title: Recovery and concordance in a secure forensic psychiatry hospital - the self rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales.
abstract: BACKGROUND
  Detention in a secure forensic psychiatric hospital may inhibit engagement and recovery. Having validated the clinician rated DUNDRUM-3 (programme completion) and DUNDRUM-4 (recovery) in a forensic hospital, we set out to draft and validate scales measuring the same programme completion and recovery items that patients could use to self-rate. Based on previous work, we hypothesised that self-rating scores might be predictors of objective progress including conditional discharge. We hypothesised also that the difference between patients' and clinicians' ratings of progress in treatment and other factors relevant to readiness for discharge (concordance) would diminish as patients neared discharge. We hypothesised also that this difference in matched scores would predict objective progress including conditional discharge.
  
  
  METHODS
  In a prospective naturalistic observational cohort study in a forensic hospital, we examined whether scores on the self-rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales or differences between clinician and patient ratings on the same scales (concordance) would predict moves between levels of therapeutic security and conditional discharge over the next twelve months.
  
  
  RESULTS
  Both scales stratified along the recovery pathway of the hospital, but clinician ratings matched the level of therapeutic security more accurately than self ratings. The clinician rated scales predicted moves to less secure units and to more secure units and predicted conditional discharge but the self-rated scores did not. The difference between clinician and self-rated scores (concordance) predicted positive and negative moves and conditional discharge, but this was not always an independent predictor as shown by regression analysis. In regression analysis the DUNDRUM-3 predicted moves to less secure places though the HCR-20 C & R score dominated the model. Moves back to more secure places were predicted by lack of concordance on the DUNDRUM-4. Conditional discharge was predicted predominantly by the DUNDRUM-3.
  
  
  CONCLUSIONS
  Patients accurately self-rate relative to other patients however their absolute ratings were consistently lower (better) than clinicians' ratings and were less accurate predictors of outcomes including conditional discharge. Quantifying concordance is a useful part of the recovery process and predicts outcomes but self-ratings are not accurate predictors.
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. davoreM@tcd.ie.|National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. davoreM@tcd.ie.
authors: Mary
authors: M
authors: Davoren
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. sarah.hennessy@hse.ie.
authors: Sarah
authors: S
authors: Hennessy
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. Catherine.conway3@hse.ie.
authors: Catherine
authors: C
authors: Conway
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. seamarr@hotmail.com.
authors: Seamus
authors: S
authors: Marrinan
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. Pauline.gill@hse.ie.
authors: Pauline
authors: P
authors: Gill
authors: Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. kennedh@tcd.ie.|National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland. kennedh@tcd.ie.
authors: Harry G
authors: HG
authors: Kennedy
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005555:Forensic Psychiatry / Q000379:methods*; D006801:Humans; D008297:Male; D037141:Mandatory Programs / Q000458:organization & administration*; D008875:Middle Aged; D015233:Models, Statistical; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011567:Psychiatric Department, Hospital / Q000458:organization & administration*; D057566:Self Report; D012720:Severity of Illness Index