There is a growing interest in violence risk assessment for psychiatric inpatients. Accurate risk assessments are particularly important for forensic psychiatric patients, because the decision to discharge a patient is heavily weighted on potential dangerousness to self and others. Risk assessment information is also important for risk management and for developing interventions for risk reduction (1).
One measure that recently has been receiving much attention is the Historical Clinical Risk Management-20 (HCR-20), a rating scale of 20 items that have been found to be predictive of violence according to the violence literature (2). Individual items are scored 0, 1, or 2, and scores are added to yield a total score with a range of 0 to 40, with higher scores indicating a higher risk of violence.
The HCR-20 differs conceptually from its predecessors, including the Violence Risk Appraisal Guide (3) and the Psychopathy Checklist-Revised (4), because it incorporates not only static items based on a person's history but also dynamic items that evaluate current clinical presentation and environmental risk factors (5). Studies indicate that the HCR-20 demonstrates good validity for predicting violence for psychiatric patients who are hospitalized (6,7,8,9,10) as well as criminal violence in the community (10,11,12).
One area that has not been fully examined is ethnic differences in violence prediction. Although studies have been conducted in various countries, such as the United Kingdom (6,7), Sweden (8,9,11), Canada (12), and the United States (13), the samples in these studies have been predominantly Caucasians of European heritage. In studies in which persons from other ethnic minority groups are included, the data are reported in aggregate (7,10,13).
This lack of data for non-European-based ethnic groups is of concern given that various indicators have suggested that culture may play a moderating role in violent behaviors and prediction. For example, preliminary epidemiologic data indicate that rates of violence and sexually aggressive behaviors among Asian Americans are generally lower than in other ethnic groups (14,15,16,17). Nationally, arrests for violent crime such as murder, forcible rape, and aggravated assault are four times lower among Asian Americans than in the general population (16). Similarly, statistics on domestic violence in Hawaii have demonstrated lower rates for non-Filipino Asians and higher rates for Euro-Americans, Native Hawaiians, and Filipinos compared with the general population (18). Asian Americans have also demonstrated relatively lower levels of parental aggression toward children and children's counter-aggression toward parents compared with Polynesian and Euro-American families (19).
Other studies indicate that predictors of violence may differ by personal characteristics mediated by ethnicity. Nagayama-Hall and associates (20) reported similar incidents of sexual violence between Asian-American and Euro-American men on the basis of self-report. However, path models revealed differences between the two groups. For Asian-American men, "loss of face" acted as a moderator to reduce sexual violence toward women. This variable was not salient for Euro-American men.
The purpose of the study reported here was to examine whether there are ethnic differences in violence prediction. We believe that the moderating effects of ethnicity are a potentially important issue, because current predictors may not apply to non-Western ethnic groups, or instruments may be less accurate for these groups. Alternatively, different predictors may be more salient for non-Western ethnic groups. If this is true, identifying these predictors may have clinical applications in risk assessment and management with this population. Although relatively small in number, the Asian and Pacific Islander groups are the fastest growing ethnic group in the United States (21). Therefore, information about this group may be useful to all clinicians.
The prediction instrument we used in this study was the HCR-20. The ethnic groups included in the study were Asian Americans, Euro-Americans, and Native Hawaiians. First we compared rates of violence between the ethnic groups. Second, we examined the predictive validity of the HCR-20 for each group. Third, we examined differences in scores on individual HCR-20 items and in the total score. Finally, we examined whether there were differences in violence predictor variables for each ethnic group. We hypothesized that Asian Americans would have a lower rate of violence than Euro-Americans and Native Hawaiians; that there would be differences in the predictive validity of the HCR-20 for each ethnic group; that there would be significant differences in scores for individual HCR-20 items, with Asian Americans scoring lower than both Euro-Americans and Native Hawaiians; and that there would be differences in the pattern of predictor variables of violence between ethnic groups.
Data were procured retrospectively from the archives of Hawaii State Hospital, which provides psychiatric treatment primarily to forensic patients. The study participants were drawn from 169 consecutive inpatient admissions from February 2002 to January 2003. The various legal statuses of these patients included court-ordered mental evaluation for fitness to stand trial, unfit to proceed on legal charges, acquitted by reason of insanity and committed to a hospital, revocation of conditional release, and transfer from prison for psychiatric stabilization. Forty-eight percent of the patients were charged with felonies, and 52 percent were charged with misdemeanors.
