Routine risk assessment and care evaluation in outpatient forensic psychiatry; feasibility, predictive validity, and outline of a RCT

van den Brink, Rob; Troquete, Nadine; Gwan Kwee; Schram, Anne-marie; van Os, Titus; Wiersma, Durk
January 2007
BMC Psychiatry;2007 Supplement 1, Vol. 7, Special section p1
Academic Journal
Background Violence risk assessment for forensic psychiatric patients has been dominated by the problem of violence prediction for release decisions. What has been neglected is the problem of ongoing risk monitoring and management for clients who receive (after)care in the community. This setting calls for a different approach; one that focuses on dynamic factors within the individual and situation, that determine the short term risk for violence and identify needs for risk management measures. We developed a risk assessment procedure for outpatient forensic psychiatry, that is integrated with routine care evaluation by the case manager and client. In a pilot study we tested its feasibility and predictive validity for violent behavior. Currently we conduct a RCT, to test if routine Risk Assessment and Care Evaluation(hence the RACE-study) actually prevents violence. Methods In the pilot study we asked the case managers of 99 clients receiving forensic home care, to discuss the client's needs for and satisfaction with care (with the CANFOR), every 3 months, and to assess the client's functioning (on the HoNOS-MDO), violence risk (on the DRAS, an adaptation of the HCR-20), and needs for care (on the CANFOR). The predictive validity of the assessments for violent behavior in the next 3 months was studied. Results Several of the routine assessments by the case manager proved predictive of violent behavior in the next months, but the predictive powers overlapped. The clinical items of the DRAS proved to be the best predictor of violent behavior (Odds Ratio 3.75; 95%CI 1.57-8.94), and the other assessments did not add to that. Conclusion Routine risk assessment and care evaluation is feasibile in outpatient forensic psychiatry. It predicts violent behavior of clients in the next months. But our procedure showed redundancy. In our current RCT we replaced all above measures by a new risk assessment measure, the Short Term Assessment of Risk and Treatability (START).


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