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
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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
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...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]....
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References
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TL;DR: In this article, a prospective study examined the relative ability of the PCL-R and two other instruments, the Historical Clinical Risk-20 (HCR-20) and the Emotional Problem Scales' Behaviour Ratings Scale, to predict officially recorded institutional aggression.
Abstract: Psychopathy has emerged as one of the constructs most predictive of violence risk in the forensic field. The Psychopathy Checklist-Revised (PCL-R) has previously been found to have acceptable reliability and validity in a sample of offenders with intellectual disability, but its predictive validity in this group has yet to be established. This prospective study examined the relative ability of the PCL-R and two other instruments, the Historical Clinical Risk-20 (HCR-20) and the Emotional Problem Scales' Behaviour Ratings Scale, to predict officially recorded institutional aggression. A sample of 60 offenders with intellectual disability in a high security forensic psychiatric setting was followed up for a period of 12 months. The PCL-R 20-item total, the PCL-R 13-item total, and PCL-R Factor 1 and Factor 2 scores did not significantly predict any type of aggressive behaviour. In contrast, the two more clinically based measures significantly predicted both interpersonal physical and verbal/propert...
78 citations
TL;DR: In this paper, the authors examined the predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) by examining relationships between SAVRY scores and violent reoffending during a 3-year period after sentencing.
Abstract: This study examines the predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) by examining relationships between SAVRY scores and violent reoffending during a 3-year period after sentencing. Two types of sentences were studied: a mandatory treatment order (N = 77) and a juvenile prison sentence (N = 40). The predictive validity of the SAVRY was significant for the two types of sentences. The predictive validity of the unstructured clinical judgment proved to be not significant. Support was found for the hypothesis that the juvenile court's sentence (treatment versus detention) might have been influenced by the unstructured clinical risk assessment of the mental health experts, even though this assessment is a poor predictor of violent reoffending.
74 citations
TL;DR: The VRAG is a very good predictor of future violence in the UK sample and the OGRS may also be of value as it can be completed quickly and without the need for mental health variables.
Abstract: Background Actuarial instruments may be useful in predicting long-term violence in mentally disordered patients. We compared two instruments that differ in terms of what they are designed to predict (general versus violent recividism) and the inclusion of stable mental health variables.
Method A large sample of mentally disordered patients were scored on two risk assessment instruments, the Violence Risk Appraisal Guide (VRAG) and the Offender Group Reconviction Scale (OGRS), based on information at the point of discharge. Their criminal histories for at least 2 years following discharge were obtained from official records.
Results Both instruments were good predictors of both violent and general offending. Over shorter periods ( 0·85], which were significantly better than the OGRS. For longer follow-up periods the instruments had approximately equal prediction accuracy. However, both instruments predicted far more offences than were in fact recorded.
Conclusions The VRAG is a very good predictor of future violence in the UK sample. The OGRS may also be of value as it can be completed quickly and without the need for mental health variables. Caution is needed, however, as both instruments appeared to over-predict the levels of reconvictions in this sample.
74 citations
TL;DR: Why Doren’s computations should lead to a different conclusion and why the percentages of recidivism associated with scores on the RRASOR and STATIC-99 scores may vary across study populations are explained are described.
Abstract: Several studies over the past decade have shown that simple rating scales can accurately rank sex offenders' long-term risk of recidivism. But when using these scales as prediction tools, evaluators often wish to translate categories of risk into probabilities of recidivism. D. M. Doren (2004) has recently suggested that evaluators may use the recidivism percentages published in original studies of the RRASOR and STATIC-99 without regard to differences in populations or base rates. This article explains why Doren's computations should lead to a different conclusion, and describes how simply comparing percentages across studies can mislead researchers and clinicians. Instead, investigators should isolate and examine the detection properties of risk assessment instruments alone, independent of the population- or setting-specific base rate. This article explains this process, using an imaginary study to illustrate how base rates and the properties of risk assessment instruments yield estimated probabilities of recidivism. The article also shows why Doren's results imply that the percentages of recidivism associated with scores on the RRASOR and STATIC-99 scores may vary across study populations. The article offers recommendations for researchers who design and evaluate actuarial methods of assessing risk and for clinicians who interpret results from risk assessment instruments.
72 citations
TL;DR: Current risk assessment practice is highly variable, indicating a lack of consensus about suitable methods, and wide variation was found in the methods used to identify risk factors and in approaches to quantifying risk.
Abstract: AIMS AND METHOD
We aimed to establish current practice in the risk assessment of harm to others within general adult psychiatry and review risk assessment documentation in use. Consultants working across 66 randomly selected trusts across England were surveyed. A qualitative analysis of risk assessment documentation was carried out.
RESULTS
Data were obtained from 45 trusts (68%). Consultants reported that 30 (67%) of the trusts had standardised forms for risk assessment. Forty-one forms were subjected to content analysis. Wide variation was found in the methods used to identify risk factors and in approaches to quantifying risk.
CLINICAL IMPLICATIONS
Current risk assessment practice is highly variable, indicating a lack of consensus about suitable methods.
67 citations