Particular clusters of symptoms may increase or decrease violence risk in schizophrenia patients. Violence risk assessment and management in community-based treatment should focus on combinations of clinical and nonclinical risk factors.

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Because severe mental illness did not independently predict future violent behavior, these findings challenge perceptions that mental illness is a leading cause of violence in the general population. Still, people with mental illness did report violence more often, largely because they showed other factors associated with violence. Consequently, understanding the link between violent acts and mental disorder requires consideration of its association with other variables such as substance abuse, environmental stressors, and history of violence.

Objective This study analyzed data from a national survey of Iraq and Afghanistan veterans to improve understanding of mental health services use and perceived barriers. Methods The National Post-Deployment Adjustment Survey randomly sampled post-9/11 veterans separated from active duty or in the Reserves or National Guard. The corrected response rate was 56% (N=1,388). Results Forty-three percent screened positive for posttraumatic stress disorder (PTSD), major depression, or alcohol misuse. Past-year psychiatric treatment was reported by 69% of the PTSD group, 67% of the depression group, and 45% of those with alcohol misuse. Most received care at Veterans Affairs (VA) facilities, although women were more likely than men to seek non-VA services. Veterans with more severe symptoms reported greater treatment utilization. Eighteen percent saw a pastoral counselor (chaplain) in the past year. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express concern about being seen as weak by others. Conclusions Veterans in greatest need were more likely to access services. More than two-thirds with probable PTSD obtained past-year treatment, mostly at VA facilities. Treatment for veterans may be improved by increasing awareness of gender differences, integrating mental health and pastoral services, and recognizing that alcohol misuse may reduce utilization. Veterans who had and had not used services endorsed different perceptions about treatment, indicating that barriers to accessing care may be distinct from barriers to engaging in care.

Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

Objective-Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives.Method-A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded.Results-Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed.Conclusions-The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.A psychiatric advance directive is a legal document that allows a patient to consent to or refuse future mental health treatment in the event of an incapacitating psychiatric crisis by documenting advance instructions or appointing a surrogate decision maker (1). Laws on psychiatric advance directives were intended to support patients' self-determination at times when they are particularly vulnerable to loss of autonomy, to help them ensure that their preferences are known, and to minimize unwanted or involuntary treatment (2, 3). Advocates for psychiatric advance directives hope that the very process of preparing these documents will enhance patients' sense of trust and collaboration with providers, thereby improving the therapeutic alliance and engagement with treatment (4, 5).Address correspondence and reprint requests to Dr. Swanson, Box 3071, Duke University Medical Center, Durham, NC 27710; jeffrey.swanson@duke.edu.. NIH Public Access Author ManuscriptAm J Psychiatry. Author manuscript; available in PMC 2013 August 20.Published in final edited form as: Am J Psychiatry. 2006 November ; 163(11): 1943-1951. doi:10.1176/appi.ajp.163.11.1943 NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptStructu...

Objective As troops return from Iraq and Afghanistan to civilian life, clinicians are starting to grapple with how best to detect those at risk of post-deployment adjustment problems. Data reveal the presence of mental health problems in these soldiers, including posttraumatic stress disorder (PTSD), head injury, and alcohol abuse. Each of these conditions has been associated with elevated anger and hostility in veterans from previous conflicts. The authors sought to identify variables empirically related to anger and hostility in Iraq and Afghanistan veterans. Method A total of 676 veterans who served since September 11, 2001, and who volunteered to participate in research studies, were interviewed with instruments designed to collect information on psychiatric symptoms, health, and possible post-deployment adjustment issues. The primary outcome measures were variables measuring aggressive impulses or urges, difficulty managing anger, and perceived problems controlling violent behavior. Results The three outcome measures were each significantly associated with PTSD hyperarousal symptoms. Other PTSD symptoms were less strongly and less consistently linked to anger and hostility. Traumatic brain injury and alcohol misuse were related to the outcome variables in bivariate but not multivariate analyses. Distinct sets of demographic, historical, and military-related variables were associated with the different facets of anger and hostility measured. Conclusions The results underscore the need to tailor interventions individually to address anger and hostility effectively and to develop theoretically sophisticated, evidence-based knowledge to identify service members at risk of problematic post-deployment adjustment.

Co-occurring PTSD and alcohol misuse was associated with a marked increase in violence and aggression in veterans. Compared with veterans with neither PTSD nor alcohol misuse, veterans with PTSD and no alcohol misuse were not significantly more likely to be severely violent and were only marginally more likely to engage in other physical aggression. Attention to cumulative effects of multiple risk factors beyond diagnosis--including demographics, violence history, combat exposure, and veterans' having money to cover basic needs like food, shelter, transportation, and medical care--is crucial for optimising violence risk management.