Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services

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.

Predicting physically violent misconduct in prison: A comparison of four risk assessment instruments

“…In contrast to some studies of relapses by former prisoners released into the community or prisoners in psychiatric facilities (Abidin et al, 2013;deVries Robbé, deVogel, Koster, et al, 2015), we did not obtain incremental values of any scales or subscales that showed fair to good AUC values. This is in line with recent studies suggesting that despite differences in the theoretical bases underlying the four instruments, they tend to measure the same core construct (Yang et al, 2010).…”

Pre- and post-sentence mental health service use by a population cohort of older offenders (≥45 years) in Western Australia

“…Co-occurrence of aggression against the self and others has been previously illustrated in violent psychiatric inpatients (46). Indeed, research has identified an overlap in the factors predictive of the risk of violence towards others and the risk of self-harm (46)(47)(48). Similar to our findings, these studies identified a history of self-harm to be strongly predictive of future violence to others (46)(47)(48) and highlighted the relevance of jointly managing both issues in forensic populations.…”

Deliberate self-harm and the nexus of violence, victimization, and mental health problems in the United States

“…One of these gaps involves whether persons who deliberately self-harm are violent toward others. Several studies allude to aggression (Haavisto et al, 2005) and one study has found that among psychiatric inpatients self-harm and violence are correlated and share common risk and protective factors (Abidin et al, 2013). Beyond these studies, little research has accrued on the connection between DSH behaviors and violent behaviors, including cruelty to animals.…”