Xin-Pei Wang

1Institute of Health&Wellbeing,University of Glasgow,Scotland,Britain.

Keywords:Violence tendency tool,Mental health disorders tool,Non-psychiatric healthcare

In recent years,there has been an increase in the number of violent incidents in Chinese general hospitals,posing a serious threat to the safety of medical staff and affecting the medical environment in China [1].Non-psychiatric patients with mental health disorders are more likely to exhibit violent tendencies,while those diagnosed with personality disorders are more likely to have psychological and physical co-morbidities [2].Current commonly used psychological assessment tools,such as Kessler Psychological Distress Scale (K10) [3] and the Hospital Anxiety and Depression Scale (HADS) [4],are not commonly used in non-psychiatric clinical practice.At the same time,most of the available psychological assessment tools are designed for hospital psychiatry.This means that the assessment of personality disorders,once removed from the clinical setting of psychiatry,can undermine the validity of the tool for screening for mental health disorders.Health care professionals other than those in the psychiatric profession usually do not have significant practice in psychiatric assessment and care and have some difficulty in using the mental disorder assessment tool.The first to address this issue was the Huaxi Emotional-distress Index (HEI) [5],a Chinese scale.This scale attempts to apply the practice of the specialist field of psychiatry to the clinical practice of non-psychiatric units in general hospitals in China.However,the scale does not include personality disorders as a separate screening item and is therefore not effective in screening patients with mental health disorders and therefore not effective in screening patients who would potentially use violence.To make up for these shortcomings,scholars such as Yanjun Meng developed a simplified assessment method:the Inpatient Psychological Experience Questionnaires(IPEQs) [6].This questionnaire was developed to provide non-psychiatric professionals with a validated tool to assess mental health and related personality disorders,to improve the identification of patients with violent tendencies and to identify mental health disorders in order to gather the necessary information for better healthcare delivery.

The IPEQs was developed in 2020 by Chinese academic Yanjun Meng et al.,used to screen for six violence-related mental health disorders in patients attending a non-psychiatric unit6:IPEQ-1 (screens for anxiety,depression and suicide);IPEQ-2 (screens for PPD,EUPD and HPD).The initial entries were generated based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) [7].Reference was made to existing self-administered screening scales:such as HADS,Symptom Checklist-90 (SCL-90),Generalized Anxiety Disorder-7 (GAD-7),Self-rating Anxiety Scale (SAS),Patient Health Questionnaire-9 items (PHQ-9),Personality Diagnostic Questionnaire-4+(PDQ-4+) and et al.The questionnaire is a self-administered scale.After completion,16 senior experts in the field were invited to conduct a panel review and two rounds of pre-testing resulted in two scales containing 12 items each.The IPEQ-1 uses Samejima’s hierarchical response model with a five-point Likert design;the IPEQ-2 uses binary responses.The final version of the IPEQ-1 has a total score between 0 and 48,with higher scores indicating greater emotional distress and violent tendencies.The recommended cut-off scores are:≤11 for normal,12～16 for mild,17～21 for moderate and≥22 for severe.The final version of the IPEQ-2 has a total score range of 0 to 12,with higher scores indicating a greater likelihood of personality disorder and violent tendencies.Each personality disorder is scored on a scale ranging from 0 to 4,with a cut-off score of 3 or higher used for each personality disorder screened.

The degree of stability of the scale results and the extent to which the true indicators can actually be measured was tested in 2020 [6].The current study conducted on the IPEQ-1 and IPEQ-2 shows Cronbach coefficients of 0.91 and 0.78 for the full questionnaire and retest reliability of 0.95 and 0.87.Therefore,it can be tentatively inferred that the IPEQs have a high degree of internal consistency and stability.There was good agreement between the IPEQs and the three commonly used existing psychometric assessment instruments,the GAD-7,PHQ-9,and PDQ-4+.The GAD-7(anxiety scale)has an alpha coefficient of 0.92.The PHQ-9,which includes components such as self-harm,has alpha coefficients of 0.89 and 0.86.The PDQ-4+is designed to assess 12 personality disorders and has alpha coefficients of 0.51 to 0.74.In the confirmatory factor analysis,both IPEQ-1 and IPEQ-2 were divided into a 12-factor structure by their entries,where all factor loadings for IPEQ-1 were above 0.50 CFA analysis indicated that IPEQ-2 had good construct validity.The IPEQ-2 had factor loadings above 0.50 except for items 1,9 and 12,which the CTT and IRT analyses suggest should be retained.

It is commendable that the questionnaire has been designed with the needs of non-psychiatry professionals in mind,helping these healthcare professionals to complete screening for clinical signs or features of the six violence-related personality disorders,screen for patients with violent tendencies and reduce barriers to communication with patients without the benefit of a psychiatrist.Although the questionnaire was divided into 1 and 2,the total number of entries was only 24,saving healthcare professionals time and effort while effectively screening for mental health disorders.It has to be said that this was a very effective attempt.However,for non-psychiatric professionals,the effectiveness of using this questionnaire to assess patients cannot be easily trusted.This is because the participants in the questionnaire are currently from only one Grade IIIA general hospital in Shanxi Province and it is not possible to determine whether all non-psychiatric patients can obtain reliable results from this scale.One hospital in one region alone cannot cover all geographical areas and different levels of hospitals in China.Therefore,additional studies that include a larger range of participants are needed as evidence.

The designer of this questionnaire has identified problems with clinical practice and has a high degree of timeliness and problem-solving ability.However,the clinical use of these two scales makes it difficult to ensure that all users are able to follow a unique standard and there is often subjective variation.Although,in terms of the data,the questionnaire has a high degree of consistency for non-psychiatrists,which overcomes the impact on the validity of the questionnaire due to differences in individual levels of expertise in their clinical practice.Many hospital brawls occur before the physician has even had the time and opportunity to identify and pre-treat that patient.This is a potential flaw in the use of this questionnaire,but one that may be related to social factors and less to the design of the questionnaire itself.