Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples ...

12 Pages·2012·0.42 MB·English

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Research
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Use of risk assessment instruments to predict violence s
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and antisocial behaviour in 73 samples involving 24 .11
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827 people: systematic review and meta-analysis /b
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OPENACCESS 6
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Seena Fazel Wellcome Trust senior research fellow in clinical science1, Jay P Singh postdoctoral 24
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research fellow2, Helen Doll statistician3, Martin Grann professor4 uly
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1DepartmentofPsychiatry,UniversityofOxford,WarnefordHospital,OxfordOX37JX,UK;2DepartmentofMentalHealthLawandPolicy,University 12
ofSouthFlorida,Tampa,FL,USA;3DepartmentofPopulationHealthandPrimaryCare,UniversityofEastAnglia,Norwich,UK;4CentreforViolence . D
Prevention,KarolinskaInstitutet,Stockholm,Sweden ow
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Abstract ConclusionsAlthoughriskassessmenttoolsarewidelyusedinclinical ed
ObjectiveToinvestigatethepredictivevalidityoftoolscommonlyused andcriminaljusticesettings,theirpredictiveaccuracyvariesdepending fro
m
toassesstheriskofviolence,sexual,andcriminalbehaviour. onhowtheyareused.Theyseemtoidentifylowriskindividualswith h
DesignSystematicreviewandtabularmeta-analysisofreplication highlevelsofaccuracy,buttheiruseassoledeterminantsofdetention, ttp
studiesfollowingPRISMAguidelines. sentencing,andreleaseisnotsupportedbythecurrentevidence.Further ://w
researchisneededtoexaminetheircontributiontotreatmentand w
DatasourcesPsycINFO,Embase,Medline,andUnitedStatesCriminal management. w
JusticeReferenceServiceAbstracts. .b
m
Introduction
ReviewmethodsWeincludedreplicationstudiesfrom1January1995 j.c
o
to1January2011iftheyprovidedcontingencydatafortheoffending Withtheincreasingrecognitionofthepublichealthimportance m
outcomethatthetoolsweredesignedtopredict.Wecalculatedthe ofviolence,12thepredictionofviolence,orviolencerisk o/
n
diagnosticoddsratio,sensitivity,specificity,areaunderthecurve,positive assessment,hasbeenthesubjectofconsiderableclinicaland 1
predictivevalue,negativepredictivevalue,thenumberneededtodetain researchinterest.Sincethelate1980s,suchassessmenthas 6 M
topreventoneoffence,aswellasanovelperformanceindicator—the mostlybeenconductedbystructuredinstrumentsafterseveral a
numbersafelydischarged.Weinvestigatedpotentialsourcesof studiesfoundunstructuredclinicalopiniontohavelittleevidence rch
heterogeneityusingmetaregressionandsubgroupanalyses. insupport.3Recentsurveyshaveestimatedthatover60%of 20
2
ResultsRiskassessmentswereconductedon73samplescomprising generalpsychiatricpatientsareroutinelyassessedforviolence 3
24847participantsfrom13countries,ofwhom5879(23.7%)offended risk,4risingtoabove80%inforensicpsychiatrichospitals.5 by
overanaverageof49.6months.Whenusedtopredictviolentoffending, Thewidespreaduseofthesetoolshasbeenpartlydrivenby gu
riskassessmenttoolsproducedlowtomoderatepositivepredictive publicconcernaboutthesafetyofmentallyillpatients,6research es
values(median41%,interquartilerange27-60%)andhighernegative evidencethatseverementalillnessisassociatedwithviolence,7-9 t. P
predictivevalues(91%,81-95%),andacorrespondingmediannumber andclinicalpracticeguidelinesinsomecountries,includingthe ro
neededtodetainof2(2-4)andnumbersafelydischargedof10(4-18). UnitedKingdomandUnitedStates,1011recommendingviolence tec
Instrumentsdesignedtopredictviolentoffendingperformedbetterthan riskassessmentforallpatientswithschizophrenia.Furthermore, ted
thoseaimedatpredictingsexualorgeneralcrime. b
y
c
o
p
y
Correspondence to: S Fazel [email protected] rig
h
Extra material supplied by the author (see http://www.bmj.com/content/345/bmj.e4692?tab=related#webextra) t.
Web figure 1: Results of a systematic search conducted to identify replication studies of nine commonly used risk assessment tools
Web figure 2: Distribution of effect sizes (reported as Cohen’s d) in studies included and not included in the current systematic review
Web appendix: Studies included in quantitative synthesis
Web table 1: Comparison of summary accuracy estimates produced by three types of risk assessment tools when moderate risk individuals were
classified as low risk
Web table 2: Metaregression analyses within three classes of risk assessment tools
Web figure 3:Summary receiver operator characteristic curve from bivariate analysis of individual violence risk assessment tools
Web figure 4:Summary receiver operator characteristic curve from bivariate analysis of individual sexual risk assessment tools
Web figure 5:Summary receiver operator characteristic curve from bivariate analysis of individual criminal risk assessment tools
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RESEARCH
criminaljusticesystemsinmanycountrieshavewelcomedthe antisocialoutcomes(basedonclinicalrecordsandother
useofriskassessmenttoassistsentencingandreleasedecisions. measures)eveniftheydidnotleadtoconvictions.Forthesake
Riskassessmenthasbeenusedtoinformindeterminate ofconsistency,however,werefertoalloutcomesasoffences.
