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Br J Psychiatry. 2014 Mar;204(3):180-7. doi: 10.1192/bjp.bp.113.131938.

Rates of violence in patients classified as high risk by structured risk assessment instruments.

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Jay P. Singh, PhD, Psychiatric/Psychological Service, Department of Justice, Z├╝rich, Switzerland; Seena Fazel, MD, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Ralitza Gueorguieva, PhD, Department of Biostatistics, School of Public Health, Alec Buchanan, PhD, MD, Department of Psychiatry, Yale University, New Haven, Connecticut, USA.



Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies.


To analyse the variation in rates of violence in individuals identified as high risk by SRAIs.


A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity.


Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study.


After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.

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