Predictive efficacy of violence risk assessment tools, implications for forensic and general psychiatry in Italy. A literature review

Objectives In the last decades, interest and research on violence risk assessment tools for patients suffering from mental disease has significantly increased, providing different approaches that vary from actuarial to structured clinical judgement. From a national perspective, it may be useful for psychiatrists not directly involved in forensic context to become familiar with tools that are mostly studied and used elsewhere. The imminent announced closing of the six national OPGs (Ospedali Psichiatrici Giudiziari) will inevitably increase the number of mentally disordered offenders directly managed by mental health services (Dipartimenti di Salute Mentale), which will be asked by the courts to assess the risk of danger of some of their clients. Our aim herein is to review the international literature over the last 10 years in terms of evidence for the predictive validity of major violence risk assessment tools in correctional, forensic and general psychiatric settings. Materials and methods A research through Medline and Embase database of clinical trials, prospective and retrospective cohort studies, systematic reviews and meta-analyses in the period 2002-2012. Results Analysis of the literature stress the evidence that violence risk assessment tools are more efficient than unstructured clinical judgement in the prediction of future violent and aggressive behavioural expressions, including rate of reconvictions. Actuarial tools, specifically VRAG, developed in the correctional sector, appear to be efficient in the prediction of this population. Structured clinical judgement tools, in particular HCR-20, are supported by a large number of studies on their predictive features, in different settings, including some evidence for the assessment of the level of security that is most appropriate for the patient within the forensic psychiatric care pathway. Conclusions The introduction and routine use of violence risk assessment tools in the correctional and forensic contexts appears to be valid. Usage of appropriate, validated risk assessment tools can augment standard clinical approaches in a number of ways. Some of their advantages derive simply from having a well-structured approach, others from consideration of specific kinds of risk factors: 'static' and 'dynamic'. The inappropriate use of tools without a firm evidence base, however, is unlikely to enhance clinical practice significantly: their utility at the level of general psychiatry is still controversial. Additional considerations are discussed.