Abstract
BackgroundThe START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. The DUNDRUM-3 and DUNDRUM-4 also measure positive factors, programme completion and recovery in forensic settings.MethodsWe compared these instruments with other validated risk instruments (HCR-20, S-RAMM), a measure of psychopathology (PANSS) and global function (GAF). We prospectively tested whether any of these instruments predict violence or self harm in a secure hospital setting (n = 98) and whether they had true protective effects, interacting with and off-setting risk measures.ResultsSAPROF and START-strengths had strong inverse (negative) correlations with the HCR-20 and S-RAMM. SAPROF correlated strongly with GAF (r = 0.745). In the prospective in-patient study, SAPROF predicted absence of violence, AUC = 0.847 and absence of self-harm AUC = 0.766. START-strengths predicted absence of violence AUC = 0.776, but did not predict absence of self-harm AUC = 0.644. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales also predicted in-patient violence (AUC 0.832 and 0.728 respectively), and both predicted in-patient self-harm (AUC 0.750 and 0.713 respectively). When adjusted for the HCR-20 total score however, SAPROF, START-S, DUNDRUM-3 and DUNDRUM-4 scores were not significantly different for those who were violent or for those who self harmed. The SAPROF had a significant interactive effect with the HCR-dynamic score. Item to outcome studies often showed a range of strengths of association with outcomes, which may be specific to the in-patient setting and patient group studied.ConclusionsThe START and SAPROF, DUNDRUM-3 and DUNDRUM-4 can be used to assess both reduced and increased risk of violence and self-harm in mentally ill in-patients in a secure setting. They were not consistently better than the GAF, HCR-20, S-RAMM, or PANSS when predicting adverse events. Only the SAPROF had an interactive effect with the HCR-20 risk assessment indicating a true protective effect but as structured professional judgement instruments all have additional content (items) complementary to existing risk assessments, useful for planning treatment and risk management.
Highlights
The Short-Term Assessment of Risk and Treatability (START) and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors
We compared these to existing validated instruments for the assessment of risk of violence (HCR-20) and self-harm (S-RAMM) and examined whether they accounted for any element of statistical prediction over and above an existing ‘gold standard’ instrument for the assessment of risk of violence, the Historical-Clinical-Risk Management-20 (HCR-20)
We have examined the utility of these instruments for assessing risk and protective factors for both violence and self-harm
Summary
The START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. A combination of both the clinical and actuarial approaches was required This led to the development of the third generation risk assessment [8] described as empirically validated structured decision making [11] or structured professional judgement (SPJ) [12]. The leading structured professional judgement instrument for the assessment of risk of violence has been the Historical-Clinical-Risk Management-20 (HCR-20) [13]. This added the distinction between fixed historical risk factors and dynamic factors that are subject to change over time and in response to treatment. Rated according to a set of defined risk items, the final judgement of risk level allows for clinical judgement rather than a simple actuarial score
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