Patients were included in the study if their self-reported ethnicity was Asian American, Euro-American, or Native Hawaiian. The Asian-American group consisted of individuals of Japanese, Chinese, Korean, Filipino, or Vietnamese heritage. All participants who reported some Hawaiian lineage were included in the Native-Hawaiian group. With the exception of Native Hawaiians, participants who were of mixed ethnic heritage—for example, Asian-Euro-Americans—were excluded from the study.
From the original sample, 108 individuals met the inclusion criteria. The breakdown in ethnicity was 41 Asian Americans, 38 Euro-Americans, and 29 Native Hawaiians. The mean±SD age of the sample was 40.1±12.6 years, and the mean educational level was 11.9±2.5 years. The gender breakdown was 88 men and 20 women. DSM-IV diagnosis was based on clinical interview and record review. The diagnostic breakdown was 22 patients with schizoaffective disorder, 14 with paranoid schizophrenia, 14 with methamphetamine-induced psychosis, 12 with psychotic disorder not otherwise specified, 12 with bipolar disorder, 11 with chronic undifferentiated schizophrenia, and 23 with another diagnosis.
All study participants were administered the HCR-20 within a week of admission by three psychologists who were trained at a workshop by the instrument's authors. The interrater reliability for 12 cases was r=.94. The outcome measure was violent episodes as identified by hospital event reports. Types of violence included threats or assaults on patients and staff. All study participants were admitted to the intake unit and were then transferred to one of six other units upon psychiatric stabilization. Three of the units specialized in dual diagnosis issues, two were general psychiatric units, and one housed many patients who had been acquitted and committed for reasons of insanity and who, because of the notoriety of their crimes, were not likely to be discharged in the near future.
Chi square tests were conducted to examine differences in rates of violence. With use of receiver operating characteristic (ROC) procedures, the area under the curve (AUC)—a composite measure of sensitivity and specificity—was calculated at each level of test score. This index determined the accuracy of the HCR-20 in predicting violence in each cultural group. A repeated-measures analysis of variance (ANOVA) was conducted to examine the effects of culture on individual HCR-20 items and overall score. Significance was set at p<.05. However, with a Bonferonni correction, the significance level for the ANOVAs was adjusted to (p<.0025), while the Bonferonni-adjusted significance level was (p<.017) for least-squares difference post hoc tests.
Stepwise multiple regressions were then conducted for each ethnic group with items on the HCR-20 used as predictor variables and number of violent event reports times log10 as the dependent variable. This manipulation was made to control for the skewed distribution of violent events per patient. The level of significance for inclusion was p<.05, and p<.10 was used for exclusion. The study was approved by an internal review board as well as statewide review boards. SPSS was used for data analyses.
No significant differences were found between the groups in demographic characteristics such as age, gender, and education or in diagnostic characteristics such as the percentage of patients with nonaffective psychotic diagnosis or in the percentage of patients who had engaged in violent acts (Table 1).
The results of the ROC analysis are presented in Table 2. The AUC was highest for Native Hawaiians (.73) and lowest for Asian Americans (.58), with the Euro-Americans falling in the middle (.64), with no significant differences between the three groups.
The overall model of HCR-20 differences by ethnic group as measured by Wilk's lambda was significant (F=37.44, df=19, 86, p<.001). The main effects of ethnicity was significant (F=12.00, df=2, 105, p<.001, r2=.19) and individual items of the HCR-20 (F=42.39, df=19, 1,995, p<.001, r2=.28) were significant. Of major importance, however, were the significant interaction effects of ethnicity and individual items of the HCR-20 (F=2.18, df=38, 1,995, p<.001, r2=.3). That is, the pattern of significant differences between individual items of the HCR-20 varied across the three ethnic groups.
Results of the ANOVAs for individual HCR-20 items by ethnic group are presented in Table 3. Significant results after Bonferroni correction included young age at first incident of violence (F=6.97, df=2, 105, p<.001), psychopathy (F=10.72, df=2, 105, p<.001), early maladjustment (F=10.75, df=2, 105, p<.001), personality disorder (F=8.65, df=2, 105, p<.001), and past supervision failure (on the part of a correctional institution or mental health agency (F=6.64, df=2, 105, p<.002). Total HCR-20 score was also significant (F=11.56, df=2, 105, p<.001).
On post hoc tests, Asian Americans demonstrated significantly lower scores than both Euro-Americans and Native Hawaiians for young age at first incident of violence (p<.002), psychopathy (p<.001), early maladjustment (p<.001), personality disorder (p<.001), past supervision failure (p<.002), and HCR total score (p<.001).