sentencingintheUK,12andhasbecomealargelyuncontested B
M
partofanexpandedcriminaljusticeprocessintheUS.13 Systematic search J
Furthermore,a2004surveyreportedthatofthe32USstates Asystematicsearchwasconductedtoidentifystudiesthat : firs
whereparoleisanoption,23hadusedsuchinstrumentsaspart measuredthepredictivevalidityoftheninetools.Wesearched t p
ofthesedecisions.14 u
thefollowingdatabasesbetween1January1995and1January b
Thecurrentgroupofriskassessmenttoolseitherprovidea 2011usingacronymsandfullnamesoftheinstrumentsas lish
probabilisticestimateofviolenceriskinaspecifiedtimeperiod keywords:PsycINFO,Embase,Medline,andUSNational ed
(actuarialinstruments),orallowforaprofessionaljudgmentto CriminalJusticeReferenceServiceAbstracts.Additionalstudies as
bemadeonrisklevel(forexample,low,moderate,orhigh) wereidentifiedthroughreferences,annotatedbibliographies, 10
aftertakingintoaccountthepresenceorabsenceofa andcorrespondencewithresearchersinthefield.Studiesinall .1
1
predeterminedsetoffactors(structuredclinicaljudgment languagesandunpublishedinvestigationswereconsideredfor 3
6
instruments).Over150ofthesestructuredmeasurescurrently inclusion.Weexcludedstudiesiftheymeasuredthepredictive /b
einxcisotm,15eacnoduanrteriessta.1r6ti1n7gtobeimplementedinlowandmiddle vreatlriodsiptyecotfivseelleycwtsicthaoleustobflianmdienagsutoreo,uiftcionmstreusm,oernitfstwheeryewcoedreed mj.e4
6
However,thesetoolsaretimeconsumingandresourceintensive, calibrationstudiesfortheactuarialtools(whichmaygive 92
typicallytakingmanyhourstocompletebyamultidisciplinary inflatedeffects).48Whenstudiesusedoverlappingsamples,we o
n
groupofprofessionals.18Theycanalsobeexpensive;training usedthesamplewiththelargestnumberofparticipantstoavoid 2
4
isrequiredformosttools,andpaymentisoftenneededfor double-counting.Usingthissearchstrategy,weidentified J
u
individualuse.Further,andmoreimportantly,theinstruments’ 251validationstudies(webfigure1). ly
predictiveaccuracyremainsasourceofconsiderableuncertainty, Tobeincludedinthemeta-analysis,studieshadtoreportrates 20
withsomereviewsrecommendingtheiruseinclinicaland oftruepositives,falsepositives,truenegatives,andfalse 12
correctionalsettingsandothersfindingthattheyleadtoan negativesatagivencut-offscorefortheoutcomewhichthe . D
unacceptablyhighnumberoffalsepositivedecisions.18-22Expert instrumentwasdesignedtopredict.Apilotstudyshowedthat ow
opinionisequallydivided.23-25 differentscorethresholdswereusedtoclassifypeopleasbeing nlo
a
Wehavethereforeconductedasystematicreviewand atlow,moderate,orhighriskoffutureoffending.Wecontacted d
e
meta-analysisofthepredictiveaccuracyofthemostcommonly studyauthorsandaskedthemtocompleteastandardisedform d
usedriskassessmentinstruments.Toconsistentlyreport iftabulardatausingthecut-offscoresrecommendedinthemost fro
m
outcomesforindividualstudies,werequestedtabulardatafrom recentversionofaninstrument’smanualwereunavailable,or
h
primaryauthors.Wehavesynthesisedthesedataacrossarange ifthenumberofparticipantsclassifiedaslow,moderate,orhigh ttp
ofaccuracyestimates,oneofwhichwasdevelopedforthe riskwasmissingfromastudyofastructuredclinicaljudgment ://w
purposesofthisreview. tool.Forpublicationsinwhichmultipletoolsdesignedtopredict w
thesameoutcomeweretestedonthesamesample(eight w
.b
Methods studies),werequestedtabulardataforalloutcomesbutonly m
includedthoseforthetoolwiththefewestreplicationstudies j.c
Review protocol toincreasethebreadthofthefindings.Thisprocedureprobably om
Wefollowedthepreferredreportingitemsforsystematicreviews didnotbiasresults,sinceχ2testsofdifferencesinproportions o/
n
andmeta-analysesstatement.26 foundnodifferencesinratesoftrueandfalsepositivesandtrue 1
andfalsenegativesinthetabulardataobtainedforincludedand 6 M
Risk assessment tools excludedtoolsfromthesamestudywiththesameoutcome. a
rc
Standardisedoutcomedatawereavailableinthemanuscripts h
Weidentifiedtheninemostcommonlyusedtoolsrisk 2
assessmentusingrecentreviews27-29andquestionnaire of30eligiblestudies(32samples).Werequestedadditional 02
Isnuvrveenytosr.y30-3R1eAvcistueadr(iLalSiIn-sRtr)u,3m2thenetPssiyncchluodpeadthtyheCLheecvkellisotf-RSeevrvisiecde d5saa2mtasptfulredosimefsotr(h6we2ha)ui.ctAhhocwcrseurowafce1yr7ee4usnstitamubdlaeiteetsos(of3rb3ot0ma)ina2nd3da5toaobfwttaehirnoeescedo2dn6avt8eartfeodr 3 by g
(PCL-R),3334theSexOffenderRiskAppraisalGuide u
(GSuOidReA(GV)R,3A53G6t)h.3e5S36tSattircu-c9t9u,r3e7d38calninditchaelVjuidoglemnecnetRtoisoklsAinpcplruadiseadl ptoroCdouhceend’bsydtuhsoisnegssatmanpdlaersdfomrewthhoidchs.4w9-5e1cTohueldmneodtiaonbtdaivnadluaeta est. P
theHistorical,Clinical,Riskmanagement-20(HCR-20);3940the (904.6o7b,taininteerdqusaamrtiplelersan(0g.e740,.405.5t4o0to.807.)9w5)a(swsiembifliagrutroet2hasthoofwthse rote
SexualViolenceRisk-20(SVR-20);41theSpousalAssaultRisk distributionofeffectsizes).Inaddition,theHodges-Lehmann cte
Assessment(SARA);42-44andtheStructuredAssessmentof d
ViolenceRiskinYouth(SAVRY).4546Wedividedtoolsinto percentiledifference,52themediandifferencebetweenall by
possiblepairsofdvaluesfromthetwogroups,wassmall(0.01, c
threecategories:thosedesignedtopredictviolentoffending o
95%confidenceinterval0.00to0.08).Finally,ofthe82studies p
(HCR-20,SARA,SAVRY,andVRAG),sexualoffending y
(SORAG,Static-99,andSVR-20),andanycriminaloffending forwhichtabulardatawasobtained,wewereabletoinclude rig
(LSI-RandPCL-R).AlthoughthePCL-Rwasoriginally informationfrom68(73samples;referencesavailableinweb ht.
