Chief Complaint: Homicidal. Assessing Violence Risk When Mental Illness Is Not To Blame



Psychiatrists routinely evaluate patients who are at increased risk of violence. When the risk flows from a treatable mental illness, our job is relatively straightforward. We treat the mental illness, and the risk is reduced accordingly.  Sometimes though, the risk flows from other factors. 

Consider a patient who is menacing, manipulative, and demanding, yet demonstrates no evidence of psychosis or mania.  Not uncommonly, this patient has a history of substance abuse and a views violence as a perfectly acceptable way to solve life’s problems.  We suspect that keeping the patient in the psychiatric hospital is unlikely to alter their violence risk. Why? Because the risk does not flow from a treatable mental illness. Yet, psychiatrists still worry about potential liability in the event of a bad outcome after discharge.  How should the psychiatrist proceed?  

This article by Dr. Saxton, Dr. Resnick, and Dr. Noffsinger, published in Current Psychiatry (May 2018), reviews a structured approach to assessing and managing violence risk when mental illness is not to blame.