H (eds) Violence and mental disorder: developments in risk assessment. University of Chicago Press, Chicago, IL, pp 203–226Google Scholar
  30. 30.
    Nestor P (2002) Mental disorder and violence: personality dimensions and clinical features. Am J Psychiatry 159:1973–1978PubMedCrossRefGoogle Scholar
  31. 31.
    McMurran M (2002) Personality disorder. Expert paper. National R&D Programme on Forensic Mental Health, EnglandGoogle Scholar
  32. 32.
    Coid J, Yang M (2010) The impact of psychopathy on violence among the household population of Great Britain. Soc Psychiatry Psychiatr Epidemiol.***Google Scholar
  33. 33.
    McCusker PJ (2007) Issues regarding the use of the classification of violence risk (COVR) assessment instrument. Int J Offender Ther Comp Criminol 51:676–685Google Scholar
  34. 34.
    Steadman HJ, Mulvey E, Monahan J, Robbins P, Appelbaum P, Grisso T, Roth L, Silver E (1998) Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighbourhoods. Arch Gen Psychiatry 55:393–401PubMedCrossRefGoogle Scholar
  35. 35.
    Fasel S, Langstrom N, Hjern A, Grann M, Lichtenstein P (2009) Schizophrenia, substance abuse and violent crime. J Am Med Assoc 301(19):2016–2023CrossRefGoogle Scholar
  36. 36.
    Elbogen E, Johnson S (2009) The intricate link between violence and mental disorder. Arch Gen Psychiatry 66(2):152–161PubMedCrossRefGoogle Scholar
  37. 37.
    Heilbrun K (2002) Violence risk: from prediction to risk management. In Carson D, Bull R (eds) Handbook of psychology in legal contexts, 2nd edn. John Wiley and Sons, NY, pp 127–143Google Scholar
  38. 38.
    Skeem JL, Miller JD, Mulvey EP et al (2005) Using a five-factor lens to explore the relation between personality traits and violence in psychiatric patients. J Consult Clin Psychol 73:454–465PubMedCrossRefGoogle Scholar
  39. 39.
    Doyle M, Dolan M (2006) Evaluating the validity of anger regulation problems, interpersonal style, and disturbed mental state for predicting inpatient violence. Behav Sci Law 24(6):783–798Google Scholar
  40. 40.
    Chemtob CM, Novaco RW, Hamada RS, Gross DM (1997) Cognitive-behavioural treatment for severe anger in post-traumatic stress disorder. J Consult Clin Psychol 139:1262–1266Google Scholar
  41. 41.
    Novaco R, Renwick S (1998) Anger predictors of the assaultativeness of forensic hospital patients. In: Sanavio E (ed) Behavior and cognitive therapy today: essays in honor of Hans J. Eysenck. Pergamon, Oxford, pp 199–208CrossRefGoogle Scholar
  42. 42.
    Haddock G, Lowens I, Brosnan N, Barrowclough C, Novaco R (2004) Cognitive-behaviour therapy for inpatients with psychosis and anger management problems within a low secure environment. Behav Cogn Psychother 32:77–98CrossRefGoogle Scholar
  43. 43.
    Arboleda-Florez J, Holley H, Crisanti A (1998) Understanding causal paths between mental illness and violence. Soc Psychiatry Psychiatr Epidemiol 33:S38–S46PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Michael Doyle
    • 1
  • Stuart Carter
    • 2
  • Jenny Shaw
    • 3
  • Mairead Dolan
    • 4
  1. 1.Community Based Medicine, Adult Forensic Mental Health Services, Greater Manchester West NHS Mental Health Foundation TrustUniversity of ManchesterManchesterUK
  2. 2.Bolton Primary Care Mental Health Service, Bolton Primary Care TrustBoltonUK
  3. 3.Department of Psychiatry, Lancashire Care NHS TrustUniversity of ManchesterManchesterUK
  4. 4.Centre for Forensic Behavioural ScienceMonash UniversityClaytonAustralia

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