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

Effects of Implementing the Short-Term Assessment of Risk and Treatability for Mechanical Restraint in a Forensic Male Population: A Stepped-Wedge, Cluster-Randomized Design

The assessment and formulation of the risk of violence and other unwanted behaviors at forensic psychiatric facilities have been attempted for decades. Structured professional judgment tools, such as the Short-Term Assessment of Risk and Treatability (START), are among the recent attempts to overcome the challenge of accomplishing these goals. This study examined the effect of implementing START in clinical practice for the most serious adverse events among the target group of severely mentally ill forensic psychiatric inpatients. Results were based on the use of mechanical restraints as an outcome. This study is a pragmatic, stepped-wedge, cluster-randomized controlled trial and was conducted over 5 years. It included eight forensic psychiatric units. Fifty out of 156 patients who had a basic aggression score of more than 0 were included in the study. We found that the rate of mechanical restraint use within the START period were 82% [relative risk (RR) = 0.18], lower than those outside of the START period. Patients evaluated within the START period were also found to have a 36% (RR = 0.64) lower risk of having higher Brøset Violence Checklist scores than patients evaluated outside the START period. Previous studies on START have primarily focused on validation, the predictive capability of the assessment, and implementation. We were only able to identify one study that aimed to identify the benefits and outcomes of START in a forensic setting. This study showed a significant reduction in the chance for inpatients in a forensic psychiatric facility to become mechanically restrained during periods where the START was used as risk assessment.

Occurrence of workplace violence and the psychological consequences of it among nurses working in psychiatric outpatient settings

WHAT IS KNOWN ON THE SUBJECT?: There is a scarcity of studies concerning violence in psychiatric outpatient settings in the 2010s in spite of the deinstitutionalization of psychiatric services. Previous research on violence in psychiatric outpatient settings has failed to consider the association between the psychological consequences of violence, exposures to violence and background factors. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: It has been known for some time that exposures to violence are harmful for psychiatric inpatient nurses; the paper demonstrates that psychiatric outpatient nurses are also at risk. The psychological consequences of exposure to violence are highly individualized and influenced by background factors. Nurses who face harassment have a greater risk of suffering psychological symptoms. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should consider the possibility of internal violence occurring when planning preventive interventions to manage and reduce workplace violence. Education targeted at violence prevention, management and debriefing should be organized systematically in psychiatric outpatient units and be taken into consideration in the mental health nursing curriculum. ABSTRACT: Introduction There is a scarcity of studies concerning violence and its consequences in psychiatric outpatient setting. Aim This study aimed to explore the occurrence of workplace violence and the psychological consequences of exposure to violence among nurses working in psychiatric outpatient settings. Method Research followed a cross-sectional survey design. Data were collected with the VIA-Q instrument. Results During the 12 months prior to the study, nurses (n = 181) had most often experienced psychological violence, with fatigue being the most common consequence. Harassment most often caused feelings of violated integrity, whereas physical violence most often caused insomnia. Significant relationships between exposure to violence and psychological consequences were identified. Discussion Workplace violence can manifest in a broad array of psychological symptoms and be harmful for nurses in psychiatric outpatient settings. It is important to discuss the subject of workplace violence and its place in the nursing curriculum and to reflect on how nurses are educated and trained to face violence in psychiatric nursing. Implications for Practice De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should take steps to abolish internal violence. Nurses need appropriate education in order to prepare them to manage workplace violence.

Validity of Short-Term Assessment of Risk and Treatability in the Japanese Forensic Probation Service

This study aimed to evaluate the predictive validity and reliability of the Short-Term Assessment of Risk and Treatability (START) in the context of the Japanese forensic probation service. START is a structured professional judgement guide for risk domains concerning negative behaviors such as violence, self-harm, suicide, substance abuse, unauthorized leave, victimization, and self-neglect. In this study, rehabilitation coordinators evaluated community-dwelling patients who were treated under the Medical Treatment and Supervision Act at baseline and followed-up for 6 months. The results revealed that START vulnerability scores significantly predicted self-harm, suicide, physical aggression, substance abuse, and self-neglect. START strength scores predicted physical violence and unauthorized leave. Specific risk estimates predicted physical violence and self-neglect. Risk judgement for future substance use may require adjustments for cultural differences, because of the lower prevalence in Japan. These results suggest that START offers a feasible and valid tool that allows clinicians to plan treatment and promote recovery of forensic patients in Japan.

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.

Routine Outcome Monitoring and Clinical Decision-Making in Forensic Psychiatry Based on the Instrument for Forensic Treatment Evaluation

Background

Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE).

Methods

Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders.

Results and Conclusions

Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources.