title: 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: BACKGROUND
  The 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  SAPROF 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.
  
  
  CONCLUSIONS
  The 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.
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dublin 14, Dundrum, Ireland.
authors.forename: Zareena
authors.initials: Z
authors.lastname: Abidin
authors.forename: Mary
authors.initials: M
authors.lastname: Davoren
authors.forename: Leena
authors.initials: L
authors.lastname: Naughton
authors.forename: Olivia
authors.initials: O
authors.lastname: Gibbons
authors.forename: Andrea
authors.initials: A
authors.lastname: Nulty
authors.forename: Harry G
authors.initials: HG
authors.lastname: Kennedy
mesh_terms: D000328:Adult; D005260:Female; D005555:Forensic Psychiatry; D006801:Humans; D007297:Inpatients / Q000523:psychology*; D007600:Judgment; D008297:Male; D001523:Mental Disorders / Q000523:psychology*; D008605:Mental Health Services; D028642:Persons with Psychiatric Disorders; D008875:Middle Aged; D011446:Prospective Studies; D012306:Risk; D018570:Risk Assessment / Q000379:methods; D016728:Self-Injurious Behavior / Q000523:psychology*; D014754:Violence / Q000523:psychology*
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