Structured risk assessment for reduction of multiple risk outcomes in a secure mental health setting: use of the START

Background: Structured risk assessment to aid prediction and prevention of risk behaviours in secure settings is common; the expected benefits have rarely been investigated.

Aims: To determine whether adverse outcomes (physical and verbal aggression, self-harm, victimisation, self-neglect, unauthorised leave, substance abuse) reduced after patients were assessed with the Short-Term Assessment of Risk and Treatability (START).

Methods: In a naturalistic study, anonymised demographic and clinical information were collected from 50 male patients. Data included START assessment and frequency of target behaviour data for three months before and after first assessment. Chi square and linear mixed models analyses were used to determine whether there was any change in the behaviours of interest.

Results: There were no significant changes in physical or verbal aggression over time, although a tendency towards fewer incidents was apparent. Other adverse behaviours were very infrequent at baseline, precluding adequate analysis.

Conclusions: In this small sample, START risk assessment did not achieve its primary purpose of significant reduction in adverse behaviours. Although we based our sample size on a power calculation, we may have over-estimated the size of anticipated change. Further, the three-month comparison periods before and after the assessment follow-up period, were rather short. Accordingly, we recommend more research on the value of this tool in practice rather than discontinuing its use.