Results of the stepwise multiple regressions were as follows. The predictor variable for Asian Americans was impulsivity (F=7.67, df=1, 40, p<.01, r2=.16). For Euro-Americans, the lone predictor variable was young age at first incident of violence (F=5.35, df=1, 37, p<.05, r2=.13). The two variables for Native Hawaiians included plans' lacking feasibility and relationship instability, with the regression equation accounting for close to half the variance (F=11.98, df=2, 28, p<.005, r2=.43).
Discussion and conclusions
Our findings provide preliminary support for the general hypothesis that ethnicity may play a moderating role in predicting violence in an inpatient psychiatric sample, although support for specific hypotheses was mixed. Contrary to our predictions, we found no differences in rates of institutional violence among the three ethnic groups. This finding runs counter to previous statistics on community sexual and domestic violence for Asian Americans (14,15,16,17,18,19) and suggests that ethnicity as a moderating factor for violence is not a unitary phenomenon and likely differs by type of violence, setting, population, and outcome measure studied.
Our prediction that the HCR-20 would demonstrate a differential predictive accuracy between ethnic groups was also not supported by our data. This finding suggests that HCR-20 has cross-cultural validity in Asian-American, Native-Hawaiian, and Euro-American samples.
Although the HCR-20 was found to demonstrate similar prediction rates for violence among the three ethnic groups, differences were found in scores on individual HCR-20 items and in predictor variables on regression analyses. Asian Americans had significantly lower scores than Euro-Americans and Native Hawaiians on HCR-20 items related to historical factors, including young age at first incident of violence, psychopathy, early maladjustment, personality disorder, and past supervision failure. The results of regression analyses showed that each ethnic group had a unique pattern of predictors and that there were differences in variance between the groups that were accounted for by corresponding models. For Asian Americans the lone predictor was impulsivity, with a small to moderate effect size (r2=.16). The regression for Euro-Americans also had only one predictor—young age at first incident of violence—with a small to moderate effect size (r2=.13). By contrast, the strongest results were demonstrated for Native Hawaiians, for whom we found three salient predictors—young age at first incident of violence, relationship instability, and risk-management plans' lacking feasibility—and a large effect size (r2=.43).
Taken together, our findings suggest that the HCR-20 demonstrates similar predictive accuracy across Asian-American, Native-Hawaiian, and Euro-American samples. However, there are unique ethnic differences in how each group scores on the instrument and in which items are more salient for predicting violence.
Given our preliminary findings, what are the possible cultural explanations for the pattern of salient indicators for violence, and how might these explanations guide treatment? For the Asian-American group, our findings can be explained by the cultural values of interdependence and "saving face," whereby any type of deviance, such as violence, brings shame to the individual and his or her family or group (22). Such values are consistent with lower scores on the HCR-20 items that measure age at first incident of violence, psychopathy, early maladjustment, personality disorder, and past supervision failure. These items relate to behaviors or characteristics that indicate a lack of concern for others and that are highly incongruent with the aforementioned Asian-American values. The lower scores on these items are not surprising given the relatively low rates of violence among Asian Americans (14,15,16,17,18).
A related cultural explanation is the tendency for Asian Americans who seek mental health services to be more severely ill than their Euro-American counterparts who use the same services (23,24). One reason for this difference in help seeking is that many Asian-American families, because of the stigma and shame associated with psychiatric illness, bring family members for psychiatric services only when they become unmanageable (25). It therefore makes sense intuitively that violence among Asian-American psychiatric inpatients would be strongly related to psychiatric symptoms, such as emotional lability. This combination of low scores on items related to historical risk factors and high scores on items related to clinical risk factors suggests that for Asian-American psychiatric inpatients, violence is associated more with aspects of current psychiatric symptoms than with premorbid characteristics.
For both Euro-Americans and Native Hawaiians, violence risk was associated with scores on historical items of the HCR-20, particularly young age at first incident of violence. This finding is more consistent with the results of other studies that have shown that previous violence, particularly violence at a young age, is a strong predictor of future violence (3,26). However, for the Native-Hawaiian participants in our study, relationship instability, or an inability to form stable intimate relationships, and environmental factors as measured by an overall risk management plan, were also significant predictors.
The salience of these factors for predicting violence among Native Hawaiians is consistent with Native Hawaiians' strong values of "aloha" (love and kindness), "ohana" (family), and "lokahi" (harmony) that stress the importance of the relationship between self and others (27) and is also consistent with Native Hawaiians' traditional conceptions of mental illness. Native Hawaiians do not have a word for mental illness; instead, they say "pilikia," or "trouble occurs" (28). Furthermore, emotional and psychological concerns are believed to result from imbalances in key relationships between the person, his or her family, and the natural and spiritual realm (28).
