Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20

BACKGROUND: We examined whether new structured professional judgment instruments for assessing need for therapeutic security, treatment completion and recovery in forensic settings were related to moves from higher to lower levels of therapeutic security and added anything to assessment of risk. METHODS: This was a prospective naturalistic twelve month observational study of a cohort of patients in a forensic hospital placed according to their need for therapeutic security along a pathway of moves from high to progressively less secure units in preparation for discharge. Patients were assessed using the DUNDRUM-1 triage security scale, the DUNDRUM-3 programme completion scale and the DUNDRUM-4 recovery scale and assessments of risk of violence, self harm and suicide, symptom severity and global function. Patients were subsequently observed for positive moves to less secure units and negative moves to more secure units. RESULTS: There were 86 male patients at baseline with mean follow-up 0.9 years, 11 positive and 9 negative moves. For positive moves, logistic regression indicated that along with location at baseline, the DUNDRUM-1, HCR-20 dynamic and PANSS general symptom scores were associated with subsequent positive moves. The receiver operating characteristic was significant for the DUNDRUM-1 while ANOVA co-varying for both location at baseline and HCR-20 dynamic score was significant for DUNDRUM-1. For negative moves, logistic regression showed DUNDRUM-1 and HCR-20 dynamic scores were associated with subsequent negative moves, along with DUNDRUM-3 and PANSS negative symptoms in some models. The receiver operating characteristic was significant for the DUNDRUM-4 recovery and HCR-20 dynamic scores with DUNDRUM-1, DUNDRUM-3, PANSS general and GAF marginal. ANOVA co-varying for both location at baseline and HCR-20 dynamic scores showed only DUNDRUM-1 and PANSS negative symptoms associated with subsequent negative moves. CONCLUSIONS: Clinicians appear to decide moves based on combinations of current and imminent (dynamic) risk measured by HCR-20 dynamic score and historical seriousness of risk as measured by need for therapeutic security (DUNDRUM-1) in keeping with Scott's formulation of risk and seriousness. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales have utility as dynamic measures that can off-set perceived 'dangerousness'.