appendix),sincetheother14studiesusedinstrumentstopredict
developedtodiagnosepsychopathicpersonalitydisorder,ithas
outcomesotherthanthoseforwhichtheyweredesigned.
becomewidelyusedforriskassessmentpurposes,asnumerous
studieshavefoundthePCL-Rscoretobestatistically
Data analysis
significantlyassociatedwithcriminalandantisocialoutcomes.47
Table1⇓reportsadditionaldetailsofalltheinstruments. WefollowedthecurrentguidanceprovidedbytheCochrane
Althoughtheseinstrumentsweremostlydesignedtopredictthe collaborationforsystematicreviewsofdiagnostictest
likelihoodofoffending,weincludedviolent,sexual,and accuracy.53Thestatisticalmethodsforsuchreviewsfocuson
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RESEARCH
twostatisticalmeasuresofdiagnosticaccuracyofthetest: allowsresearcherstoquantifytheimplicationsofrelyingona
sensitivity(theproportionofoffenderswhoariskassessment riskinstrumenttomakedischargeorreleasedecisions.
toolpredictedtooffend)andspecificity(theproportionof
non-offenderswhoariskassessmenttoolpredictedwouldnot Tests of assumptions B
M
offend).Theaimoftheanalysiswastoquantifyandcompare J
thesestatisticsaswellastheerrorrates(falsepositiveandfalse Sditaagnndoarsdticmoedtad-sarnaatliyotsicanpdooblointhgsaesnsusimtivpittiyonasnwdespreecmifeitciftoyr.5960 : firs
negativediagnoses)foreachtypeoftest.Therequiredanalysis Sincetherewasasignificantcorrelationbetweenthesensitivities t p
isabivariateanalysisofsensitivityandspecificityforeach u
andspecificitiesproducedbythesamplesineachclassofrisk b
studyaccountingforcorrelationbetweensensitivitiesand lis
assessmenttools,poolingassumptionsforareasunderthecurve h
specificities.54Theresultingmodelwithoutcovariatesisa e
werenotmet.60Inaddition,becausethemedianbaserateof d
differentparameterisationofthehierarchicalsummaryreceiver a
operatingcharacteristicmodel.55Weusedsummaryreceiver o(vfifoelnednicneg3w2i.0th%in,ienatcehrqculaarstsiloefratonogles2v2a.r2i-e4d6c.6o%ns;idseexraubally16.9%, s 10
operatorcharacteristicplotstodisplaytheresultsofeachstudy 7.4-28.2%;criminal28.4%,20.7-46.0%),baseratedependent .1
inreceiveroperatingcharacteristicspace,plottingeachstudy 1
statisticswerenotpooled(suchasthepositiveandnegative 3
plottedasasinglesensitivity-specificitypoint.Parameter predictivevaluesandboththenumberneededtodetainandthe 6/b
estimatesfromthebivariatemodelproducedasummaryreceiver m
operatingcharacteristiccurvewithasummaryoperatingpoint numbersafelydischarged),andmedianswithinterquartileranges j.e
werecalculated. 4
(thatis,summaryvaluesforsensitivityandspecificity),95% 6
9
confidenceregion,and95%predictionregion.Weusedthe Investigation of heterogeneity 2 o
summarypointfromeachcurvetocalculatethesummary n
diagnosticoddsratioandboththesensitivityandspecificity, ThestandardQandI2statistics61donotaccountfor 24
eachwith95%confidenceintervals. heterogeneityexplainedbyphenomenasuchaspositivity Ju
thresholdeffects,andthenumericalestimatesoftherandom ly
Sincebinarytestoutcomesaredefinedonthebasisofacut-off 2
effecttermsinthebivariateregressionarenoteasilyinterpreted. 0
valuefortestpositivity,wechosethesevaluesapriori.Risk 1
Therefore,themagnitudeofobservedheterogeneityin 2
aasssienssstmruemnetntotsoflosrairdeepnrteifdyoinmginhaignhtleyrurissekdinindicvliindiucaalls,s1i9ttuhautiso,nwse meta-analysesofdiagnosticaccuracyisinsteadbestdetermined . Do
bythescatterofpointsinthesummaryreceiveroperating w
combinedparticipantswhowereclassifiedasbeingatmoderate n
characteristicplotandfromthepredictionellipse.53Inparticular, lo
orhighriskforfutureoffendingandcomparedthemwiththose a
thepredictionregiondepictsaregionwithinwhich,assuming d
classifiedaslowrisk.Wedidsecondaryanalysesbycomparing e
themodeliscorrect,wehave95%confidencethatthetrue d
participantsclassifiedashighriskwiththoseclassifiedaslow sensitivityandspecificityofafuturestudyshouldlie.53 fro
ormoderaterisk,anapproachconsistentwithscreening,and m
alsobycompletelyexcludingthoseclassifiedasmoderaterisk. Sincethediagnosticoddsratiosmetpoolingassumptions,we h
usedrandomeffectsmetaregressiontoinvestigatesourcesof ttp
Accuracy estimates heterogeneitybetweenstudiesinsamplediagnosticoddsratios ://w
foreachclassoftools.Metaregressioninvestigatestherelation w
Weusedarangeofaccuracyestimatestoreportonthepredictive w
betweenaccuracyestimatesanddichotomousorcontinuous .b
validityoftheriskassessmenttools.Firstly,thesummary sampleorstudycharacteristics.62Weformallyexploredthe m
operatingpointwasusedtoestimatethesummarydiagnostic moderatingroleofthefollowingvariables:sex(proportionof j.co
oddsratioandbothsensitivityandspecificity.Weobtained m