Given these beliefs and values, it makes sense that persons who cannot form stable intimate relationships may be at risk of engaging in violent behaviors. Conversely, it may be that those who are violent within their intimate relationship are particularly prone to violence in general (29). These values also suggest that interactions with the environment, including supports, stressors, destabilizers, and compliance with treatment, are important for determining violence risk among Native Hawaiians.
Ethnic differences in violence risk prediction may also be useful in developing more culture-specific approaches to violence risk reduction. Our findings suggest that, for Asian-American psychiatric patients, interventions that target impulsivity or emotional lability may be a potential strategy for reducing violence risk. By contrast, for Native Hawaiians, interventions that target improvement of interpersonal relationships—for example, hooponopono, an indigenous mental health intervention—may be more effective (27).
In summary, our study provides preliminary evidence that ethnicity plays a moderating role in the prediction of violence among psychiatric inpatients. The possible existence of ethnic differences may be clinically important for more accurate predictions of violence and for the development of more effective intervention strategies for patients from ethnic minority groups. This issue will become more salient as the percentage of individuals from ethnic minority groups in the general population increases in Western societies.
Given the small sample, the uniqueness of the sample, the overrepresentation of men, and the use of ethnicity as a proxy for culture, caution should be taken in generalizing our findings to other Asian and Pacific Islander populations as well as to female populations. Our findings need to be replicated with similar populations located in other psychiatric institutions. The inclusion of cultural identity measures would be useful in obtaining a more pure measure of culture. Incorporating such measures would also control for a possible confounding effect in our study given that many of the patients in the Native-Hawaiian group were of multiple ethnicities, including individuals from Asia and Europe. Another limitation was the use of event reports as a measure of violent events, because this measure may underestimate the actual number of violent events.
We hope this study promotes more research on cultural factors in risk management measures such as the HCR-20 and stimulates clinicians to consider potential cultural effects when making predictions of violence among psychiatric inpatients. Similar studies should include other ethnic groups, such as Hispanics and African Americans, to determine equivalency and examine whether these groups have unique patterns of salient violence predictors on the HCR-20.
Dr. Fujii, Dr. Tokioka, and Dr. Lichton are affiliated with the department of psychology at Hawaii State Hospital, 45-710 Keaahala Road, Kaneohe, Hawaii (e-mail, firstname.lastname@example.org). Dr. Hishinuma is with the department of psychiatry of the John A. Burns School of Medicine in Oahu, Hawaii. This study was presented at the annual convention of the American Psychological Association, held July 28 to August 1, 2004, in Honolulu.
Table 1. Demographic characteristics of 169 psychiatric inpatients who participated in a study of violence risk assessmenta
aThe duration of admission ranged from eight to 847 days, with a mean±SD of 192.9±165.3 days. The skewness of the distributions was 1.72, and the kurtosis was 3.23.
Table 2. Area under the curve (AUC) of scores for total scores on the Historical Clinical Risk Mangement-20 (HCR-20) and for historical (H), clinical (C), and risk-management (R) items, by cultural group
Table 3. Analysis of variance of Historical Clinical Risk Mangement-20 (HCR-20) scores by ethnic group
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Structured Professional Judgment (SPJ) approaches to violence risk assessment are increasingly being adopted into clinical practice in international forensic settings. The aim of this study was to examine the predictive validity of the Historical Clinical Risk -20 (HCR-20) violence risk assessment scale for outcome following transfers from high to medium security in a United Kingdom setting.
The sample was predominately male and mentally ill and the majority of cases were detained under the criminal section of the Mental Health Act (1986). The HCR-20 was rated based on detailed case file information on 72 cases transferred from high to medium security. Outcomes were examined, independent of risk score, and cases were classed as "success or failure" based on established criteria.
The mean length of follow up was 6 years. The total HCR-20 score was a robust predictor of failure at lower levels of security and return to high security. The Clinical and Risk management items contributed most to predictive accuracy.
Although the HCR-20 was designed as a violence risk prediction tool our findings suggest it has potential utility in decisions to transfer patients from high to lower levels of security.
