Glen L. Xiong, MD

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making.

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.²

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk.

Impulsivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single (known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings— 2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess impor­tant risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

A common misconception is that persons who are mentally ill are inherently dangerous. However, there is, at most, a weak overall relation­ship between mental illness and violence. Increased violence is more likely to occur during periods of acute psychiatric symp­toms.1 Because few patients evaluated in most clinical settings will commit a violent act, it is important to assess for specific risk factors for violence to guide clinical deci­sion making. 

The acronym DISTURBED can be a reminder about important patient-specific features that correlate with violence. There are several variables to consider when iden­tifying persons who are more likely to com­mit acts of violence.² 

Demographics. Young age, male sex, cognitive deficits, less formal educa­tion, unemployment, financial hardship, and homelessness are associated with an increased risk of violence. A person’s living environment and ongoing social circum­stances are important considerations when assessing violence risk. 

Impusivity. Persons who display impul­sive behaviors generally are more likely to behave violently. This is particularly true in persons who have been given a diagnosis of antisocial personality disorder or border­line personality disorder. Impulsivity often can be treated with medication, behav­ioral therapy, and other psychotherapeutic modalities.

Substance use is associated with an increased risk of violence in people with and without other mental health issues. Alcohol can increase the likelihood of vio­lence through intoxication, withdrawal, or brain changes related to chronic drinking. Some illicit drugs are associated with vio­lence, including phencyclidine, cocaine, methamphetamine, inhalants, anabolic ste­roids, and so-called bath salts. Be cautious when treating a patient who is intoxicated with one or more of these substances.

Threats. Persons who express a threat are more likely to behave violently³; those who voice threats against an identified target should be taken seriously. The more specific the threat, the more consideration it should be given. In a clinical setting, the potential target should be informed as soon as pos­sible about the threat. If a patient is voicing a threat against a person outside the clinical setting, you may have a duty to protect by reporting that threat to law enforcement.

Untreated psychosis. Be aware of patients who have untreated or undertreated symp­toms, including psychosis and substance intoxication. Patients in a triage setting or who are newly admitted to an inpatient unit often present the greatest risk because their symptoms have not been treated. People with paranoid delusions are at a higher risk of assaulting their perceived persecutors. Those who are highly disorganized also are more prone to lash out and commit a vio­lent act.^4,5

Repeat violence. The best predictor of vio­lence is a history of violence. The severity of the violent acts is an important consider­ation. Even a person who has only a single known) past violent act can pose a high risk if the act was murder, rape, or another highly violent assault. Learning details about past assaults, through reviewing available records or gathering collateral information, is important when assessing violence risk.

Behaviors. There are physical warning signs that often are observed immediately before a person commits a violent act. Potential warning signs include: punch­ing a wall or breaking objects; tightening of facial muscles; clenching of fists; and pacing. These behaviors suggest a risk of imminent violence and should be closely monitored when assessing a patient who might be prone to violence. If a patient does not respond to redirection, he (she) may require staff intervention.

Eagerness. Much like when assessing the risk of suicide, intent is an important con­sideration in assessing the risk of violence. A person who is eager to commit an act of violence presents significant risk. Basic inquiries about homicidal ideation are insuf­ficient; instead, explore potential responses to situations that might have a direct impact on the individual patient. For example, if the patient has had frequent disagreements with a family member, inquiring about hypotheti­cal violent scenarios involving that family member would be valuable.

Distress. Persons who are concerned about safety often are inclined to lash out in perceived self-defense. For example, fear often is reported by psychiatric inpatients immediately before they commit an act of violence. In inpatient psychiatric units, providing a quiet room, or a similar ame­nity, can help prevent an assault by a patient who feels cornered or afraid. The staff can ease patients’ concerns by taking a calm and caring approach to addressing their needs.

Valuable tool for maintaining a safe environment
We recommend that clinicians—especially those who have little clinical experience (medical students, residents)—refer to this mnemonic before starting work in emer­gency and inpatient psychiatric settings—2 settings in which assessment of violence risk is common. The mnemonic will help when gathering information to assess important risk factors for violence.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Mental health care professionals are at increased risk of being assaulted by patients, especially in emergency and inpatient settings. Less experienced clinicians are at an even higher risk: Studies estimate that up to 56% percent of psychiatric residents have been physically assaulted by a patient.¹ Some researchers have examined systematic approaches to improving violence risk assessment²; however, the assessment and interview process itself poses a risk to residents and medical students. We recommend using the mnemonic CAUTION to remind clinicians about safety considerations when working in psychiatric settings.