samplethatwasmale),ethnicity(proportionofsamplethatwas
estimatesfortheareaunderthecurve,positivepredictivevalue, white),meanparticipantage,typeofinstrument(actuarialv on/
negativepredictivevalue,numberneededtodetain,andnumber structuredclinicaljudgment),temporaldesign(prospectivev 1
safelydischargedfromtheindividualsampleestimates. retrospective),settinginwhichassessmentwasconducted 6 M
Thediagnosticoddsratioistheratiooftheoddsofapositive (correctional,forensicpsychiatric,generalpsychiatric,or arc
testresultinanoffenderrelativetotheoddsofapositiveresult mixture),locationofoffendingoutcome(communityonlyv h
2
inanon-offender,andisrecommendedforusewithdiagnostic insideinstitutionorother),meanlengthoffollow-up(months), 0
instruments.56Theareaunderthecurveisanindexofsensitivity samplesize,andpublicationstatus(publishedinpeerreviewed 23
andspecificityacrossscorethresholds,andiscurrently journalvnot).Wealsoconductedsubgroupanalysesusingthe by
consideredtheaccuracyestimateofchoiceinviolencerisk bivariatemodelsonthesevariables.Detailedexaminationof gu
assessmentwhenmeasuringpredictiveaccuracy.57Neitherthe theoveralldifferencesbetweenindividualinstrumentshave es
diagnosticoddsrationortheareaunderthecurveareaffected beenreportedinasubsetofthesamples.63Wedidallanalyses t. P
bybaseratesofoffending.Thepositivepredictivevalueisthe inStata10.264usingthemetandi(forbivariatemodel ro
proportionofparticipantsclassifiedasatriskwhogoonto meta-analysis),metan(randomeffectsmeta-analysis),and tec
offend,whereasthenegativepredictivevaluereferstothe metareg(metaregression)commands. ted
proportionofthoseclassifiedasnotatriskwhodonotgoonto b
y
offend.Thenumberneededtodetainisthenumberofpeople Results c
o
judgedtobeatriskwhowouldneedtobedetainedtoprevent p
y
oneincidentofsubsequentviolence.1958Thisoutcomeallows Descriptive characteristics rig
somequantificationoftheimplicationsofusingriskassessment Wecollectedinformationfor24847participantsin73samples ht.
toolstomakedetentiondecisions.Finally,thenumbersafely
from68independentstudies(table2⇓).Standardisedoutcome
dischargedisanewperformancestatisticthatwedevelopedfor
informationfrom43ofthesamples(14798(59.6%)
thepurposesofthisreview.Thisaccuracyestimatecalculates
participants)wasnotreportedinmanuscriptsandobtained
thenumberofparticipantsjudgedtobeatlowriskwhocould
directlyfromstudyauthors.Of24847participants,5879
bedischargedintothecommunitybeforeasingleactofviolence
(23.7%)offendedoveranaverageof49.6months(standard
occurs(1÷[1−negativepredictivevalue]−1).Acomplementto
deviation40.5).Studieswereconductedin13countries:Austria,
thenumberneededtodetain,thenumbersafelydischarged,
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RESEARCH
Belgium,Canada,Denmark,Finland,Germany,theNetherlands, Discussion
NewZealand,Serbia,Spain,Sweden,theUK,andtheUS.
Thissystematicreviewandmeta-analysisexaminedthe
Predictive validity predictivevalidityofviolenceriskassessmenttoolsfrom73 B
M
samplesinvolving24847individualsin13countries.Our
J
Wdseexepuefanoldu,inondrgadoninfyftechrreeinmtyciepnsealio)n.feOrsisvtikemraaasltsle,essbsoamfsepednretodinnicsdttiirvaugemnaoecnscttuic(rvaoicodyldesnce, ppriresirknfocairspmsaealsnsficmnedeoninft.gthIwfesuaessmetdheataotstuihnreefrsoerdmwepatesrnehadetimtnegreonogtneatnnhedeitpmyuairnnpaothgseeemofetnhte : first pu
ratios,violenceriskassessmenttoolsperformedbest,andhad decisions,thentheseinstrumentsperformedmoderatelywell blis
higherpositivepredictivevaluesthantoolsaimedatpredicting inidentifyingthoseindividualsathigherriskofviolenceand h
e
sexualoffending.Riskassessmentinstrumentsforviolenceand otherformsofoffending.However,ifusedassoledeterminants d a
sexualoffendingproducedhighsensitivitiesandnegative ofsentencing,andreleaseordischargedecisions,these s
predictivevalues.Inaddition,riskassessmentinstrumentsfor instrumentsarelimitedbytheirpositivepredictivevalues:41% 10
generaloffendinghadlowerdiagnosticoddsratios,areasunder ofpeoplejudgedtobeatmoderateorhighriskbyviolencerisk .11
thecurve,sensitivities,andnegativepredictivevaluesandhigher assessmenttoolswentontoviolentlyoffend,23%ofthose 36
specificitiesandpositivepredictivevaluesthantheothertwo judgedtobeatmoderateorhighriskbysexualriskassessment /bm
classesofinstrument(table3⇓,figs1-3⇓⇓⇓). toolswentontosexuallyoffend,and52%ofthosejudgedto j.e
4
Forassessmentinstrumentspredictingtheriskofviolent beatmoderateorhighriskbygenericriskassessmenttools 6
9
outcomes,thesummarydiagnosticoddsratiowas6.1(95% wentontocommitanyoffence.Insampleswithlowerbase 2