Over the last 3 decades there have been significant developments in the field of violence risk assessment and management. It is increasingly recognized that individuals with mental disorder have an increased (4 to 6 times higher) risk of committing a violent crime [1,2]. Since the work of Monahan  unstructured clinical approaches to risk assessment in psychiatric patients have been questioned due to their low levels of accuracy. The literature suggests that there are a number of factors that are associated with violence and poor outcome in patients discharged from civil and forensic settings including major mental illness, substance abuse and psychopathy [4-7]. Over the last 15 years there have been notable developments in systematizing the risk assessment field which have led to the introduction of a number of risk assessment tools that provide a more structured approach to decision making [6,8,9]. The latter Structured Professional Judgment (SPJ) approach provides guidelines for assessing risk using systematized, empirically based, risk factors that can be coded but can still allow flexibility to take account of case-specific issues. One of the most researched instruments to use a SPJ approach is the Historical Clinical Risk-20 scale [8-10]. This measure has 10 historical, relatively static factors that do not change over time, and 10 dynamic (5 clinical and 5 risk management) items that are subject to change with treatment. See table 1 for item content. There are now a substantial number of international studies looking at the validity of the HCR-20 as a violence risk assessment tool. These include studies from Canada, Sweden, the Netherlands, Scotland, Germany, England and the United States. See [6,9-13]. Most of the published studies have focused on the validity of measures such as the HCR-20 in predicting in-patient and post discharge violence and aggression in male samples, although there is increasing data on female patients [14,15].
Interestingly, we previously  looked at the predictive validity and clinical utility of the HCR-20 as a predictor of more generic post discharge outcome in patients discharged from medium secure care to the community in the UK. We found that the HCR-20 was a good predictor of self-reported violence, readmission, and particularly readmission under the criminal sections of the England and Wales Mental Health Act, 1986, but did not necessarily relate to the intensity of supervision post discharge. This suggested that the HCR-20 may be a useful instrument for assessing the risk of poor outcome (in more general terms than violent recidivism) in decisions to transfer patients from higher to lower levels of security including the community. This led us to wonder if this instrument had value in predicting outcome decisions across levels of security in the forensic rehabilitation process.
In England and Wales (E&W) and most European and Canadian and United States (US) forensic services, the rehabilitation of high security patients who are detained in High Security Psychiatric Hospitals (HSPHs) usually occurs via transfer to progressively lower levels of security prior to discharge into the community [17,18]. Apart from the UK few jurisdictions have systematically looked at the outcomes of patients across levels of security and international comparative data is currently quite limited. A review of the medium to long term outcomes of discharges from HSPHs in E&W, with follow up between 2-11 years, suggests that hospital readmission rates range between 7 - 22% . Reconviction studies of released HSPH patients also suggest that the rate of serious reconvictions ranges from 3% to 24% overall, [20-22]. However, Davison et al.  reported that rates were notably higher in patients with a diagnosis of Axis II personality disorder rather than an Axis I disorder.
A range of independent clinical studies suggest that poor outcome for HSPH patients appears to be linked with a variety of risk factors including; younger age, a higher number of previous convictions, a history of psychiatric admissions, mental impairment, psychopathy or a sexual index offence [19,24-26], but few of these risk factors have been examined together in the context of a comprehensive risk assessment protocol. Given that SPJ approaches to risk assessment have been adopted as good clinical practice in most US and European jurisdictions, but there is limited evidence on the applicability in clinical practice, we wanted to investigate the utility of the HCR-20 in decision making on transfers from high to medium and lower levels of security in a UK context.
Available data from the limited number of studies examining the outcomes of HSPH patients transferred to medium security in E&W suggest that between 26-33% are returned to high security, and between 9-11% are reconvicted for serious offences [26-28]. Given the growing interest in the use of more structured clinical risk assessment and management tools in clinical decision making [6,9,29-35], we investigated the potential utility of a Structured Professional Judgment (SPJ) approach to violence risk assessment using the Historical Clinical Risk violence risk scheme (HCR-20; ) in the decision to transfer cases between high and lower levels of forensic secure care. The HCR-20 has repeatedly been shown to be a robust predictor of institutional and community violence in mentally disordered samples across a range of settings and international centers [9,16,33-39].
We have previously shown that the HCR-20 was actually a useful predictor of self-reported violence and readmission to hospital in patients transferred from medium and low secure care to the community  and that clinically based supervision levels post discharge was unrelated to systematic risk assessment status . As there was one report that suggested that the HCR-20 was useful in characterizing risk status in patients managed by community mentally health services in the UK , we examined its utility as an assessment tool in decisions to transfer patients from high to lower levels of security.
