How short should short-term risk assessment be? Determining the optimum interval for START reassessment in a secure...

The Short-Term Assessment of Risk and Treatability (START) is a tool used in some mental health services to assess patients to see if they are at risk of violence, self-harm, self-neglect or victimization. The recommended time between assessments is 3 months but there is currently no evidence to show that this is best practice. We have investigated whether assessing at 1- or 2-month intervals would be more accurate and therefore facilitate more individualized risk management interventions. We found that many patients who were rated as low risk had been involved in risk behaviours before 3 months had passed; some patients who were rated at increased risk did not get involved in risk behaviours at all. Results are mixed for different outcomes but on balance, we think that the recommendation to conduct START assessment every 3 months is supported by the evidence. However, reassessment should be considered if risk behaviours are not prevented and teams should always consider whether risk management practices are too restrictive.

The Short-Term Assessment of Risk and Treatability (START) guides assessment of potential adverse outcomes. Assessment is recommended every 3 months but there is no evidence for this interval. We aimed to inform whether earlier reassessment was warranted. We collated START assessments for N = 217 adults in a secure mental health hospital, and subsequent aggressive, self-harm, self-neglect and victimization incidents. We used receiver operating characteristic analysis to assess predictive validity; survival function analysis to examine differences between low-, medium-, and high-risk groups; and hazard function analysis to determine the optimum interval for reassessment. The START predicted aggression and self-harm at 1, 2 and 3 months. At-risk individuals engaged in adverse outcomes earlier than low-risk patients. About half warranted reassessment before 3 months due to engagement in risk behaviour before that point despite a low-risk rating, or because of non-engagement by that point despite an elevated risk rating. Risk assessment should occur at appropriate intervals so that management strategies can be individually tailored. Assessment at 3-month intervals is supported by the evidence. START assessments should be revisited earlier if risk behaviours are not prevented; teams should constantly re-evaluate the need for restrictive practices.