confidenceinterval4.6to8.1)withmoderatelevelsof ratesthanthosethatcontributedtothereview,suchasingeneral on
heterogeneity(individualpointsmoderatelyscatteredinreceiver psychiatry,positivepredictivevalueswillprobablybeeven 2
4
operatingcharacteristicspace,fig1)andamedianareaunder lower.25However,negativepredictivevalueswerehigh,and J
u
thecurveof0.72(interquartilerange0.68-0.78;table3).Of suggestthatthesetoolscaneffectivelyscreenoutindividuals ly
thoseindividualswhowentonviolentlyoffend,92%(95% atlowriskoffutureoffending.Whetherthecautiousoptimism13 20
1
confidenceinterval88%to94%)hadbeenclassifiedasbeing thatexpertshavedescribedinrelationtotheabilitytopredict 2
atmoderateorhighriskoffutureviolence(thatis,sensitivity). violenceseemsjustifiedwilldependontheusetowhichthese . D
o
Ofthoseparticipantswhodidnotgoontoviolentlyoffend, instrumentsareput. w
n
36%(28%to44%)hadbeenjudgedtobeatlowrisk(thatis, lo
specificity).Ofthosepredictedtoviolentlyoffend,41%did Comparisons with other medical tools ad
e
(interquartilerange27-60%;positivepredictivevalue),which d
wasequivalenttoamediannumberneededtodetainoftwo Aconmymcoomnpmaerdisiocnalodfiathgensoestriicskanadsspersosgmneonsttiscctooroelsswpoitsheostsheevreral from
(two-four).Ofthosewhowerepredictednottoviolentlyoffend,
difficulties.Firstly,comparisonwithdiagnostictoolsismostly h
91%didnot(81-95%;negativepredictivevalue),equivalentto inappropriatebecauseriskassessmentinstrumentsattemptto ttp
amediannumbersafelydischargedof10(fourto18). predictthelikelihoodofafutureoutcome,whereasdiagnostic ://w
Similarfindingswereobtainedwhenindividualsjudgedtobe instrumentattempttodetectthepresenceofacurrentcondition. w
w
atmoderateriskweregroupedwiththosejudgedtobeatlow Secondly,althoughitmaybepossibletocompareperformance .b
riskforthesecondaryanalyses,butwithconsiderablyhigher statisticsofthesetoolswiththoseestimating,forexample, m
specificitiesandlowersensitivities(webtable1).When cardiovascularrisk,theimplicationsofpositivepredictivevalues j.co
moderateriskindividualswereexcludedfromanalyses, needtobeconsideredinevaluatinganycomparisons.Violence m
assessmenttoolsforviolenceriskproducedconsiderablylarger riskassessmentpotentiallyleadstodetentionofindividualsfor on/
summarydiagnosticoddsratios(16.8,10.8to26.3)and longerthannecessary,withitsrelatedeconomic,65social,66and 1
6
specificities(0.72,0.63to0.80). civilrightsconsequences.67Bycomparisonwithcommon M
a
medicalprognostictools,itispossibletoarguethatthe rc
Investigation of heterogeneity predictiveaccuracyofviolenceriskassessmentneedstobe h
2
Sincewesawmoderatelevelsofheterogeneityforthe higherbecauseoftheseconsequences,whichextendbeyond 02
instrumentsassessingviolenceriskandhigherlevelsfor thepersontootherpeople.Ontheotherhand,itisprecisely 3 b
instrumentsassessingsexualandgeneraloffendingrisk(scatter becauseoftheriskstootherpeoplethatlowpositivepredictive y g
ofpointsfromthelinebeinggreaterandthepredictionellipses valuesmaynotbeasimportantastheabilityoftheseinstruments u
e
lbairvgaerri)a,tewmedoiddelmtoetdareetegrrmesisnieonanayndposussbigbrloeuepxapnlaanlyastieosnussfionrgtthhies tpoerpfroerdmicatntcheomseetahsautrea,rethneontuamtrbiesrk.saOfeulryidnitsrochdaurcgtieodn,coofualdnohvelepl st. P
heterogeneity.Theseanalysesfoundnoevidencethatsex, quantifythisinfutureresearch. rote
ethnicity,age,typeofinstrument,temporaldesign,assessment Despitethesecaveats,theareasunderthecurvefoundinthis cte
setting,locationofoffendingoutcome,lengthoffollow-up, review(0.66to0.74)werenotdissimilartothosefoundin d
b
samplesize,orpublicationstatuswasassociatedwithdifferences studiesexaminingscoresfromthemostvalidatedcardiovascular y
c
inpredictivevalidity(webtable2).Inaddition,wehave riskschemeinpredictingcardiovasculardiseaseevents.Areas o
p
presentedsummaryreceiveroperatingcharacteristiccurvesfor underthecurvefromtheFraminghamscoringsystemrange y
eachtypeofinstrument(webfigures3-5).Subtypesoftools from0.57to0.86,theSCOREfrom0.65to0.85,andQRISK rig
h
performedsimilarly,lyingwithinthe95%predictionregion, from0.76to0.79.68Manyofthesestudiesreportassociations t.
withthepossibleexceptionoftheSAVRYthatproducedhigher betweenpredictedandobservedrisks,69whichmaybehelpful
levelsofpredictiveaccuracythantheotherviolencerisk forfutureresearchinviolenceriskassessment.Finally,the
assessmentinstruments. standardbywhichtheseinstrumentsarecomparedwilldiffer
dependingontheirsetting.Inforensicpsychiatry,amore
meaningfulcomparisonwillbewithunstructuredclinical
judgment,andclinicaltrialsareneededtotestwhetherstructured
riskassessmentreducesadverseoutcomes.