The study was conducted in the Edenfield Centre Medium secure unit in the North West region of E&W. The 2005-6 cohort under study was based on all HSPH patients admitted to the Edenfield medium secure unit (MSU) psychiatric facility from its inception in September 1986 to June 2001, and who had a terminated MSU admission episode by May 2002. That is, they had been discharged to the community or returned to the HSPH from the MSU by May 2002. In cases where a patient had several admissions to the MSU, the first admission was used as the index admission case for the purposes of this study. The study criteria generated a total of 72 consecutive patients discharged from HSPH to the Edenfield Centre whose index admission to the latter unit had terminated either through discharge to the community or lower levels of security (success), or transfer back to high security/reconviction (failure). Of all admissions to the Edenfield centre, this HSPH sample represented 11% of all admissions to the unit during that time period. The remainder of the transfers/admissions had come from prisons or from area/local mental health services. The majority were detained under section 41 (restriction order) of the UK Mental Health Act 1986. That is, the patients were detained in hospital following a court appearance for an offence that was deemed associated with mental disorder requiring inpatient treatment and whose discharge could only be approved by the Home Office (now Ministry of Justice) or following appeal to a Mental Health Review Tribunal.
The mean age of the HSPH cohort under study was 36.4 years (SD = 11.5). Sixty- three (87%) were male and 57 (79%) were Caucasians. The remainder were of Afro-Caribbean (10%) or Asian/mixed race origin (11%). Clinical case files, which record multi-axial diagnoses, indicated that the majority had an Axis I clinical diagnosis particularly schizophrenia, but there were high rates of co-morbidity with Axis II pathology. A significant proportion of the cohort met criteria for substance abuse dependence. Forty-seven patients (65%) had more than one clinical diagnosis recorded. See table 2.
Clinical diagnosis according to DSM-IV (several diagnoses possible, n = 72)
The majority (55, 76%) had previous admissions to a psychiatric hospital. Fifty-nine (82%) had previous convictions with a range of 1-35 offences. The mean age at first conviction was 19.5 years (SD = 8.3). The frequency of particular index offences were as follows; violence against others (64%); violent sex offences (17%); arson with intent to endanger life and criminal damage (19%). See table 3.
Index offences (index offences not mutually exclusive, n = 72)
Prior to transfer to the MSU, the mean length of stay at the HSPH was 7.4 years (SD = 5.8). The majority (59, 82%) were transferred to the MSU on trial leave to test their suitability for rehabilitation into the community. The mean length of MSU stay was 1.2 years (SD = 1.0).
The Local Research and Ethics Committee (LREC) granted approval for the study. Responsible Medical Officers (RMOs) gave consent for access to patient's files.
The HCR-20 was rated from the detailed case files based by a trained psychiatrist on the data available in the medium secure unit following transfer from high security. The case files were reviewed and the HCR-20 scored based on data available prior to their transfer out of, or discharge from, the medium secure unit, but this was conducted blind to subsequent outcomes. The HCR-20 scale has ten Historical-H items, five Clinical-C items, and five Risk-R items. The H items are based on empirical literature on violence risk assessment and tend to remain static over time. The C and R items are amenable to change with intervention and supervision. All 20 items are coded using a "0" rating for absence of an item, "1" for possible presence of the item and "2" for definite evidence for this item. Descriptors and criteria for each item are provided in the manual  but HCR-20 items are listed in table 1.
Outcome was classed as "success" or "failure" based on the work of Quinn and Ward  and Cope and Ward  who used similar criteria for outcome measures in their study. Success was based on successful rehabilitation from the MSU to the community with no adverse events (readmission/reconviction) during the study period.
Failure was based on:
(i) Direct return to the HSPH,
(ii) Return to the HSPH after discharge to the community and
(iii) Reconviction for a serious offence after discharge to the community. Re-conviction data was extracted from combined sources including case files and the official records in the Offenders Index of the Home Office. A reconviction was regarded as being "serious" in cases of murder, manslaughter, assault, rape, indecent assault towards adult male, adult female or child, robbery and arson, based on the criteria of Bailey and MacCulloch .
Data were analyzed using the Statistical Package for Social Sciences SPSS for Windows (version 14) Chicago Illinois Inc. Where possible, outcome data was coded into dichotomous groups e.g. outcome present or absent. Receiver Operating Characteristics (ROC) analyses , were used to examine the predictive validity of the HCR-20 score for dichotomous outcome measures as they are relatively independent of the base rate for violence in a given population. ROCs also offer the advantage of plotting the trade-off between sensitivity (true positive rate) and 1-specificity (false positive rate). The Area under the curve (AUC) statistic ranges from 0 (perfect negative prediction) to 1 (perfect positive prediction) with 0.50 representing a chance level of prediction. ROC AUC statistics of 0.76 approximate to Cohen's d of 1 which is considered a large effect size [7,38].