Communication. Talking about safety should be a priority during daily rounds. Routinely ask staff and other personnel about safety concerns. In inpatient settings, post a safety board where hospital staff can record aggressive behaviors and other safety issues displayed by patients. Notify staff whenever you plan to interact with patients at risk for aggression or when a patient seems agitated.

Attire. Follow proper dress codes to ensure personal safety and improve your ability to quickly assist others in need. Avoid wearing necklaces, ties, and high heels in inpatient psychiatric units. Valuable accessories (eg, expensive wrist watches) should not be worn because they may be broken during a “take down.”

Untreated symptoms. Be aware of patients with untreated or undertreated symptoms, including psychosis or substance intoxication. Emergency room patients or newly admitted inpatients often present the greatest risk because of their untreated symptoms (eg, patients with paranoid delusions).

Threats. Patients who express threats are at significantly increased risk of assaulting someone.³ Patients who have recently voiced threats should not be engaged alone or without adequate staff support. Inform all residents and students about specific patients who have voiced threats. Agitated and threatening patients can pose a risk to everyone in the unit, regardless of whether they have worked directly with the clinician.

Impulsivity. Approach impulsive and aggressive patients with particular caution. Until the aggression is controlled, these patients are at risk for sudden assaults when they feel provoked. Warning signs include punching a wall or breaking objects on the unit, facial muscle tightening, clenching of fists, and pacing. If a patient does not respond to redirection from staff, he or she may require seclusion, emergency medications, or both.

Options. Whenever possible, provide patients with choices, especially when a patient requests discharge or demands a particular medication. Avoid taking an authoritarian stance by clarifying reasons why the patient’s requests are being denied and by providing alternatives and options. For instance, if discharge is not indicated, direct a patient to contact the patients’ rights advocate. You also can give some agitated patients the option of taking a voluntary “timeout” or going to an isolated area to calm down.

Navigate safely. Identify potential exits from the room before the encounter. Residents and medical students should have a clear understanding of where to escape from a potential assault. Also, it is important to point out to patients where the door is should they feel threatened. Do not block the door when interviewing paranoid patients.

We suggest that less experienced clinicians refer to this mnemonic before starting work in emergency and inpatient psychiatric settings. Safety is an important consideration. By considering these basic concepts, we believe that safety can be improved.

Mental health care professionals are at increased risk of being assaulted by patients, especially in emergency and inpatient settings. Less experienced clinicians are at an even higher risk: Studies estimate that up to 56% percent of psychiatric residents have been physically assaulted by a patient.¹ Some researchers have examined systematic approaches to improving violence risk assessment²; however, the assessment and interview process itself poses a risk to residents and medical students. We recommend using the mnemonic CAUTION to remind clinicians about safety considerations when working in psychiatric settings.

Communication. Talking about safety should be a priority during daily rounds. Routinely ask staff and other personnel about safety concerns. In inpatient settings, post a safety board where hospital staff can record aggressive behaviors and other safety issues displayed by patients. Notify staff whenever you plan to interact with patients at risk for aggression or when a patient seems agitated.

Attire. Follow proper dress codes to ensure personal safety and improve your ability to quickly assist others in need. Avoid wearing necklaces, ties, and high heels in inpatient psychiatric units. Valuable accessories (eg, expensive wrist watches) should not be worn because they may be broken during a “take down.”

Untreated symptoms. Be aware of patients with untreated or undertreated symptoms, including psychosis or substance intoxication. Emergency room patients or newly admitted inpatients often present the greatest risk because of their untreated symptoms (eg, patients with paranoid delusions).

Threats. Patients who express threats are at significantly increased risk of assaulting someone.³ Patients who have recently voiced threats should not be engaged alone or without adequate staff support. Inform all residents and students about specific patients who have voiced threats. Agitated and threatening patients can pose a risk to everyone in the unit, regardless of whether they have worked directly with the clinician.

Impulsivity. Approach impulsive and aggressive patients with particular caution. Until the aggression is controlled, these patients are at risk for sudden assaults when they feel provoked. Warning signs include punching a wall or breaking objects on the unit, facial muscle tightening, clenching of fists, and pacing. If a patient does not respond to redirection from staff, he or she may require seclusion, emergency medications, or both.

Options. Whenever possible, provide patients with choices, especially when a patient requests discharge or demands a particular medication. Avoid taking an authoritarian stance by clarifying reasons why the patient’s requests are being denied and by providing alternatives and options. For instance, if discharge is not indicated, direct a patient to contact the patients’ rights advocate. You also can give some agitated patients the option of taking a voluntary “timeout” or going to an isolated area to calm down.

