Routine Violence Risk Assessment in Community Forensic Mental Healthcare

We developed a method for periodic monitoring of violence risk, as part of routine community forensic mental healthcare. The feasibility of the method was tested, as well as its predictive validity for violent and risk enhancing behavior in the subsequent months. Participants were 83 clients who received forensic psychiatric home treatment, and six case managers. The method proved feasible and informative. Violent and risk enhancing behavior could be predicted to a reasonable extent (AUC = .77, 95% CI = .70-.85; respectively .76, .70-.82). Dynamic risk factors had an incremental predictive value over static factors in the prediction of violent behavior (OR = 4.30, 1.72-10.73). The professional judgment of the case managers added further predictive power (OR = 2.16, 1.40-3.33), corroborating the structured professional judgment approach. Finally, unmet needs for care of the client were associated with a reduced risk for violent and risk enhancing behavior (OR = .80, 0.69-0.93, and 0.84, 0.72-0.97). This latter finding suggests that in cases with unmet needs the case manager saw opportunities to do something about the risk. Currently we are testing whether using the method actually prevents violence. Copyright (C) 2009 John Wiley & Sons, Ltd

Stressful life events as a link between problems in nonverbal communication and recurrence of depression

Background.- Interpersonal difficulties and stressful life events are important etiological factors in (recurrence of) depression. This study examines whether stressful life events mediate the influence of problems in nonverbal communication on recurrence of depression. Methods.- We registered nonverbal expressions of involvement from videotaped behavior of 101 remitted outpatients and their interviewers. During a 2-year follow-up, We assessed stressful life events and recurrence of depression. Results.- The less congruent the levels of nonverbal involvement behavior of participants and interviewers, the higher the incidence of stressful life events, and -via these - the risk of recurrence. Limitations.- Nonverbal behavior was measured in an experimental setting. Conclusions.- The results suggest that lack of nonverbal congruence during social interaction contributes to the occurrence of stressful life events, which in turn may trigger depression. (c) 2006 Elsevier B.V All rights reserved

The association between levels of cortisol secretion and fear perception in patients with remitted depression predicts recurrence

This study examines the association between cortisol secretion and fear perception in remitted patients to identify mechanisms underlying risk for recurrence of depression. We hypothesized that the stronger the association between cortisol secretion and fear perception in persons with remitted depression, the more recurrence would be experienced. We also investigated whether high levels of cortisol and fear perception per se predict more recurrence. These effects were assumed to be stronger in women than in men. In a prospective design, we investigated 77 outpatients with remitted depression and related the association between their 24-hour urinary free cortisol secretion and fear perception (from ambiguous faces and from vocal expressions) to recurrence of depression within 2 years. We applied Cox regression models, partial correlations, and Fisher z tests. In 21 patients, depression recurred. Irrespective the channel of perception (eye or ear), the interaction between fear perception and cortisol secretion was significantly related to recurrence of depression. Patients high or low on both variables are more at risk. This increased risk was also reflected by a significant association between cortisol secretion and facial fear perception, but only among subjects who experienced recurrence. A trend in the same direction was found for vocal fear perception. Fear perception and cortisol secretion per se did not predict recurrence. No gender differences were found. The association between cortisol secretion and fear perception (probably indicative for altered fear circuits in the brain) constitutes a mechanism underlying risk for recurrence of depression

Single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) for violent behaviour in outpatient forensic psychiatry

The single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) has not been thoroughly investigated, although this has great clinical relevance for the selection of treatment targets. Furthermore, it remains unclear whether the characteristic START additions of scoring strengths next to vulnerabilities and selecting key items, add incremental predictive validity. Finally, predictive validity has primarily been studied in inpatient settings and included mainly patients with a psychotic disorder. We analysed data from a mixed diagnostic sample of 195 forensic psychiatric outpatients with a 3-month and 170 patients with a 6-month follow-up period, using logistic regression analysis. The occurrence of violent or criminal behaviour was established based on the case manager's recordings in the patient's file. Only 5 of the 20 START items were found to have predictive validity: Impulse Control, Attitudes, Material Resources, Rule Adherence and Conduct. The last three were the only items for which incremental predictive validity was found with respect to scoring it as a strength and a vulnerability. Selection of key items did not add to the predictive validity. While possibly having therapeutic significance, the scoring of strength next to vulnerability and the selection of key items, may not be beneficial for risk assessment

Weak self-directed learning skills hamper performance in cumulative assessment

Background: Self-regulated learning is an important determinant of academic performance. Previous research has shown that cumulative assessment encourages students to work harder and improve their results. However, not all students seem to respond as intended. We investigated the influence of students' behavioral traits on their responsiveness to a cumulative assessment strategy. Method: The cumulative test results of a third-year integrated ten-week course unit were analyzed. The test was divided into three parts delivered at 4, 8 and 10 weeks. Low starters (below median) with low or high improvement (below or above the median) were identified and compared regarding their behavioral traits (assessed with the Temperament and Character Inventory questionnaire). Results: A total of 295 students filled out the questionnaire. A percentage of 70% of the students below the median on the first two test parts improved during the final part. Students who were less responsive to improve their test results, scored low only on the TCI scale "self directedness" (t = 2.49; p = 0.011). Conclusion: Behavioral traits appear to influence student reactions to feedback on test results, with students with low self-directedness scores being particularly at risk. They can thus be identified and should receive special attention from student counselors

Predictive Validity of the Short-Term Assessment of Risk and Treatability for Violent Behavior in Outpatient Forensic Psychiatric Patients

It remains unclear whether prediction of violence based on historical factors can be improved by adding dynamic risks, protective strengths, selection of person-specific key strengths or critical vulnerabilities, and structured professional judgment (SPJ). We examine this in outpatient forensic psychiatry with the Short-Term Assessment of Risk and Treatability (START) at 3 and 6 months follow-up. An incident occurred during 33 (13%) out of 252 3-month and 44 (21%) out of 211 6-month follow-up periods (n = 188 unique clients). Pearson correlations for all predictor variables were in the expected directions. Prediction of recidivism based on historical factor ratings (odds ratio [OR] = 1.10) could not be improved through the addition of dynamic risk, protective strength, or key or critical factor scores (all ORs ns). The addition of the SPJ improved the model to modest accuracy (area under the curve [AUC] = .64) but made no independent significant contribution (OR = 1.55, p = .21) for the 3-month follow-up. For the 6-month follow-up, SPJ scores also increased predictive accuracy to modest (AUC = .67) and made a significant independent contribution to the prediction of the outcome (OR = 1.98, p = .04). Multicollinearity limits were unviolated. Limitations apply, however, results are similar to those from clinical, researcher rated samples and are discussed in the light of setting specific characteristics. Although it is too early to advocate implementing risk assessment instruments in clinical practice, we can conclude that clinicians in a heterogeneous outpatient forensic psychiatric setting can achieve similar results with the START as clinicians and research staff in more homogeneous inpatient settings

Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry

Background: In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning. Methods: In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied. Results: Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95% CI: 0.60-0.80). Conclusions: In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry