The predictive validity of the short-term assessment of risk and treatability (START) for multiple adverse outcomes in a secure psychiatric inpatient setting

The Short-Term Assessment of Risk and Treatability (START) aims to assist mental health practitioners to estimate an individual’s short-term risk for a range of adverse outcomes via structured consideration of their risk (“Vulnerabilities”) and protective factors (“Strengths”) in 20 areas. It has demonstrated predictive validity for aggression but this is less established for other outcomes. We collated START assessments for N = 200 adults in a secure mental health hospital and ascertained 3-month risk event incidence using the START Outcomes Scale. The specific risk estimates, which are the tool developers’ suggested method of overall assessment, predicted aggression, self-harm/suicidality, and victimization, and had incremental validity over the Strength and Vulnerability scales for these outcomes. The Strength scale had incremental validity over the Vulnerability scale for aggressive outcomes; therefore, consideration of protective factors had demonstrable value in their prediction. Further evidence is required to support use of the START for the full range of outcomes it aims to predict

Predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes:the effect of diagnosis

The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N = 527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.</p

Predictive validity of the HCR-20 for violent and non-violent sexual behaviour in a secure mental health service

BackgroundViolent and non-violent sexual behaviour is a fairly common problem among secure mental health service patients, but specialist sexual violence risk assessment is time-consuming and so performed infrequently.AimsWe aimed to establish whether a commonly used violence risk assessment tool, the Health Clinical Risk management 20(HCR-20), has predictive validity specifically for inappropriate sexual behaviour.MethodsA pseudo-prospective cohort design was used for a study in the adult wards of a large provider of specialist secure mental health services. Routine clinical team HCR-20 assessments were extracted from records, and incidents involving inappropriate sexual behaviour were recorded for the 3 months following assessment.ResultsOf 613 patients, 104 (17%) had engaged in at least one inappropriate sexual behaviour; in 65 (10.6%), the sexual act was violent. HCR-20 total score, clinical and risk management subscales, predicted violent and non-violent sexual behaviour. The negative predictive value of the HCR-20 for inappropriate sexual behaviour was over 90%.ConclusionsPrediction of violent sexual behaviour may be regarded as well within the scope of the HCR-20 as a structured professional judgement tool to aid violence risk prediction, but we found that it also predicts behaviours that may be of concern but fall below the violence threshold. High negative predictive values suggest that HCR-20 scores may have some utility for screening out patients who do not require more specialist assessment for inappropriate sexual behaviour

Experiences of women in secure care who have been prescribed clozapine for borderline personality disorder

Background: Clozapine is an atypical antipsychotic medicine which can cause significant side-effects. It is often prescribed off-license in severe cases of borderline personality disorder contrary to national treatment guidelines. Little is known about the experiences of those who take clozapine for borderline personality disorder. We explored the lived-experience of women in secure inpatient care who were prescribed clozapine for borderline personality disorder. Findings: Adult females (N=20) participated in audio-taped semi-structured interviews. Transcripts were subject to thematic analysis. The central themes related to evaluation, wellbeing, understanding and self-management; for many, their subjective wellbeing on clozapine was preferred to prior levels of functioning and symptomatology, sometimes profoundly so. The negative and potentially adverse effects of clozapine were explained as regrettable but relatively unimportant. Conclusions: When psychological interventions are, at least initially, ineffective then clozapine treatment is likely to be evaluated positively by a group of women with borderline personality disorder in secure care despite the potential disadvantages

Electrically-Conductive Polyketone Nanocomposites Based on Reduced Graphene Oxide

In this work, we investigated the functionalization of polyketone 30 (PK30) with glycyl-glycine (Gly-Gly) via the Paal-Knorr reaction with the aim of homogenously dispersing two types of reduced graphene oxide (rGO, i.e., lrGO and hrGO, the former characterized by a lower degree of reduction in comparison to the latter) by non-covalent interactions. The functional PK30-Gly-Gly polymer was effective in preparing composites with homogeneously distributed rGO characterized by an effective percolation threshold at 5 wt. %. All the composites showed a typical semiconductive behavior and stable electrical response after several heating/cooling cycles from 30 to 115 °C. Composites made by hrGO displayed the same resistive behaviour even if flanked by a considerable improvement on conductivity, in agreement with the more reduced rGO content. Interestingly, no permanent percolative network was shown by the composite with 4 wt. % of lrGO at temperatures higher than 45 °C. This material can be used as an ON-OFF temperature sensor and could find interesting applications as sensing material in soft robotics applications

Decision-making and risk-taking in forensic and non-forensic patients with schizophrenia spectrum disorders: A multicenter European study