Navigate safely. Identify potential exits from the room before the encounter. Residents and medical students should have a clear understanding of where to escape from a potential assault. Also, it is important to point out to patients where the door is should they feel threatened. Do not block the door when interviewing paranoid patients.

We suggest that less experienced clinicians refer to this mnemonic before starting work in emergency and inpatient psychiatric settings. Safety is an important consideration. By considering these basic concepts, we believe that safety can be improved.

Mental health care professionals are at increased risk of being assaulted by patients, especially in emergency and inpatient settings. Less experienced clinicians are at an even higher risk: Studies estimate that up to 56% percent of psychiatric residents have been physically assaulted by a patient.¹ Some researchers have examined systematic approaches to improving violence risk assessment²; however, the assessment and interview process itself poses a risk to residents and medical students. We recommend using the mnemonic CAUTION to remind clinicians about safety considerations when working in psychiatric settings.

Communication. Talking about safety should be a priority during daily rounds. Routinely ask staff and other personnel about safety concerns. In inpatient settings, post a safety board where hospital staff can record aggressive behaviors and other safety issues displayed by patients. Notify staff whenever you plan to interact with patients at risk for aggression or when a patient seems agitated.

Attire. Follow proper dress codes to ensure personal safety and improve your ability to quickly assist others in need. Avoid wearing necklaces, ties, and high heels in inpatient psychiatric units. Valuable accessories (eg, expensive wrist watches) should not be worn because they may be broken during a “take down.”

Untreated symptoms. Be aware of patients with untreated or undertreated symptoms, including psychosis or substance intoxication. Emergency room patients or newly admitted inpatients often present the greatest risk because of their untreated symptoms (eg, patients with paranoid delusions).

Threats. Patients who express threats are at significantly increased risk of assaulting someone.³ Patients who have recently voiced threats should not be engaged alone or without adequate staff support. Inform all residents and students about specific patients who have voiced threats. Agitated and threatening patients can pose a risk to everyone in the unit, regardless of whether they have worked directly with the clinician.

Impulsivity. Approach impulsive and aggressive patients with particular caution. Until the aggression is controlled, these patients are at risk for sudden assaults when they feel provoked. Warning signs include punching a wall or breaking objects on the unit, facial muscle tightening, clenching of fists, and pacing. If a patient does not respond to redirection from staff, he or she may require seclusion, emergency medications, or both.

Options. Whenever possible, provide patients with choices, especially when a patient requests discharge or demands a particular medication. Avoid taking an authoritarian stance by clarifying reasons why the patient’s requests are being denied and by providing alternatives and options. For instance, if discharge is not indicated, direct a patient to contact the patients’ rights advocate. You also can give some agitated patients the option of taking a voluntary “timeout” or going to an isolated area to calm down.

Navigate safely. Identify potential exits from the room before the encounter. Residents and medical students should have a clear understanding of where to escape from a potential assault. Also, it is important to point out to patients where the door is should they feel threatened. Do not block the door when interviewing paranoid patients.

We suggest that less experienced clinicians refer to this mnemonic before starting work in emergency and inpatient psychiatric settings. Safety is an important consideration. By considering these basic concepts, we believe that safety can be improved.

Dr. Xiong is assistant clinical professor, departments of internal medicine and psychiatry and behavioral sciences, University of California, Davis. Dr. Kenedi is an adjunct professor of psychiatry at Duke University Medical Center in Durham, NC, and a consultant (attending physician) in internal medicine and liaison psychiatry, Auckland City Hospital, Auckland, New Zealand.

Principal Source: U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.

Cardiovascular disease (CVD) is the leading cause of death in the United States, accounting for >50% of all deaths. In persons age >40, the lifetime risk of death from CVD is 2 in 3 for men and more than 1 in 2 for women.¹ Persons with severe mental illness have nearly twice the risk of death from CVD compared with the general population, which may be attributed to:

• lifestyle factors, including poor diet, lack of exercise, and tobacco dependence²
• antipsychotic medications, which have been shown to increase the risk of CVD³
• lower likelihood of undergoing cardiovascular procedures—including percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery—after myocardial infarction (MI).⁴

Psychiatrists are often the primary contact for patients with mental illness, giving us an opportunity to collaborate with primary care physicians and apply preventative measures that can reduce illness and improve patients’ morbidity and mortality. In addition to evaluating patients for possible hypercholesterolemia and diabetes, adding daily aspirin for primary prevention of heart attacks and strokes is an easily implementable option that could make a real difference in their health and quality of life.