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RESEARCH
Clinical implications threetimesasmanystudiesasthe2001reviewandarecent
meta-analysisthatonlycomparedheadtoheadinvestigations
Oneimplicationofthesefindingsisthat,evenafter30yearsof
oftooluse.75
development,theviewthatviolence,sexual,orcriminalrisk
B
canbepredictedinmostcasesisnotevidencebased.This M
Strengths and limitations J
mademssiangisetriastiiomnpsowrthaontmfoarythhaevgeeunnerraelalpiustbiclice,xmpeecdtiaat,ioannsdosformisek Thestrengthsofthecurrentreviewincludetheincorporation : firs
predictionforclinicians.70Thisexpectationisnotashighin ofnewtabulardata,thereportingofmultipleaccuracyestimates, t p
u
othermedicalspecialties,inwhichtheexpectationthatthe andameta-analysisusingbivariatemodels.Wereceivednew b
doctorwillidentifytheindividualpatientwhowillhavean tabulardatafor14798people(60%ofpeopleincludedinthe lish
e
adverseeventisnotaprimaryissuewhereaspsychiatry,inmany review),andhencehavereportedaconsiderableamountofnew d
countriessuchastheUK,hasdevelopedacultureofinquiries.71 data.Finally,byusingarangeofaccuracyestimates,wehave as
Asecondandrelatedimplicationisthatthesetoolsarenot attemptedtominimisebiasesthatmaybeassociatedwith 10
sufficientontheirownforthepurposesofriskassessment.In reportingonlyoneofthem. .11
3
somecriminaljusticesystems,experttestimonycommonlyuse Limitationsincludethatwesolelyexaminedthepredictive 6
scoresfromtheseinstrumentsinasimplisticwaytoestimate qualitiesoftheseriskassessmenttools,anddidnotaccountfor /bm
anindividual’sriskofseriousrepeatoffending.67However,our theirpotentialroleininformingmanagementandreminding j.e
reviewsuggeststhatriskassessmenttoolsintheircurrentform clinicianstoenquireaboutpotentiallyimportantprognosticand 46
canonlybeusedtoroughlyclassifyindividualsatthegroup modifiablefactors.76Inaddition,wefoundmoderatetohigh 92
level,andnottosafelydeterminecriminalprognosisinan levelsofheterogeneity.Heterogeneitywastobeexpected,in on
individualcase.Thisapproachismostlyusedinforensic viewofthedifferenttypesofsamplesincludedintheprimary 2
4
psychiatryintheUKandotherwesterncountries,wherethey studies(fromprison,securehospitals,andgeneralpsychiatric J
u
formpartofawiderclinicalassessmentprocess.These hospitals)andoutcomesmeasured.7778Weexploredsourcesof ly
instrumentsmayalsoassistindevelopingriskmanagement heterogeneityandfoundnocleartrends.Investigating 20
1
plansinselectedhighriskgroups,assuggestedbyrecentclinical heterogeneityindiagnosticoddsratiosmeantthatincidenceof 2
guidelinesinEnglandandWales.72Furthermore,theyare theoutcomewasaccountedfor.Onepossiblesourceof . D
o
preferabletounstructuredclinicaljudgmentowingtotheir heterogeneitywasthepotentialeffectsofinterventionaftera w
n
increasedtransparencyandreliability. riskassessment,particularlyinpeopledeemedhighrisk.We lo
a
Anotherimplicationisthatactuarialinstrumentsfocusingon compareddiagnosticoddsratiosbetweenprospectiveand d
e
historicalriskfactorsperformnobetterthantoolsbasedon retrospectivestudiesthatwouldbeexpected,tosomeextent,to d
clinicaljudgment,afindingcontrarytosomeprevious measurethis,sincehighriskparticipantsidentifiedin fro
m
reviews.2173Finally,ourreviewsuggeststhattheseinstruments prospectivestudieswouldprobablyhavebeenenrolledin h
shouldbeuseddifferently.Sincetheyhadhighernegative interventionsdesignedtoreduceviolencerisk.However,we ttp
predictivevalues,onepotentialapproachwouldbetousethem foundnodifferencesinmetaregressionorsubgroupanalysis. ://w
toscreenoutlowriskindividuals.Researchersandpolicy Nevertheless,clinicaltrialsareneededdirectlytotestthe w
makerscouldusethenumbersafelydischargedtodetermine possibleeffectsofintervention.Althoughwetestedfor w.b
thepotentialscreeninguseofanyparticulartool,althoughits publicationstatusandfoundnoclearpatterns,wecannotexclude m
usecouldbelimitedforcliniciansdependingontheimmediate thepossibilitythatsuchbiascouldexistinthestudiesthatwe j.c
o
andserviceconsequencesoffalsepositives.Afurthercaveatis wereunabletoinclude.Registersofsuchinvestigationswould m
thatspecificitieswerenothigh—therefore,althoughthedecision assistfuturereviews.79Inaddition,fewsamplesreportedon o/
n
makercanbeconfidentthatapersonistrulylowriskifscreened womenand,thus,thisreviewwasunderpoweredtoexamine 1
out,whensomeonefailstobescreenedoutaslowrisk,doctors whetherpredictivevaliditywasdifferentfrommen. 6 M
cannotbecertainthatthispersonisnotlowrisk.Inotherwords, a
manyindividualsassessedasbeingatmoderateorhighrisk Wethankthefollowingstudyauthorsforprovidingtabulardataforthe rch
couldbe,infact,lowrisk.Ultimately,however,whatconstitutes analyses:AprilBeckmann,SarahBeggs,SusanneBengtsonPedersen, 20
anappropriatebalancebetweentheethicalimplicationsof Klaus-PeterDahle,RebeccaDempster,MaireadDolan,KevinDouglas, 23
detainingpeoplebasedonthepredictiveabilityofthesetools ReinhardEher,JorgeFolino,MonicaGammelgård,RobertHare,Grant b
y
andtheneedforpublicprotectionwillprimarilybeapolitical Harris,LeslieHelmus,AndreasHill,HildaHo,CliveHollin,Christopher g
u
consideration. Kelly,DrewKingston,P.RandyKropp,MichaelLacy,CalvinLangton, e
s
HenryLodewijks,JanLooman,KarinArbachLucioni,JeremyMills, t. P
Comparison with other studies CatrinMorrissey,ThierryPham,CharlotteRennie,MartinRettenberger, ro
MarnieRice,MichaelSeto,DavidSimourd,GabrielleSjöstedt,Jennifer te
Previousmeta-analysesonriskassessmenthavefocusedon c
Skeem,RobertSnowden,CornelisStadtland,DavidThornton,Jodi te
comparinginstrumentswithoneanother,ormeasuringhow d
individualtoolsperformacrosssexesandethnicgroups.74A Viljoen,ViviennedeVogel,ZoeWalkington,andGlennWalters. by
systematicreviewpublishedin2001examinedtheaccuracyof Contributors:SFdevisedandcoordinatedtheproject,assistedindata co
violenceriskassessmentinhighriskgroups,19andwasbased acquisitionandinterpretation,anddraftedandrevisedthemanuscript. py
on21studies.Itestimatedthatsixpeopleneededtobedetained JPSassistedindataacquisition,performedthestatisticalanalyses, rig
topreventoneviolentoffence,comparedwithourcurrent assistedininterpretingresults,andassistedindraftingandrevisingthe ht.