Overall, 32 patients (44.4%) were rated as having a successful outcome in that they were successfully rehabilitated to the community with no adverse events during the study period.
Forty patients (55.5%) had an outcome that was classed as a "failure" based on the assigned categories. Thirty-three (46%) patients returned directly to the high-security hospital from the MSU; one patient was recalled to the HSPH with treatment-resistant mental illness; one patient was recalled after a serious re-conviction and five further patients were re-convicted of serious offences.
Reconviction data- Community outcomes
Of the 39 patients (54%) who were discharged to the community (mean 6 years SD 3.6), 8 (21%) were reconvicted. Mean length of time until re-offending was 5.25 years (SD = 3.7). Six (15%) were for serious offences (violence against the person).
The predictive validity of the HCR-20 for outcomes
The mean total HCR-20 score was 22.06 (SD 7.2), The H score was 12.47 (SD 3.5), C was 4.29 (SD 3.0) and R 5.29 (SD2.5). Table 3 shows the ROC curve analyses for the total and subscale scores of the HCR-20 for "failed outcome". The HCR-20 total score was a reasonably robust predictor of "failure". Analysis of the subscale scores indicated that the C and R subscales rather than the H subscale were significantly better than chance predictors. See Table 4 and figure 1.
HCR-20 subscale and total HCR-20 score as predictor for outcome "failure"
Area under curve: Historical, clinical and risk subscale as well as total HCR-20 score as a predictor of the outcome "failure".
To date, there are a limited number of studies looking at the forensic outcomes of high security patients who have been discharged via medium secure care [27,28]. In this study the 72 HSPH patients had similar characteristics to those described in other MSUs e.g. [28,41-44] in that they were predominately male with extensive forensic and psychiatric histories. In a pseudo-prospective study design we examined the predictive accuracy of the HCR-20 for outcomes following transfer from high to medium secure psychiatric care. As far as we know this is the first international study to look at the HCR-20 in this way as most studies have focused on either institutional or community violence [12,16,29,33,35-37,45-48]. It is also the first to report data on the validity of this measure at predicting a broader range of outcomes following transfer to lower levels of security in the UK or elsewhere. We predicted that high scores on the Historical Clinical Risk -20 scale would be predictive of poor outcome in medium secure services. We did indeed find that the HCR-20 score was a good predictor of failed transfer. The total score ROC AUC curve was 0.86 which is much higher than the modest to moderate ROCs reported in many previous studies . It is also noteworthy that it was the clinical and risk management subscales that contributed most to this effect. Studies have reported varying degrees of contribution from the dynamic subscales but the research evidence seems to suggest that the contribution of dynamic scales vary as a function of the stage of rehabilitation. In Gray's et al's  pseudo prospective 2 year follow up study of patients discharged from medium security to the community only the Historical and Risk scales were predictive. The clinical scales did not show notable accuracy. They suggest that the lack of predictive accuracy in their sample may reflect the clinical stability of those deemed suitable for discharge to the community as well as the differences in follow up time. Our finding that the clinical and risk items both contribute significantly to the prediction of poor outcomes fits with our previous studies in medium secure samples [16,45] and also fits with the notion that the clinical items may be more robust predictors of negative outcomes if failure is also determined by clinical issues such as lack of response to medication. There are a number of studies that have compared the post discharge outcomes of patients and using the HCR-20 with Violence Risk Appraisal Guide  and the Psychopathy Checklist Revised  or Psychopathy Checklist- Screening Version (PCL;SV.) which are measures of psychopathy that have been shown to be predictive of post discharge violence . In one study  193 psychiatric patients were assessed using both the HCR-20 and The PCL: SV. At 2 year follow up, the AUCs for the HCR-20 ranged from 0.76-0.80 for a range of aggressive and threatening behaviors, but the PCL: SV had only moderate predictive power. Interestingly, the HCR-20 had incremental validity over and above the PCL: SV. Similar findings were noted in our previous prospective 24 week follow up study of patients discharged from medium secures and civil psychiatric settings work who had been assessed using the HCR-20, VRAG and PCL:SV. Here we found that the HCR-20 and PCL:SV were better predictors of violence post discharge than the VRAG, but in the regression analyses the HCR-20 (particularly the clinical and risk scales) had incremental validity over and above the PCL:SV . A Swedish retrospective study on 40 male forensic patients  also found that the HCR-20 was highly predictive of violent recidivism and that the clinical and risk management scales predicted recidivism much better than the historical scale. Overall, our findings seem to suggest that the HCR-20 is a useful tool in predicting those who will fail in their rehabilitation. The broader literature also suggests that it has utility in predicting post discharge recidivism (particularly violent outcomes) for both forensic and correctional samples . There is a growing literature that suggests it has utility in predicting in-patient aggression and outcome  although the findings have been less robust as in-patient aggression may be more associated with heightened affect and active psychotic symptoms in US studies . While there is now little doubt that structured risk assessment instruments outperform clinical judgment for the prediction of violent behavior and poor outcome for predominately male samples [6,11], there is relatively little data on female forensic or correctional samples. The vast majority of risk assessment studies in women have been based on psychopathy assessments [54,55] and there is limited data on the validity and utility of the HCR-20 in women . Some studies looking at gender differences in the HCR-20 do not note significant differences between men and women [8,14] however, work by de Vogel & de Ruiter  showed that the HCR-20 total score demonstrated lower predictive accuracy for violent outcome in women compared to men. Given the observed gender differences future studies need to address this issue.