New aspirin recommendations

The U.S. Preventive Services Task Force (USPSTF) found evidence that daily aspirin decreases the incidence of MI in men and ischemic strokes in women.¹ However, total mortality for either gender was not significantly reduced.⁵ The USPSTF’s updated recommendations reflect results of the Women’s Health Study⁶ with different guidelines for men and women.

The USPSTF recommends daily aspirin for men age 45 to 79 and for women age 55 to 79 when the benefits of decreased MI for men and ischemic strokes for women outweigh the risks of increased GI bleeding ( Table 1 ).¹ This grade A recommendation means there is high certainty of substantial net benefit.

Aspirin is not recommended for patients age ≥80 because of insufficient evidence of harm or benefit. The risks of MI in men age <45 and stroke in women age <55 are low, and daily aspirin generally is not indicated.

Optimal aspirin dose is unclear. The USPSTF recommends approximately 75 mg/d (effectively 81 mg/d or 1 “baby aspirin” in most U.S. settings). Higher aspirin doses might not be more effective for primary prevention and could increase the risk of GI bleeding. Note that some patients with a history of cardiovascular or cerebrovascular events might receive higher aspirin doses for secondary prevention of additional injury.

Risk assessment. In addition to age, other risk factors for CVD include:

• diabetes
• high total cholesterol (>240 mg/dL)
• low high-density lipoprotein cholesterol or so-called “good cholesterol” (<40 mg/dL for men, <50 mg/dL for women)
• hypertension
• smoking
• family history.

Several online tools—based on data from the Framingham Heart Study and other cohorts—can help estimate a patient’s CVD risk ( see Related Resources ), or consult with your patient’s primary care physician.

Potential harm of aspirin. USPSTF considers age and gender the most important risk factors for GI bleeding. GI bleeding is defined as serious hemorrhage, perforation, or other complications that could lead to hospitalization or death. Other risk factors include:

• upper GI pain
• history of gastric or duodenal ulcers
• NSAID use
• heavy, regular alcohol consumption.

In general, men have twice the risk of GI bleeding compared with women.¹ The baseline number of GI bleeding events for individuals without a history of GI pain or bleeds taking daily aspirin is 4 per 10,000 person-years for women and 8 per 10,000 for men.¹ Patients with preexisting GI ulcers who receive daily aspirin have more than 2 to 3 times the baseline risk of serious GI bleeding.⁷ NSAIDs taken with daily aspirin can quadruple the risk of GI bleeding compared with aspirin use alone, although antacid therapy can reduce this risk.⁸ Co-administered anticoagulants (eg, warfarin) also significantly increase the risk—especially when compliance with medication and monitoring is poor. Aspirin also increases the risk of hematuria, easy bruising, and epistaxis.

Because consuming >3 standard drinks a day also increases the risk of GI bleeding by up to 6 fold, patients with untreated chronic alcohol abuse or dependence might not be good candidates for daily aspirin therapy.⁹ Contrary to popular belief and pharmaceutical marketing, enteric-coated tablets do not seem to reduce the risk of bleeding because aspirin impacts platelet function, not the lining of the stomach.

Table 1

USPSTF recommendations for daily aspirin use
in primary prevention of cardiovascular disease

Aspirin for psychiatric patients

Patients who have serious mental illness are at increased risk for CVD and often experience systemic barriers to receiving appropriate medical care.¹⁰ Psychiatrists can provide and advocate for primary care services for our patients, including daily aspirin use to prevent CVD when appropriate, and encourage a closer relationship with a primary care physician before an adverse event occurs. Aspirin use in psychiatric patients is associated with:

• potential drug-drug interaction with valproate¹¹
• mildly increased risk of bleeding as a result of reduced platelet function with the use of selective serotonin reuptake inhibitors.¹²

Balancing benefits vs risks. The USPSTF recommendation assumes that the value of preventing 1 MI or stroke is roughly equivalent to (or slightly less than) the cost of 1 GI bleeding event caused by aspirin. For example, among 1,000 men age 45 to 79 who have a ≥4% risk of MI over 10 years, 12.8 MIs would be prevented for every 8 GI bleeds caused by aspirin by following the current recommendations.¹

The USPSTF guidelines are based on average levels of risk for age and gender. Some men age <45 may decide that it is more important to avoid a cardiovascular event rather than an episode of GI bleeding and might choose to begin daily aspirin. Aspirin use should be discouraged in most patients at high risk for GI bleeding. The point where the potential benefits outweigh the risks must be determined on an individual basis ( Table 2 ).

