Predictive validity of the START for unauthorised leave and substance abuse in a secure mental health setting:a pseudo-prospective cohort study

Background Risk assessment and management is central to the nursing role in forensic mental health settings. The Short Term Assessment of Risk and Treatability (START) aims to support assessment through identification of risk and protective factors. It has demonstrated predictive validity for aggression; it also aims to aid risk assessment for unauthorised leave and substance abuse where its performance is relatively untested. Objectives To test the predictive validity of the START for unauthorised leave and substance abuse. Design A naturalistic, pseudo-prospective cohort study. Settings Four centres of a large UK provider of secure inpatient mental health services. Participants Inpatients resident between May 2011 and October 2013 who remained in the service for 3-months following assessment with the START by their clinical team. Exclusion criteria were missing assessment data in excess of prorating guidelines. Of 900 eligible patients 73 were excluded leaving a final sample size of n = 827 (response rate 91.9%). Mean age was 38.5 years (SD = 16.7); most participants (72.2%) were male; common diagnoses were schizophrenia-type disorders, personality disorders, organic disorders, developmental disorders and intellectual disability. Methods Routinely conducted START assessments were gathered. Subsequent incidents of substance abuse and unauthorised leave were coded independently. Positive and negative predictive values of low and elevated risk were calculated. Receiver Operating Characteristic analysis was conducted to ascertain the predictive accuracy of the assessments based on their sensitivity and specificity. Results Patient-based rates of unauthorised leave (2.4%) and substance abuse (1.6%) were low. The positive and negative predictive values for unauthorised leave were 5.9% and 98.4%; and for substance abuse 8.1% and 99.0%. The START specific risk estimate for unauthorised leave predicted its associated outcome (Area under the curve = .659, p < .05, 95% CI .531, .786); the substance abuse risk estimate predicted its outcome with a large effect size (Area under the curve = .723, p < .01, 95% CI .568, .879). Conclusions The study provides limited support for the START by demonstrating the predictive validity of its specific risk estimates for substance abuse and unauthorised leave. High negative predictive values suggest the tool may be of most utility in screening out low risk individuals from unnecessary restrictive interventions; very low positive predictive values suggest caution before implementing restrictive interventions in those rated at elevated risk. Researchers should investigate how multidisciplinary teams formulate risk assessments for these outcomes since they outperform the quantitative element of this tool

Predictive validity of the short-term assessment of risk and treatability (START) for aggression and self-harm in a secure mental health service:gender differences

The START predicts aggressive outcomes and to some extent self-harm. However, it is not known whether gender moderates its performance. This study used routinely collected data to investigate the predictive ability of the START for aggression and self-harm in secure psychiatric patients. Utility of the START was examined separately for men and women. The START was a stronger predictor of aggression and self-harm in women than men. The specific risk estimates produced large effect sizes for the prediction of aggression and self-harm in women; none of the AUC values reached the threshold for a large effect size in the male sample

Use of the HCR-20 for violence risk assessment:views of clinicians working in a secure inpatient mental health setting

Purpose: To explore how raters combine constituent components of HCR-20 risk assessment for inpatient aggression, and how relevant they rate the tool for different diagnostic and demographic groups.Design/methodology/approach: A cross-sectional survey design was used. N=45 mental health clinicians working in a secure hospital responded to an online survey about their risk assessment practice.Findings: HCR-20 Historical and Clinical sub-scales were rated the most relevant to violence prediction but four of the five items rated most relevant were Historical items. A recent history of violence was rated more important for risk formulation than Historical and Risk management items, but not more important than Clinical items. While almost all respondents believed predictive accuracy would differ by gender, the tool was rated similarly in terms of its relevance for their client group by people working with men and women respectively.Research limitations/ implications: This was an exploratory survey and results should be verified using larger samples.Practical implications: Clinicians judge recent violence and Clinical items most important in inpatient violence risk assessment but may over-value historical factors. They believe that recent violent behaviour is important in risk formulation; however, while recent violence is an important predictor of future violence, the role it should play in SPJ schemes is poorly codified.Social implications: It is important that risk assessment is accurate in order to both protect the public and to protect patients from overly lengthy and restrictive detention.Originality/ value: Despite the vast number of studies examining the predictive validity of tools like HCR-20 very little research has examined the actual processes and decision-making behind formulation in clinical practice

Role of assessment components and recent adverse outcomes in risk estimation and prediction:use of the Short Term Assessment of Risk and Treatability (START) in an adult secure inpatient mental health service

The Short Term Assessment of Risk and Treatability is a structured judgement tool used to inform risk estimation for multiple adverse outcomes. In research, risk estimates outperform the tool's strength and vulnerability scales for violence prediction. Little is known about what its’component parts contribute to the assignment of risk estimates and how those estimates fare in prediction of non-violent adverse outcomes compared with the structured components. START assessment and outcomes data from a secure mental health service (N=84) was collected. Binomial and multinomial regression analyses determined the contribution of selected elements of the START structured domain and recent adverse risk events to risk estimates and outcomes prediction for violence, self-harm/suicidality, victimisation, and self-neglect. START vulnerabilities and lifetime history of violence, predicted the violence risk estimate; self-harm and victimisation estimates were predicted only by corresponding recent adverse events. Recent adverse events uniquely predicted all corresponding outcomes, with the exception of self-neglect which was predicted by the strength scale. Only for victimisation did the risk estimate outperform prediction based on the START components and recent adverse events. In the absence of recent corresponding risk behaviour, restrictions imposed on the basis of START-informed risk estimates could be unwarranted and may be unethical

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

Did Massive Primordial Stars Preenrich the Lyman Alpha Forest?

