Abstract
The assessment and formulation of the risk of violence and other unwanted behaviors at forensic psychiatric facilities have been attempted for decades. Structured professional judgment tools, such as the Short-Term Assessment of Risk and Treatability (START), are among the recent attempts to overcome the challenge of accomplishing these goals. This study examined the effect of implementing START in clinical practice for the most serious adverse events among the target group of severely mentally ill forensic psychiatric inpatients. Results were based on the use of mechanical restraints as an outcome. This study is a pragmatic, stepped-wedge, cluster-randomized controlled trial and was conducted over 5 years. It included eight forensic psychiatric units. Fifty out of 156 patients who had a basic aggression score of more than 0 were included in the study. We found that the rate of mechanical restraint use within the START period were 82% [relative risk (RR) = 0.18], lower than those outside of the START period. Patients evaluated within the START period were also found to have a 36% (RR = 0.64) lower risk of having higher Brøset Violence Checklist scores than patients evaluated outside the START period. Previous studies on START have primarily focused on validation, the predictive capability of the assessment, and implementation. We were only able to identify one study that aimed to identify the benefits and outcomes of START in a forensic setting. This study showed a significant reduction in the chance for inpatients in a forensic psychiatric facility to become mechanically restrained during periods where the START was used as risk assessment.
Highlights
Valid and reliable measures to assess the risk of violence and other challenging behaviors at forensic psychiatric facilities have been in demand for decades, and several structured professional judgment tools have been developed and introduced into clinical practice [1,2,3,4,5,6,7,8]
If we had followed the intention-to-treat principle, we would not have been able to evaluate the effect of Short-Term Assessment of Risk and Treatability (START); instead, we would have obtained the effect of the ability of the unit to perform START
The rate of mechanical restraint use within the START period was 82% lower than that outside the START period [relative risk (RR) = 0.18; 95% confidence interval (CI), 0.08–0.41; p < 0.01; p = 3.01 × 10–5]
Summary
Valid and reliable measures to assess the risk of violence and other challenging behaviors at forensic psychiatric facilities have been in demand for decades, and several structured professional judgment tools have been developed and introduced into clinical practice [1,2,3,4,5,6,7,8]. In 2014, the Danish government ordered a reduction of mechanical restraint use in inpatient settings by half before 2020, signaling that this was considered the most intrusive type of coercion applied. This study aimed to examine the effects of START implementation in clinical practice on the most serious adverse events as expressed by the necessity for mechanical restraint use among the target group of severely mentally ill forensic psychiatric inpatients
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