How predictable is violence and suicide in community psychiatric practice?

There has been concern about the danger from psychiatric patients being treated in the community. We sought to assess the level of risk of violence and suicide in patients seen routinely by a community mental health team. Risk assessment questionnaires were completed by community mental health team professionals for all contacts with all patients seen by the team over a 1-month period. Twenty-six per cent (81/318) of patients seen were considered at 'moderate' or higher risk of suicide and 23% (73/ 318) at risk of violent behaviour. The variables best identifying those judged at risk of suicide were previous episodes of depressive illness and previous deliberate self-harm. The variables identifying risk of violence were previous violence to person or property, specific threats towards another, expression of emotions related to violence in the mental state examination and absence of previous depressive illness. A large number of patients seen by the community teams are at risk of suicide and violence; yet suicide or incidents of serious violence are rare. This highlights the difficulty in accurate prediction and the limits of risk management strategies recommended by inquiries following such events.