Integrating static and modifiable risk factors in violence risk assessment for forensic psychiatric patients: a feasibility study of FoVOx

Figures & data

Figure 1. Flow chart of discharged forensic psychiatric patients that were included in the study.

Table 1. Baseline characteristics.

Variables	All patients (n = 95)		Violent recidivists, convicted (n = 6)
Age, median (range)	46 (21–82)		36 (30–59)
Age, mean (SD)	47 (15)		41 (11)
	n	%	n	%
Sex, male	80	84	3	50
Previous violent crime	89	94	6	100
Previous serious violent crime	39	41	5	83
Primary discharge diagnosis
Schizophrenia spectrum	46	48	1	17
Bipolar disorder	5	5	0	0
Unipolar depression	0	0	0	0
Anxiety disorder	1	1	0	0
Other	43	45	5	83
Drug use disorder at hospitalization or discharge	30	32	4	67
Any previous drug use disorder (lifetime)	44	46	5	83
Alcohol use disorder at hospitalization or discharge	35	37	3	50
Personality disorder diagnosis at discharge	7	7	3	50
Up to 6 months before admission, which can be full/part-time education	9	9	1	17
Five or more previous psychiatric inpatient episodes	24	25	1	17
Length of current inpatient stay >1 year	88	93	6	100

Table 2. Risk categories assigned by clinicians versus categories based on FoVOx scores.

	All patients (n = 95)	Violent recidivists, convicted (n = 6)
FoVOx categories
Low	28 (30%)	1 (17%)
Medium	60 (63%)	4 (67%)
High	7 (7%)	1 (17%)
Clinician’s assessment at discharge
Low	64 (67%)	2 (33%)
Medium	21 (22%)	4 (67%)
High	5 (5%)	0 (0%)
Don’t know	5 (5%)	0 (0%)
	FoVOx (all patients)
Clinicians (all patients)	Low	Medium	High
Low	20	36	5
Medium	6	15	2
High	0	6	0
	Low	Medium/High
Low	20	41
Medium/High	6	23

FoVOx risk categories are based on pre-specified risk levels. Low: < 5%; medium: 5–20%; high:> 20%.

Table 3. Qualitative feedback on additional factors not considered in FoVOx.

	General	Factors reducing risk	Factors increasing risk
Modifiable Risk Factors	Risk of relapse of substance abuse Varied adherence to medication Other individual factors	Gained insight Clinical presentation of patient over time Good adherence to medication Ceased recurrent and compulsive thoughts Well coordinated social measures	Lack of insight Ongoing recurrent and compulsive thoughts Specific types of index violence
Static Risk Factors	Oddness of index crime Other individual factors	Severe somatic illness Suitable accommodation Inaccurate diagnosis at discharge Honor-related violence	Dementia Psychopathy/Chronic manipulative tendencies Not arranged accommodation Autism not specifically taken into account Impulsivity

Table 4. Psychiatrists’ qualitative feedback on FoVOx future utility.

Themes	Sub-themes	Helpful	Potential limitations
Assist decision-making	As part of the discharge planning	Speeds the decision-making when the tool corresponds to the subjective risk assessment.	Other factors had a much higher impact than the FoVOx factors in the discharge planning.
	In communication with third parties	Simple and easy to use for communication with the court, relatives and the community.	Risk assessment tools cannot solely be referred to in the Swedish court system.
	In communication with the patient	Gives the patient an objective argument of why he/she has a certain risk level.	Lacks dynamic factors, which patients often ask for over the course of several assessments.
Impact of risk management	Early perception of risk	Gives a quick objective view of the risk for this specific type of patient.	The lack of dynamic or other factors might give false assurance or hesitancy.
	Planning patient management	Highlights risk factors previously not considered by junior colleagues or other health care workers.	May give false assurance or hesitancy.
	Reassurance or control	Similar risk assessment of FoVOx strengthens the clinician’s confidence and choice of action.	General clinical impression of greater value than actuarial risk points.

Data availability statement

All data is subject to ethical approval, and cannot be shared with third parties.