Table 2

Aspirin to prevent cardiovascular disease and stroke:
When benefits outweigh risks

Related resources

• National Cholesterol Education Program. Online heart attack risk assessment tool. http://hp2010.nhlbihin.net/atpiii/calculator.asp.
• Framingham Heart study calculator. www.framinghamheartstudy.org/risk/coronary.html.
• National Cholesterol Education Program. www.nhlbi.nih.gov/health/public/heart/chol/wyntk.htm#risk.
• Colorado Neurological Institute. Online stroke risk assessment tool. www.thecni.org/Public/CNICenters/StrokeCenter/StrokeRiskCalculator/index.cfm.
• Agency for Healthcare Research and Quality. Fact sheet on aspirin to prevent cardiovascular disease. www.ahrq.gov/clinic/cvd/aspprovider.htm.

Drug brand names

• Valproate • Depacon
• Warfarin • Coumadin

Disclosures

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Kenedi receives grant/research support from Duke University Medical Center and Auckland University.

Dr. Xiong is assistant clinical professor, departments of internal medicine and psychiatry and behavioral sciences, University of California, Davis. Dr. Kenedi is an adjunct professor of psychiatry at Duke University Medical Center in Durham, NC, and a consultant (attending physician) in internal medicine and liaison psychiatry, Auckland City Hospital, Auckland, New Zealand.

Principal Source: U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.

Cardiovascular disease (CVD) is the leading cause of death in the United States, accounting for >50% of all deaths. In persons age >40, the lifetime risk of death from CVD is 2 in 3 for men and more than 1 in 2 for women.¹ Persons with severe mental illness have nearly twice the risk of death from CVD compared with the general population, which may be attributed to:

• lifestyle factors, including poor diet, lack of exercise, and tobacco dependence²
• antipsychotic medications, which have been shown to increase the risk of CVD³
• lower likelihood of undergoing cardiovascular procedures—including percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery—after myocardial infarction (MI).⁴

Psychiatrists are often the primary contact for patients with mental illness, giving us an opportunity to collaborate with primary care physicians and apply preventative measures that can reduce illness and improve patients’ morbidity and mortality. In addition to evaluating patients for possible hypercholesterolemia and diabetes, adding daily aspirin for primary prevention of heart attacks and strokes is an easily implementable option that could make a real difference in their health and quality of life.

New aspirin recommendations

The U.S. Preventive Services Task Force (USPSTF) found evidence that daily aspirin decreases the incidence of MI in men and ischemic strokes in women.¹ However, total mortality for either gender was not significantly reduced.⁵ The USPSTF’s updated recommendations reflect results of the Women’s Health Study⁶ with different guidelines for men and women.

The USPSTF recommends daily aspirin for men age 45 to 79 and for women age 55 to 79 when the benefits of decreased MI for men and ischemic strokes for women outweigh the risks of increased GI bleeding ( Table 1 ).¹ This grade A recommendation means there is high certainty of substantial net benefit.

Aspirin is not recommended for patients age ≥80 because of insufficient evidence of harm or benefit. The risks of MI in men age <45 and stroke in women age <55 are low, and daily aspirin generally is not indicated.

Optimal aspirin dose is unclear. The USPSTF recommends approximately 75 mg/d (effectively 81 mg/d or 1 “baby aspirin” in most U.S. settings). Higher aspirin doses might not be more effective for primary prevention and could increase the risk of GI bleeding. Note that some patients with a history of cardiovascular or cerebrovascular events might receive higher aspirin doses for secondary prevention of additional injury.

Risk assessment. In addition to age, other risk factors for CVD include:

• diabetes
• high total cholesterol (>240 mg/dL)
• low high-density lipoprotein cholesterol or so-called “good cholesterol” (<40 mg/dL for men, <50 mg/dL for women)
• hypertension
• smoking
• family history.

Several online tools—based on data from the Framingham Heart Study and other cohorts—can help estimate a patient’s CVD risk ( see Related Resources ), or consult with your patient’s primary care physician.

Potential harm of aspirin. USPSTF considers age and gender the most important risk factors for GI bleeding. GI bleeding is defined as serious hemorrhage, perforation, or other complications that could lead to hospitalization or death. Other risk factors include:

• upper GI pain
• history of gastric or duodenal ulcers
• NSAID use
• heavy, regular alcohol consumption.

In general, men have twice the risk of GI bleeding compared with women.¹ The baseline number of GI bleeding events for individuals without a history of GI pain or bleeds taking daily aspirin is 4 per 10,000 person-years for women and 8 per 10,000 for men.¹ Patients with preexisting GI ulcers who receive daily aspirin have more than 2 to 3 times the baseline risk of serious GI bleeding.⁷ NSAIDs taken with daily aspirin can quadruple the risk of GI bleeding compared with aspirin use alone, although antacid therapy can reduce this risk.⁸ Co-administered anticoagulants (eg, warfarin) also significantly increase the risk—especially when compliance with medication and monitoring is poor. Aspirin also increases the risk of hematuria, easy bruising, and epistaxis.