Studies of patients with schizophrenia and offenders with severe mental disorders decision-making performance have produced mixed findings. In addition, most earlier studies have assessed decision-making skills in offenders or people with mental disorders, separately, thus neglecting the possible additional contribution of a mental disorder on choice patterns in people who offend. This study aimed to fill this gap by comparing risk-taking in patients with schizophrenia spectrum disorders (SSD), with and without a history of serious violent offending assessing whether, and to what extent, risk-taking represents a significant predictor of group membership, controlling for their executive skills, as well as for sociodemographic and clinical characteristics. Overall, 115 patients with a primary diagnosis of SSD were recruited: 74 were forensic patients with a lifetime history of severe interpersonal violence and 41 were patients with SSD without such a history. No significant group differences were observed on psychopathological symptoms severity. Forensic generally displayed lower scores than non-forensic patients in all cognitive subtests of the Brief Assessment of Cognition in Schizophrenia (except for the "token motor" and the "digit sequencing" tasks) and on all the six dimensions of the Cambridge Gambling Task, except for "Deliberation time", in which forensic scored higher than non-forensic patients. "Deliberation time" was also positively, although weakly correlated with "poor impulse control". Identifying those facets of impaired decision-making mostly predicting offenders' behaviour among individuals with mental disorder might inform risk assessment and be targeted in treatment and rehabilitation protocols

Pharmacological interventions to reduce violence in patients with schizophrenia in forensic psychiatry.

Abstract Background The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings. Methods For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review. Results Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterogeneous study designs and outcomes meta-analytic methods could not be applied. Conclusion Due to substantial methodological limitations it is difficult to draw any firm conclusions about the most effective pharmacological strategies to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying more rigorous methods regarding case-definition, outcome measures, sample sizes, and study designs are urgently needed

Neurocognition and social cognition in patients with schizophrenia spectrum disorders with and without a history of violence: results of a multinational European study

Objective: Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence. Methods: Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery. Results: Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group. Conclusions: These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice

Pattern of neural responses to verbal fluency shows diagnostic specificity for schizophrenia and bipolar disorder

Background: Impairments in executive function and language processing are characteristic of both schizophrenia and bipolar disorder. Their functional neuroanatomy demonstrate features that are shared as well as specific to each disorder. Determining the distinct pattern of neural responses in schizophrenia and bipolar disorder may provide biomarkers for their diagnoses. Methods: 104 participants underwent functional magnetic resonance imaging (fMRI) scans while performing a phonological verbal fluency task. Subjects were 32 patients with schizophrenia in remission, 32 patients with bipolar disorder in an euthymic state, and 40 healthy volunteers. Neural responses to verbal fluency were examined in each group, and the diagnostic potential of the pattern of the neural responses was assessed with machine learning analysis. Results: During the verbal fluency task, both patient groups showed increased activation in the anterior cingulate, left dorsolateral prefrontal cortex and right putamen as compared to healthy controls, as well as reduced deactivation of precuneus and posterior cingulate. The magnitude of activation was greatest in patients with schizophrenia, followed by patients with bipolar disorder and then healthy individuals. Additional recruitment in the right inferior frontal and right dorsolateral prefrontal cortices was observed in schizophrenia relative to both bipolar disorder and healthy subjects. The pattern of neural responses correctly identified individual patients with schizophrenia with an accuracy of 92%, and those with bipolar disorder with an accuracy of 79% in which misclassification was typically of bipolar subjects as healthy controls. Conclusions: In summary, both schizophrenia and bipolar disorder are associated with altered function in prefrontal, striatal and default mode networks, but the magnitude of this dysfunction is particularly marked in schizophrenia. The pattern of response to verbal fluency is highly diagnostic for schizophrenia and distinct from bipolar disorder. Pattern classification of functional MRI measurements of language processing is a potential diagnostic marker of schizophrenia

The effect of psychosis associated CACNA1C, and its epistasis with ZNF804A, on brain function

CACNA1C‐rs1006737 and ZNF804A‐rs1344706 polymorphisms are amongst the most robustly associated with schizophrenia (SCZ) and bipolar disorder (BD), and recently with brain phenotypes. As these patients show abnormal verbal fluency (VF) and related brain activation, we asked whether the latter was affected by these polymorphisms (alone and in interaction) – to better understand how they might induce risk. We recently reported effects on functional VF‐related (for ZNF804A‐rs1344706) and structural (for both) connectivity. We genotyped and fMRI‐scanned 54 SCZ, 40 BD and 80 controls during VF. With SPM, we assessed the main effect of CACNA1C‐rs1006737, and its interaction with ZNF804A‐rs1344706, and their interaction with diagnosis, on regional brain activation and functional connectivity (psychophysiological interactions ‐ PPI). Using public data, we reported effects of CACNA1C‐rs1006737 and diagnosis on brain expression. The CACNA1C‐rs1006737 risk allele was associated with increased activation, particularly in the bilateral prefronto‐temporal cortex and thalamus; decreased PPI, especially in the left temporal cortex; and gene expression in white matter and the cerebellum. We also found unprecedented evidence for epistasis (interaction between genetic polymorphisms) in the caudate nucleus, thalamus, and cingulate and temporal cortical activation; and CACNA1C up‐regulation in SCZ and BD parietal cortices. Some effects were dependent on BD/SCZ diagnosis. All imaging results were whole‐brain, voxel‐wise, and familywise‐error corrected. Our results support evidence implicating CACNA1C and ZNF804A in BD and SCZ, adding novel imaging evidence in clinical populations, and of epistasis – which needs further replication. Further scrutiny of the inherent neurobiological mechanisms may disclose their potential as putative drug targets