First and foremost, clinicians should carefully evaluate for the presence of a mental health diagnoses and any active mental health symptoms. Mental illness alone accounts for only a small portion of violence. However, when assessing a patient with a serious mental illness for potential violence, psychotic are particularly important to explore. In their 2009 meta-analysis, Douglas et al. found that psychosis (including delusions, perceptual impairment, impaired communication, and disorganized behavior) was the most important general psychiatric symptom associated with violent behavior. Illicit drugs and alcohol substantially increase the risk of aggression. The use of stimulants, such as cocaine, crack, amphetamines, and PCP are of particular concern. Substance use comorbid with a mental health diagnosis poses an even greater risk of future violence than either condition alone. In addition to exploring general mental status during an evaluation, clinicians should pay close attention to their patient’s affect. Individuals who are angry and lack empathy for others are at increased risk for violent behavior. All threats should lead to clinicians attempting to gather further details, such as understanding the exact relationship of the patient to any intended victim. In addition to assessing any threat to harm others, clinicians should also assess the suicide risk as many homicidal patients also report suicidal ideation. Other important areas to explore when possible include a past history of violence, access to a weapon (particularly a firearm), any recent movement or use of a weapon, recent stressors.
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