Because consuming >3 standard drinks a day also increases the risk of GI bleeding by up to 6 fold, patients with untreated chronic alcohol abuse or dependence might not be good candidates for daily aspirin therapy.⁹ Contrary to popular belief and pharmaceutical marketing, enteric-coated tablets do not seem to reduce the risk of bleeding because aspirin impacts platelet function, not the lining of the stomach.

Table 1

USPSTF recommendations for daily aspirin use
in primary prevention of cardiovascular disease

Aspirin for psychiatric patients

Patients who have serious mental illness are at increased risk for CVD and often experience systemic barriers to receiving appropriate medical care.¹⁰ Psychiatrists can provide and advocate for primary care services for our patients, including daily aspirin use to prevent CVD when appropriate, and encourage a closer relationship with a primary care physician before an adverse event occurs. Aspirin use in psychiatric patients is associated with:

• potential drug-drug interaction with valproate¹¹
• mildly increased risk of bleeding as a result of reduced platelet function with the use of selective serotonin reuptake inhibitors.¹²

Balancing benefits vs risks. The USPSTF recommendation assumes that the value of preventing 1 MI or stroke is roughly equivalent to (or slightly less than) the cost of 1 GI bleeding event caused by aspirin. For example, among 1,000 men age 45 to 79 who have a ≥4% risk of MI over 10 years, 12.8 MIs would be prevented for every 8 GI bleeds caused by aspirin by following the current recommendations.¹

The USPSTF guidelines are based on average levels of risk for age and gender. Some men age <45 may decide that it is more important to avoid a cardiovascular event rather than an episode of GI bleeding and might choose to begin daily aspirin. Aspirin use should be discouraged in most patients at high risk for GI bleeding. The point where the potential benefits outweigh the risks must be determined on an individual basis ( Table 2 ).

Table 2

Aspirin to prevent cardiovascular disease and stroke:
When benefits outweigh risks

Related resources

• National Cholesterol Education Program. Online heart attack risk assessment tool. http://hp2010.nhlbihin.net/atpiii/calculator.asp.
• Framingham Heart study calculator. www.framinghamheartstudy.org/risk/coronary.html.
• National Cholesterol Education Program. www.nhlbi.nih.gov/health/public/heart/chol/wyntk.htm#risk.
• Colorado Neurological Institute. Online stroke risk assessment tool. www.thecni.org/Public/CNICenters/StrokeCenter/StrokeRiskCalculator/index.cfm.
• Agency for Healthcare Research and Quality. Fact sheet on aspirin to prevent cardiovascular disease. www.ahrq.gov/clinic/cvd/aspprovider.htm.

Drug brand names

• Valproate • Depacon
• Warfarin • Coumadin

Disclosures

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Kenedi receives grant/research support from Duke University Medical Center and Auckland University.

Dr. Xiong is assistant clinical professor, departments of internal medicine and psychiatry and behavioral sciences, University of California, Davis. Dr. Kenedi is an adjunct professor of psychiatry at Duke University Medical Center in Durham, NC, and a consultant (attending physician) in internal medicine and liaison psychiatry, Auckland City Hospital, Auckland, New Zealand.

Principal Source: U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.

Cardiovascular disease (CVD) is the leading cause of death in the United States, accounting for >50% of all deaths. In persons age >40, the lifetime risk of death from CVD is 2 in 3 for men and more than 1 in 2 for women.¹ Persons with severe mental illness have nearly twice the risk of death from CVD compared with the general population, which may be attributed to:

• lifestyle factors, including poor diet, lack of exercise, and tobacco dependence²
• antipsychotic medications, which have been shown to increase the risk of CVD³
• lower likelihood of undergoing cardiovascular procedures—including percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery—after myocardial infarction (MI).⁴

Psychiatrists are often the primary contact for patients with mental illness, giving us an opportunity to collaborate with primary care physicians and apply preventative measures that can reduce illness and improve patients’ morbidity and mortality. In addition to evaluating patients for possible hypercholesterolemia and diabetes, adding daily aspirin for primary prevention of heart attacks and strokes is an easily implementable option that could make a real difference in their health and quality of life.

New aspirin recommendations

The U.S. Preventive Services Task Force (USPSTF) found evidence that daily aspirin decreases the incidence of MI in men and ischemic strokes in women.¹ However, total mortality for either gender was not significantly reduced.⁵ The USPSTF’s updated recommendations reflect results of the Women’s Health Study⁶ with different guidelines for men and women.