There are a number of limitations to this study including small sample size and a focus on a mainly male Caucasian cohort. Given recent reports that there are gender and ethnic differences in scores on some HCR-20 items this is an area that warrants further study [14,15,64]. Furthermore, although our cohort were fairly representative of patients detained in medium levels of security in the UK, they may not be comparable to cohorts of medium secure patients in other European and US jurisdictions where there may be greater representation of ethnic minority groups and female patients. It is also possible that the findings may not be generalisable to high security samples as this cohort had already been clinically selected as suitable for transfer to lower levels of security. In this study, we relied on clinical recording of multi-axial diagnoses, rather than standardized assessment tools. While the clinical files do record multi-axial diagnoses, it is possible that the lack of assessment using structured assessment tools may have resulted in under recording of Axis II and III pathology in particular.
The findings from this study would suggest that measures such as the HCR-20 may have value in routine clinical decisions as they may assist in the assessment of those who are likely to succeed or fail on trial leaves to lower levels of security. Although the HCR-20 is increasingly being adopted into clinical practice in European forensic settings including Germany, Sweden and the Netherlands, there are relatively few UK centers outside high secure forensic facilities that use the HCR-20 as a core component of routine clinical practice. The Edenfield Centre Medium secure unit in the North of England has adopted this instrument into routine clinical practice following a series of research based validation studies to examine its utility as part of its ongoing risk assessment research program. We have shown that it is a robust predictor of post discharge outcome (readmission and self report violence) in patients discharged from our medium secure service . We have also shown that the HCR-20 is one of the most robust predictors of community violence 24 weeks post discharge in patients discharged from both forensic and civil psychiatric services . More recent studies by Gray and colleagues  confirm the validity of the HCR-20 in the prediction of violent recidivism in patients discharged from medium secure units in the UK. Several services in the United States and Europe have also published research studies supporting its reliability, validity and clinical utility across a range of levels of security as well as the community . A key strength of the HCR-20 is its utility in guiding clinical judgment about risk management and it is this aspect of the instrument that has lead to its acceptance into routine clinical practice . The development of the HCR-20 companion guide  has assisted with this process, but more work is needed to refine the role of structured risk assessment tools in clinical decision making . Many studies rely on official records of reconviction as an outcome measure. We suggest that there are limitations in the use of reconviction data as a proxy measure of success in assessing the efficacy of forensic services [59,60] including the fact that there may be bias in the prosecution of psychiatric patients which limits the accuracy of this data in assessing and comparing outcomes [61,62]. This however remains one of the most cited performance indicators. In recent years, there has been a move away from reliance on criminal outcomes alone and recent work suggests alternative measures such as readmission and collateral and self reported criminality may be useful indicators of outcomes [16,45]. Further studies are needed to track and monitor the mental health and criminal outcomes of patients discharged from high and lower levels of security and to compare the outcomes of patients who are discharged to the community and followed up using an integrated, as opposed to a parallel, model of aftercare .
The authors declare that they have no competing interests.
MD conceived of the study, and participated in its design and coordination and drafted the manuscript. RB carried out the field work, assisted in data analysis and assisted in drafting the manuscript. All authors read and approved the final manuscript.
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