report.HDassistedinstatisticalanalysisandcriticallyrevisedthe
review’sestimateoftwopeopleneedingdetention.This
manuscriptforimportantintellectualcontent.MGassistedininterpreting
differencewasdespitethemedianbaserateofviolencebeing
resultsandcriticallyrevisingthemanuscriptforimportantintellectual
similarinbothreviews(currentreview,32%(interquartilerange
content.SFandJPShadfullaccesstoallofthedatainthestudyand
22-46%)v2001review,26%,15-41%).Unliketheprevious
takeresponsibilityfortheintegrityofthedataandtheaccuracyofthe
report,thepresentmeta-analysisfocusedonstructured
dataanalysis,andwillactasguarantors.
assessmentinstrumentsandincludedbothinstitutionaland
communitysamples.Thecurrentreportreviewedmorethan Funding:SFisfundedbytheWellcomeTrust.
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BMJ2012;345:e4692doi:10.1136/bmj.e4692(Published24July2012) Page6of12
RESEARCH
Whatisalreadyknownonthistopic
Instrumentsbasedonstructuredriskassessmentpredictantisocialbehaviourmoreaccuratelythanthosebasedonunstructuredclinical
judgment B
M
Morethan100suchtoolshavebeendevelopedandareincreasinglyusedinclinicalandcriminaljusticesettings J
Considerableuncertaintyexistsabouthowthesetoolsshouldbeusedandforwhom : firs
Whatthisstudyadds t p
u
b
Thecurrentlevelofevidenceisnotsufficientlystrongfordefinitivedecisionsonsentencing,parole,andreleaseordischargetobemade lis
solelyusingthesetools h
e
Thesetoolsappeartoidentifylowriskindividualswithhighlevelsofaccuracy,buthavelowtomoderatepositivepredictivevalues d
a
Theextenttowhichtheseinstrumentsimproveclinicaloutcomesandreducerepeatoffendingneedsfurtherresearch s
1
0
.1
Competinginterests:AllauthorshavecompletedtheUnifiedCompeting 29 KemshallH.Riskassessmentandmanagementofknownsexualandviolentoffenders: 13
areviewofcurrentissues.UKHomeOffice,2001. 6
Interestformatwww.icmje.org/coi_disclosure.pdf(availableonrequest 30 ArcherRP,Buffington-VollumJK,StrednyRV,HandelRW.Asurveyofpsychological /b
fromthecorrespondingauthor)anddeclare:SFisfundedbythe testusepatternsamongforensicpsychologists.JPersAssess2006;87:84-94. m
WellcomeTrust;nofinancialrelationshipswithanyorganisationsthat 31 LallySJ.Whattestsareacceptableforuseinforensicevaluations?:asurveyofexperts. j.e
ProfPsycholResPract2003;34:491-8. 4
mighthaveaninterestinthesubmittedworkintheprevious3years; 32 AndrewsDA,BontaJ.LSI-R:thelevelofserviceinventory-revised.Multi-HealthSystems, 69
nootherrelationshipsoractivitiesthatcouldappeartohaveinfluenced 33 H19a9re5.RD.TheHarepsychopathychecklist-revised(PCL-R).Multi-HealthSystems,1991. 2 o
thesubmittedwork. 34 HareRD.TheHarepsychopathychecklist-revised.2nded.Multi-HealthSystems,2003. n 2
Ethicalapproval:Noethicsapprovalwassoughtbecauseonlysecondary 35 Qrisukin.sAemyeVrLic,aHnaPrrsisycGhTo,loRgiciceaMlAEs,sCoocriamtiioernC,1A9.9V8io.lentoffenders:appraisingandmanaging 4 J
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Datasharing:Datasharing:Noadditionaldataavailable. 37 Hrisakr.ri2snAdJeRd,.PAhmeneirxicAa,nHPasnyscohnolRogKi,caTlhAosrnstoocniaDti.oSn,ta2t0ic0-69.9codingrules:revised2003. ly 20
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74 SinghJP,FazelS.Forensicriskassessment:ametareview.CrimJusticeBehav 0
2010;37:965-88. AttributionNon-commercialLicense,whichpermitsuse,distribution,andreproductionin .1
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nc/2.0/andhttp://creativecommons.org/licenses/by-nc/2.0/legalcode. /b
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BMJ2012;345:e4692doi:10.1136/bmj.e4692(Published24July2012) Page8of12
RESEARCH
Tables
B
Table1|Characteristicsofnineincludedriskassessmenttools M
J
Instrumenttypeandname Noofitems Population Outcome Currentmanual : firs
Actuarial t p
u
LSI-R* 54 Adultoffenders Criminaloffending AndrewsandBonta(1995)32 b
lis
PCL-R† 20 Non-specific Notapplicable‡ Hare(2003)33,34 h
e
SORAG 14 Sexualoffenders Sexualoffending Quinseyetal(2006)35,36 d a
s
Static-99§ 10 Sexualoffenders Sexualoffending Harrisetal(2003)37,38 1
0
VRAG 12 Mentallydisorderedviolent Violentoffending Quinseyetal(2006)35,36 .1
offenders 13
6
Structuredclinicaljudgment /b
m
HCR-20 20 Psychiatricpatients Violentoffending Websteretal(1997)39,40 j.e
SVR-20 20 Sexualoffenders Sexualoffending Boeretal(1997)41 46
9
SARA 20 Spousalassaulters Violentoffending Kroppetal(1999)42-44 2
o
SAVRY 24 Adolescentoffenders Violentoffending Borum,Bartel,andForth(2003)45,46 n 2
4
*Lowandlowtomoderateriskcategoriescombinedtomakelowriskbin.Moderatetohighandhighriskcategoriescombinedtomakehighriskbin. J
u
†Psychopathicpatients(score>30)consideredhighriskgroup,non-psychopathicpatients(<30)consideredlowriskgroup.PCL-RscoresareincludedinSORAG, ly
2
VRAG,HCR-20,andSVR-20,andthusthepredictivevalidityoftheseinstrumentsdesignedfordifferentoutcomesiscorrelated. 0
1
‡PCL-Rwasdesignedasapersonalityassessment.Itstartedtobeusedasariskinstrumenttopredictcriminaloffendingfrom1988onwards.80 2
§Moderate-lowandmoderate-highriskcategoriescombinedtomakemoderateriskbin. . D
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t.