The USPSTF recommends daily aspirin for men age 45 to 79 and for women age 55 to 79 when the benefits of decreased MI for men and ischemic strokes for women outweigh the risks of increased GI bleeding ( Table 1 ).¹ This grade A recommendation means there is high certainty of substantial net benefit.

Aspirin is not recommended for patients age ≥80 because of insufficient evidence of harm or benefit. The risks of MI in men age <45 and stroke in women age <55 are low, and daily aspirin generally is not indicated.

Optimal aspirin dose is unclear. The USPSTF recommends approximately 75 mg/d (effectively 81 mg/d or 1 “baby aspirin” in most U.S. settings). Higher aspirin doses might not be more effective for primary prevention and could increase the risk of GI bleeding. Note that some patients with a history of cardiovascular or cerebrovascular events might receive higher aspirin doses for secondary prevention of additional injury.

Risk assessment. In addition to age, other risk factors for CVD include:

• diabetes
• high total cholesterol (>240 mg/dL)
• low high-density lipoprotein cholesterol or so-called “good cholesterol” (<40 mg/dL for men, <50 mg/dL for women)
• hypertension
• smoking
• family history.

Several online tools—based on data from the Framingham Heart Study and other cohorts—can help estimate a patient’s CVD risk ( see Related Resources ), or consult with your patient’s primary care physician.

Potential harm of aspirin. USPSTF considers age and gender the most important risk factors for GI bleeding. GI bleeding is defined as serious hemorrhage, perforation, or other complications that could lead to hospitalization or death. Other risk factors include:

• upper GI pain
• history of gastric or duodenal ulcers
• NSAID use
• heavy, regular alcohol consumption.

In general, men have twice the risk of GI bleeding compared with women.¹ The baseline number of GI bleeding events for individuals without a history of GI pain or bleeds taking daily aspirin is 4 per 10,000 person-years for women and 8 per 10,000 for men.¹ Patients with preexisting GI ulcers who receive daily aspirin have more than 2 to 3 times the baseline risk of serious GI bleeding.⁷ NSAIDs taken with daily aspirin can quadruple the risk of GI bleeding compared with aspirin use alone, although antacid therapy can reduce this risk.⁸ Co-administered anticoagulants (eg, warfarin) also significantly increase the risk—especially when compliance with medication and monitoring is poor. Aspirin also increases the risk of hematuria, easy bruising, and epistaxis.

Because consuming >3 standard drinks a day also increases the risk of GI bleeding by up to 6 fold, patients with untreated chronic alcohol abuse or dependence might not be good candidates for daily aspirin therapy.⁹ Contrary to popular belief and pharmaceutical marketing, enteric-coated tablets do not seem to reduce the risk of bleeding because aspirin impacts platelet function, not the lining of the stomach.

Table 1

USPSTF recommendations for daily aspirin use
in primary prevention of cardiovascular disease

Aspirin for psychiatric patients

Patients who have serious mental illness are at increased risk for CVD and often experience systemic barriers to receiving appropriate medical care.¹⁰ Psychiatrists can provide and advocate for primary care services for our patients, including daily aspirin use to prevent CVD when appropriate, and encourage a closer relationship with a primary care physician before an adverse event occurs. Aspirin use in psychiatric patients is associated with:

• potential drug-drug interaction with valproate¹¹
• mildly increased risk of bleeding as a result of reduced platelet function with the use of selective serotonin reuptake inhibitors.¹²

Balancing benefits vs risks. The USPSTF recommendation assumes that the value of preventing 1 MI or stroke is roughly equivalent to (or slightly less than) the cost of 1 GI bleeding event caused by aspirin. For example, among 1,000 men age 45 to 79 who have a ≥4% risk of MI over 10 years, 12.8 MIs would be prevented for every 8 GI bleeds caused by aspirin by following the current recommendations.¹

The USPSTF guidelines are based on average levels of risk for age and gender. Some men age <45 may decide that it is more important to avoid a cardiovascular event rather than an episode of GI bleeding and might choose to begin daily aspirin. Aspirin use should be discouraged in most patients at high risk for GI bleeding. The point where the potential benefits outweigh the risks must be determined on an individual basis ( Table 2 ).