We examine the dynamical evolution and statistical properties of the supernova ejecta of massive primordial stars in a cosmological framework to determine whether this first population of stars could have enriched the universe to the levels and dispersions seen by the most recent observations of the Lyman-Alpha forest. We evolve a lambda CDM model in a 1 Mpc^3 volume to a redshift of z = 15 and add ``bubbles'' of metal corresponding to the supernova ejecta of the first generation of massive stars in all dark matter halos with masses greater than 5 times 10^5 solar masses. These initial conditions are then evolved to z = 3 and the distribution and levels of metals are compared to observations. In the absence of further star formation the primordial metal is initially contained in halos and filaments. Photoevaporation of metal-enriched gas due to the metagalactic ultraviolet background radiation at the epoch of reionization (z ~ 6) causes a sharp increase of the metal volume filling factor. At z = 3, ~ 2.5% of the simulation volume (approx. 20% of the total gas mass) is filled with gas enriched above a metallicity of 10^-4 Z_solar, and less than 0.6% of the volume is enriched above a metallicity of 10^-3 Z_solar. This suggests that, even with the most optimistic prescription for placement of primordial supernova and the amount of metals produced by each supernova, this population of stars cannot entirely be responsible for the enrichment of the Lyman-$\alpha$ forest to the levels and dispersions seen by current observations unless we have severely underestimated the duration of the Pop III epoch. However, comparison to observations show that Pop III supernovae can be significant contributors to the very low overdensity Lyman-Alpha forest.Comment: 4 pages, 3 figures (color). Accepted to ApJ Letters. Replaced version has some correction

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 inpatient aggression:the effect of intellectual disability on accuracy

BackgroundPeople with intellectual disability (ID) account for a large proportion of aggressive incidents in secure and forensic psychiatric services. Although the Historical, Clinical, Risk Management 20 (HCR-20) has good predictive validity in inpatient settings, it does not perform equally in all groups and there is little evidence for its efficacy in those with ID.MethodA pseudo-prospective cohort study of the predictive efficacy of the HCR-20 for those with ID (n = 109) was conducted in a UK secure mental health setting using routinely collected risk data. Performance of the HCR-20 in the ID group was compared with a comparison group of adult inpatients without an ID (n = 504). Analysis controlled for potential covariates including security level, length of stay, gender and diagnosis.ResultsThe HCR-20 total score was a significant predictor of any aggression and of physical aggression for both groups, although the area under the curve values did not reach the threshold for a large effect size. The clinical subscale performed significantly better in those without an ID compared with those with. The ID group had a greater number of relevant historical and risk management items. The clinicians' summary judgment significantly predicted both types of aggressive outcomes in the ID group, but did not predict either in those without an ID.ConclusionsThis study demonstrates that, after controlling for a range of potential covariates, the HCR-20 is a significant predictor of inpatient aggression in people with an ID and performs as well as for a comparison group of mentally disordered individuals without ID. The potency of HCR-20 subscales and items varied between the ID and comparison groups suggesting important target areas for improved prediction and risk management interventions in those with ID

Reliable and clinically significant change in outcomes for forensic mental health inpatients:use of the HoNOS-Secure

Outcomes measures are commonly derived from post-discharge recidivism, readmission, and mortality rates but information about common outcomes across admission is scant. We determined whether reliable and clinically significant change in risk-related need, behavior, functioning, and symptoms occurred during admission by analysing routinely collected HoNOS-secure data (N = 418). We calculated between-group differences in baseline scores and rates of change, the proportion of patients for whom change was reliable, and, of those, the proportion whose scores fell by a clinically significant margin. Reliable change was demonstrated for 4.8% and 5.7% of patients on the HoNOS-secure scale and security scale respectively, and that change was rarely clinically significant. In a context in which services rarely report on routinely collected data for a range of outcomes, we found that HoNOS-secure captured little of any clinical change that may have occurred. Further research should determine whether the HoNOS-secure is a suitable tool for routine outcomes reporting

Protective factors in risk assessment schemes for adolescents in mental health and criminal justice populations: a systematic review and meta-analysis of their predictive efficacy

The consideration of protective factors has been integrated into a number of instruments whose aim is assess the risk of adverse outcomes among adolescents in high-risk mental health and criminal justice populations; however, little is known about their contribution to accurate risk prediction. We systematically reviewed the evidence for predictive efficacy of nine selected tools that require assessors to consider protective factors. Three tools had been tested for predictive ability but only one (the Structured Assessment of Violence Risk in Youth) had been examined in multiple studies. Meta-analysis revealed that risk prediction based on the results did not improve over that based on a deficits model. Important decisions based on results of some protective factor-based tools should be treated with extreme caution since they lack empirical support. The importance of protective factors in problematic behavior has been demonstrated elsewhere, but this has not translated into significantly improved tools for use in clinical risk assessment in mental health and criminal justice populations