This article describes a systematic review of the psychometric properties of the Short-Term Assessment of Risk and Treatability (START) and a meta-analysis to assess its predictive efficacy for the 7 risk domains identified in the manual (violence to others, self-harm, suicide, substance abuse, victimization, unauthorized leave, and self-neglect) among institutionalized patients with mental disorder and/or personality disorder. Comprehensive terms were used to search 5 electronic databases up to January 2013. Additional articles were located by examining references lists and hand-searching. Twenty-three papers were selected to include in the narrative review of START's properties, whereas 9 studies involving 543 participants were included in the meta-analysis. Studies about the feasibility and utility of the tool had positive results but lacked comparators. START ratings demonstrated high internal consistency, interrater reliability, and convergent validity with other risk measures. There was a lack of information about the variability of START ratings over time. Its use in an intervention to reduce violence in forensic psychiatric outpatients was not better than standard care. START risk estimates demonstrated strong predictive validity for various aggressive outcomes and good predictive validity for self-harm. Predictive validity for self-neglect and victimization was no better than chance, whereas evidence for the remaining outcomes is derived from a single, small study. Only 3 of the studies included in the meta-analysis were rated to be at a low risk of bias. Future research should aim to investigate the predictive validity of the START for the full range of adverse outcomes, using well-designed methodologies, and validated outcome tools.

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The Historical, Clinical and Risk Management Scales (HCR-20) may be a better predictor of inpatient aggression for selected demographic and clinical groups but homogeneity of study samples has prevented definitive conclusions. The aim of this study, therefore, was to test the predictive validity of the HCR-20 as a function of gender, diagnosis, age, and ethnicity while controlling for potential covariates. A pseudo-prospective cohort study (n=505) was conducted in a UK secure/forensic mental health setting using routinely collected data. The HCR-20 predicted aggression better for women than men, and for people with schizophrenia and/or personality disorder than for other diagnostic groups. In women, the presence of the risk management items (R5) was important while men׳s aggression was best predicted solely by current clinical features from the C5 scale. R5 items were better than C5 items for predicting aggression in people with organic and developmental diagnoses. Our data provide additional information on which HCR-20 raters can formulate overall summary judgements about risk for inpatient aggression based on important demographic and clinical characteristics.

The Short-Term Assessment of Risk and Treatability (START) aims to assist mental health practitioners to estimate an individual's short-term risk for a range of adverse outcomes via structured consideration of their risk ("Vulnerabilities") and protective factors ("Strengths") in 20 areas. It has demonstrated predictive validity for aggression but this is less established for other outcomes. We collated START assessments for N = 200 adults in a secure mental health hospital and ascertained 3-month risk event incidence using the START Outcomes Scale. The specific risk estimates, which are the tool developers' suggested method of overall assessment, predicted aggression, self-harm/suicidality, and victimization, and had incremental validity over the Strength and Vulnerability scales for these outcomes. The Strength scale had incremental validity over the Vulnerability scale for aggressive outcomes; therefore, consideration of protective factors had demonstrable value in their prediction. Further evidence is required to support use of the START for the full range of outcomes it aims to predict.