Table 2

Aspirin to prevent cardiovascular disease and stroke:
When benefits outweigh risks

Related resources

• National Cholesterol Education Program. Online heart attack risk assessment tool. http://hp2010.nhlbihin.net/atpiii/calculator.asp.
• Framingham Heart study calculator. www.framinghamheartstudy.org/risk/coronary.html.
• National Cholesterol Education Program. www.nhlbi.nih.gov/health/public/heart/chol/wyntk.htm#risk.
• Colorado Neurological Institute. Online stroke risk assessment tool. www.thecni.org/Public/CNICenters/StrokeCenter/StrokeRiskCalculator/index.cfm.
• Agency for Healthcare Research and Quality. Fact sheet on aspirin to prevent cardiovascular disease. www.ahrq.gov/clinic/cvd/aspprovider.htm.

Drug brand names

• Valproate • Depacon
• Warfarin • Coumadin

Disclosures

Dr. Xiong reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Kenedi receives grant/research support from Duke University Medical Center and Auckland University.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

Medication nonadherence challenges psychiatrists in most clinical settings.¹ Supportive psychotherapy techniques—outlined in the mnemonic PROGRESS—can improve adherence and strengthen the therapeutic relationship. They also can help restore adaptive living skills, promote patient autonomy, minimize relapse, and improve attitudes toward treatment.

Praise. Reinforce positive behavior with genuine praise. Build an inventory of phrases to congratulate patients when they meet their goals or demonstrate a new effort. Follow praise with a question that elicits feedback from patients about their behavior.

Reassure. Because patients may lose faith in medications’ efficacy, use reassurance to explain the time frame for drugs to reach therapeutic levels. Instill hope and remind patients that psychiatric illnesses can improve. Point out that although medications have limitations they do help reduce symptoms.

Optimize regimens. Find an appropriate dosing and frequency that minimizes side effects and facilitates a daily routine of taking medication.² This will help alleviate patients’ anxiety and support confidence in managing their medications.

Guide. Provide verbal and written guidance about what patients can expect from their medications. Include information about side effects and explore supplemental treatment options such as healthy eating, psychotherapy, community rehabilitation programs, and refraining from substances. If patients are unsure about why they take medication, help identify their goals and point out how pharmacotherapy might improve their symptoms.

Remind. Brainstorm with patients about how they can set up ambient cues to help them remember to take medications. Environmental associations promote autonomous behavior that can become second nature. For example, patients may learn to associate breakfast with taking medications. If patients place their medications on the table where they eat their meals, this may reinforce breakfast as a cue to take their medications.

Encourage patients to complete tasks that could help them achieve their goals. This includes taking medications as prescribed and communicating with mental healthcare providers to report side effects or during times of crisis.

Solidify strengths. Build on patients’ adaptive skills and strengths. Identifying efforts to improve their illnesses may turn roadblocks into opportunities to build rapport.

Support self-efficacy. Commend patients, for example, when they can explain and break down into steps the complexities of refilling and taking their medications.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.

With the rapid emergence of novel therapies, psychiatrists face the challenge of deciphering the clinical application of published clinical trials. Although double-blind, randomized, placebo-controlled trials are the gold standard, their validity should be carefully examined.¹ The FRISBEE mnemonic from Duke University’s psychiatry residency program can help you incorporate evidence-based medicine into your patient care.

Follow-up. Carefully interpret studies with inadequate follow-up or high drop-out rates. The reason for patient discontinuation might not be related to the studied intervention.

Randomization. To control for unknown confounding variables, patient assignment must be randomized.

Intent-to-treat analysis. ITT assumes that complete data are available during final analysis on every subject, but subjects often drop out. To compensate for drop-outs, researchers could:

• carry forward the last available measurement as the final result, known as last observation carried forward (LOCF).
  
• use data only from patients who complete entire study protocol (completer analysis method).
  

Both methods have statistical limitations, but LOCF generally is preferred because it accounts for every subject who enrolled in the study.²

Similar baseline. Compare known characteristics of the treatment and placebo groups at baseline. Confounding variables, such as illness severity or medical or psychiatric comorbidities, should appear equally among randomized patient groups. Not all variables will be similar because of random effects, however.

Blinding. With ineffective blinding, patients or researchers can tell which treatment was administered. If this occurs, the study’s outcome likely is biased by treatment expectations. To detect faulty blinding, some studies ask patients and/or providers if they can guess the intervention that was delivered.

Equal treatment. Even with proper randomization and blinding, other intervention-related treatments—such as blood work to monitor side effects or the duration or frequency of provider contact—might not be administered equally among patient groups. This can clue patients and researchers into which intervention was administered and create bias.

Equivalence to your patient. A typical study patient often has few medical and psychiatric comorbidities or psychosocial risk factors. Your patient might be substantially different. Carefully compare the patients in the study with the patient in your office before choosing a treatment.