Rates of violence in patients classified as high risk by structured risk assessment instruments
01 Mar 2014-British Journal of Psychiatry (Royal College of Psychiatrists)-Vol. 204, Iss: 3, pp 180-187
TL;DR: After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation and assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base.
Abstract: Background
Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies.
Aims
To analyse the variation in rates of violence in individuals identified as high risk by SRAIs.
Method
A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity.
Results
Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study.
Conclusions
After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.
Citations
More filters
Molde University College1, North Carolina State University2, University of South Florida3, University of Barcelona4, University of New South Wales5, Centre for Mental Health6, National University of La Plata7, Universidad Autónoma de Yucatán8, Karolinska Institutet9, Castle Peak Hospital10, University of Southern Denmark11, University of Mons12, Simon Fraser University13, University of Mainz14, Maastricht University15, University of Konstanz16
TL;DR: It is suggested that violence risk assessment is a global phenomenon, as is the use of instruments to assist in this task, and improved feedback following risk assessments and the development of risk management plans could improve the efficacy of health services.
Abstract: Mental health professionals are routinely called upon to assess the risk of violence presented by their patients. Prior surveys of risk assessment methods have been largely circumscribed to individual countries and have not compared the practices of different professional disciplines. Therefore, a Web-based survey was developed to examine methods of violence risk assessment across six continents, and to compare the perceived utility of these methods by psychologists, psychiatrists, and nurses. The survey was translated into nine languages and distributed to members of 59 national and international organizations. Surveys were completed by 2135 respondents from 44 countries. Respondents in all six continents reported using instruments to assess, manage, and monitor violence risk, with over half of risk assessments in the past 12 months conducted using such an instrument. Respondents in Asia and South America reported conducting fewer structured assessments, and psychologists reported using instruments more ...
186 citations
TL;DR: These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines by using a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes.
Abstract: These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.
95 citations
TL;DR: It is found that the new, common STATIC risk categories not only increase concordance of risk classification (from 51% to 72%)—they also allow evaluators to make the same inferences for offenders in the same category regardless of which instrument was used to assign category membership.
Abstract: This article describes principles for developing risk category labels for criterion referenced prediction measures, and demonstrates their utility by creating new risk categories for the Static-99R and Static-2002R sexual offender risk assessment tools. Currently, risk assessments in corrections and forensic mental health are typically summarized in 1 of 3 words: low, moderate, or high. Although these risk labels have strong influence on decision makers, they are interpreted differently across settings, even among trained professionals. The current article provides a framework for standardizing risk communication by matching (a) the information contained in risk tools to (b) a broadly applicable classification of "riskiness" that is independent of any particular offender risk scale. We found that the new, common STATIC risk categories not only increase concordance of risk classification (from 51% to 72%)-they also allow evaluators to make the same inferences for offenders in the same category regardless of which instrument was used to assign category membership. More generally, we argue that the risk categories should be linked to the decisions at hand, and that risk communication can be improved by grounding these risk categories in evidence-based definitions. (PsycINFO Database Record
81 citations
Cites background from "Rates of violence in patients class..."
...There are currently hundreds of different offender risk tools used worldwide (Singh et al., 2014), each with its own interpretive categories....
[...]
TL;DR: It is found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only.
71 citations
Cites background from "Rates of violence in patients class..."
...The need to be cautious in the use of risk assessment instruments for individual clinical decisions is compounded by the low and varying base rates for violent recidivism in the local population of which the assessed person is a member and the assessed person is compared with [71]....
[...]
TL;DR: A prediction model in a Swedish prison population that can assist with decision making on release by identifying those who are at low risk of future violent offending, and those at high risk of violent reoffending who might benefit from drug and alcohol treatment is developed.
68 citations
References
More filters
TL;DR: In this article, it was predicted that good treatment behavior (in terms of in-session behavior, homework quality, and global ratings of motivation and change achieved) would be associated with parole success and lower recidivism in a sample of 283 sex offenders.
Abstract: Consistent with findings in other areas of clinical practice, it was predicted that good treatment behavior (in terms of in-session behavior, homework quality, and global ratings of motivation and change achieved) would be associated with parole success and lower recidivism in a sample of 283 sex offenders This prediction was not supported: Good treatment behavior was unrelated to parole failure or general recidivism, and it was associated with higher serious recidivism (a new violent or sexual offense) after an average time at risk of 32 months Further exploration revealed that men who scored higher in psychopathy and better in treatment behavior were the most likely to reoffend These results could have important implications for risk management and treatment planning
393 citations
TL;DR: Survival analyses revealed that those offenders high in both psychopathy and sexual deviance were an especially high-risk group, and predictive accuracy was higher for child molesters than for rapists.
Abstract: Four actuarial instruments for the prediction of violent and sexual reoffending (the Violence Risk Appraisal Guide [VRAG], Sex Offender Risk Appraisal Guide [SORAG], Rapid Risk Assessment for Sex Offender Recidivism [RRASOR] and Static-99) were evaluated in 4 samples of sex offenders (N = 396). Although all 4 instruments predicted violent (including sexual) recidivism and recidivism known to be sexually motivated, areas under the receiver operating characteristic (ROC) were consistently higher for the VRAG and the SORAG. The instruments performed better when there were fewer missing items and follow-up time was fixed, with an ROC area up to .84 for the VRAG, for example, under such favorable conditions. Predictive accuracy was higher for child molesters than for rapists, especially for the Static-99 and the RRASOR. Consistent with past research, survival analyses revealed that those offenders high in both psychopathy and sexual deviance were an especially high-risk group.
365 citations
TL;DR: The reliability and validity of judgments concerning risk for violence made using the Spousal Assault Risk Assessment Guide (SARA) showed good convergent and discriminant validity with respect to other measures related to risk for general and violent criminality.
Abstract: We evaluated the reliability and validity of judgments concerning risk for violence made using the Spousal Assault Risk Assessment Guide (SARA; Kropp, Hart, Webster, & Eaves, 1994, 1995, 1998). We analyzed SARA ratings in six samples of adult male offenders (total N = 2681). The distribution of ratings indicated that offenders were quite heterogeneous with respect to the presence of individual risk factors and to overall perceived risk. Structural analyses of the risk factors indicated moderate levels of internal consistency and item homogeneity. Interrater reliability was high for judgments concerning the presence of individual risk factors and for overall perceived risk. SARA ratings significantly discriminated between offenders with and without a history of spousal violence in one sample, and between recidivistic and nonrecidivistic spousal assaulters in another. Finally, SARA ratings showed good convergent and discriminant validity with respect to other measures related to risk for general and violent criminality.
354 citations
339 citations
TL;DR: The ARAIs cannot be used to estimate an individual's risk for future violence with any reasonable degree of certainty and should be used with great caution or not at all.
Abstract: Background Actuarial risk assessment instruments (ARAIs) estimate the probability that individuals will engage in future violence.
Aims To evaluate the `margins of error' at the group and individual level for risk estimates made using ARAIs.
Method An established statistical method was used to construct 95% CI for group and individual risk estimates made using two popular ARAIs.
Results The 95% CI were large for risk estimates at the group level; at the individual level, they were so high as to render risk estimates virtually meaningless.
Conclusions The ARAIs cannot be used to estimate an individual's risk for future violence with any reasonable degree of certainty and should be used with great caution or not at all. In theory, reasonably precise group estimates could be made using ARAIs if developers used very large construction samples and if the tests included few score categories with extreme risk estimates.
295 citations