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BMJ2012;345:e4692doi:10.1136/bmj.e4692(Published24July2012) Page9of12
RESEARCH
Table2|Descriptiveanddemographiccharacteristicsofsamplesinvestigatingpredictivevalidityofriskassessmenttoolsdesignedto
predictviolent,sexual,andcriminaloutcomes.Dataareno(%)ofsamplesunlessstatedotherwise.SD=standarddeviation
Categoryandgroup Violent(n=30) Sexual(n=20) Criminal(n=23) B
M
Sourceofstudy J
Journalarticle 21(70) 18(90) 18(78) : firs
Conference 4(13) 0 0 t p
u
b
Dissertation 4(13) 2(10) 3(13) lis
h
Governmentreport 1(3) 0 2(8) e
d
Toolinformation a
s
Typeoftool 1
0
Actuarial 9(30) 16(80) 23(100) .1
1
3
Structuredclinicaljudgment 21(70) 4(20) 0 6
/b
Toolused m
HCR-20 9(30) — – j.e
4
6
LSI-R — — 11(48) 9
2
PCL-R — — 12(52) o
n
SARA 3(10) — — 2
4
SAVRY 9(30) — — Ju
ly
SORAG — 3(15) — 2
0
Static-99 — 13(65) — 1
2
SVR-20 — 4(20) — . D
o
VRAG 9(30) — — w
n
Demographic(mean(SD)insample) lo
a
d
Maleparticipants(no) 137(98) 519(713) 409(590) e
d
Whiteparticipants(no) 92(49) 201(185) 213(165) fro
Age(years) 28.3(10.0) 39.7(4.0) 35.2(4.6) m
h
Studydesign ttp
Samplesize(mean(SD)) 148(94) 510(681) 439(720) ://w
Assessmentsetting w
w
Correctional 9(30) 12(60) 21(91) .b
m
Forensicpsychiatric 11(37) 6(30) 0 j.c
o
Generalpsychiatric 5(17) 0 0 m
Mixed 3(10) 1(5) 2(9) o/
n
Unstatedorunclear 2(7) 1(5) 0(0) 1
6
Locationofoutcome M
a
Community 21(70) 18(90) 22(96) rc
h
Intra-institutional 6(20) 0 1(4) 2
0
2
Mixed 3(10) 2(10) 0 3
b
Temporaldesign y
g
Prospective 12(40) 5(25) 14(61) u
e
s
Retrospective 17(57) 15(75) 9(39) t. P
Notstatedorunclear 1(3) 0 0 ro
Lengthoffollow-up(months;mean(SD)) 39.4(29.6) 82.4(50.4) 33.9(24.8) tec
te
Sourceofoutcome d
b
Criminalregister 16(53) 17(85) 17(74) y
c
Institutionalrecords 6(20) 0 1(4) o
p
y
Collateralreport 2(7) 0 0 rig
h
Mixed 6(20) 3(15) 5(22) t.
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BMJ2012;345:e4692doi:10.1136/bmj.e4692(Published24July2012) Page10of12
RESEARCH
Table3|Summaryaccuracyestimatesproducedbythreetypesoftoolsforriskassessment
Violentoffending(n=30)* Sexualoffending(n=20)† Criminaloffending(n=23)‡
B
Summaryestimates(95%CI)fromsummaryreceiveroperatingcharacteristiccurve M
DSeiangsnitoivsittiycoddsratio 60..0972((40..5888ttoo80..0954)) 30..8888((20..3863ttoo60..4902)) 20..8441((20..0298ttoo30..8586)) J: firs
Specificity 0.36(0.28to0.44) 0.34(0.20to0.51) 0.80(0.67to0.89) t pu
b
Individualstudyestimates(median(IQR)) lis
h
Areaunderthecurve 0.72(0.68-0.78) 0.74(0.66-0.77) 0.66(0.58-0.67) e
d
Positivepredictivevalue 0.41(0.27-0.60) 0.23(0.09-0.41) 0.52(0.32-0.59) a
s
Negativepredictivevalue 0.91(0.81-0.95) 0.93(0.82-0.98) 0.76(0.61-0.84) 10
.1
Numberneededtodetain 2(2-4) 5(2-11) 2(2-3) 1
3
Numbersafelydischarged 10(4-18) 14(5-48) 3(2-6) 6
/b
m
CI=confidenceinterval;IQR=interquartilerange;n=numberofsamples. j.e
*HCR-20,SARA,SAVRY,andVRAG. 46
9
†SORAG,Static-99,andSVR-20. 2
‡LSI-RandPCL-R. on
2
4
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