HCR-20: PREDICTING RELAPSE IN PATIENTS DISCHARGED FROM FORENSIC PSYCHIATRY HOSPITAL

ORIGINAL ARTICLES HCR-20: PREDICTING RELAPSE IN PATIENTS DISCHARGED FROM FORENSIC PSYCHIATRY HOSPITAL 1 2, 3 4 2 Monica D. Moºescu, Roxana Chiriþã Magdalena Dragu, Alina V. Ungureanu, Vasile Chiriþã Abstract: Background: The HCR-20 (Historical Clinical Risk Management) is a violence risk-assessment instrument but studies have shown his effectiveness for general offending. It is extensively used (even mandatory in Netherlands) in the psychiatric medico-legal assessment. In Romania data on the HCR 20 samples is limited and there is a lack of use for such instruments in risk assessment methodologies. Objective: To examine the predictive validity of the HCR- 20 in relation to post-discharge outcomes in patients with compulsory treatment order. Method: The study was an observational one-year followup study of 22 patients passed from compulsory hospitalization to outpatient compulsory treatment as medical safety measures disposed by Court. The HCR-20 was completed at discharge and the patients were followed for offending, violent behavior, readmissions and compliance of compulsory outpatient treatment. The data were collected from Psychiatry and Safety Measures Hospital Sapoca, Buzau Medico-Legal Department and Police Department. Results: 41% of the cases had a violent behavior or reoffending with an average time for relapse of 36,4 weeks. One third (31.8%) had failure to compulsory outpatient treatment. Poor post-discharge outcomes (relapse but not failure to compulsory outpatient treatment) had a statistically significant association with historical, risk, total s (but not for C ) and, especially, with final risk judgment of the HCR-20 confirmed by ROC analyze and survival analyses. Conclusions: This study confirms predictive value of the HCR-20 for relapse (violent behavior or/and re-offending) for mentally ill persons with compulsory outpatient treatment as medical safety measure disposed by Court sentence but, taking into consideration the methodological limitations, future studies are needed to confirm the validity of the prediction. Key words: risk assessment, forensic psychiatry, compulsory outpatient treatment Rezumat: Introducere: HCR-20 (Historical Clinical Risk Management - 20) este un instrument de evaluare a riscului de violenþã dar studiile au arãtat eficacitatea sa ºi pentru comportamentul antisocial în general. Este intens folosit (fiind chiar obligatoriu în Olanda) în cadrul expertizãrii medico-legale psihiatrice. În România datele despre HCR-20 sunt sãrace ºi existã un deficit în utilizarea acestui tip de instrumente în metodologiile de evaluare a riscului. Obiectiv: Examinarea validitãþii predictivitãþii HCR-20 în relaþie cu rezultatele obligarii la tratament ambulator dupã extenare. Metoda: Este un studiu observaþional, prospectiv, pe 1 an de zile, realizat pe 22 de pacienþi care au trecut de la internarea medicalã obligatorie la tratament obligatoriu ambulator ca mãsurã de siguranþã medical dispusã prin sentinþã penalã. HCR-20 a fost cotat la externare ºi pacienþii au fost monitorizaþi pentru violenþã, comportament antisocial, reinternãri ºi respectarea tratamentului ambulator obligatoriu. Datele au fost colectate de la Spitalul de Psihiatrie ºi pentru Mãsuri de Siguranþã Sãpoca, Serviciul de Medicinã Legalã Buzãu ºi Poliþie. Rezultate: 41% dintre participanþi au avut comportament violent sau antisocial cu o duratã medie pânã la recãdere de 36,4 sãptãmâni. O treime (31,8%) nu s-a prezentat la tratamentul ambulator obligatoriu. Rezultatele slabe dupã externare (violenþa sau comportamentul antisocial) s-au asociat semnificativ cu scorurile H, R, total (dar nu ºi cu scorul C) ºi, mai ales, cu riscul final evaluat la HCR- 20. Aceste rezultate au fost confirmate de analiza ROC ºi analizele de supravieþuire. Concluzii: Rezultatele confirmã valoarea predictivã a HCR-20 pentru recãdere (comportament violent sau antisocial) la pacienþii asistaþi cu mãsura de siguranþã a obligãrii la tratatment conform unei sentinþe penale dar, având în vedere limitele studiului, este nevoie de studii ulterioare care sã confime valoarea predictivã a HCR-20 pentru a o impune ºi în sistemul de mãsuri de siguranþã medicalã din România. 1 MD, PhD, Psychiatry and for Safety Measures Hospital Sapoca, Buzau;Address: SPMS Sapoca, Buzau, 127540, phone:0238528146, fax: 0238528474, md_mosescu@yahoo.com; 2 Professor, MD, PhD, University of Medicine and Pharmacy Gr. T. Popa Iasi; Clinical Hospital of Psychiatry Socola, Iasi; 3 MD, PhD, Chairperson, Medical - Legal Services, Buzau County; 4 MD, Psychiatry and for Safety Measures Hospital Sapoca; Received July 14, 2010, Revised October 06, 2010, Accepted January 20, 2011 80

Romanian Journal of Psychiatry, vol. XIII, No.2, 2011 INTRODUCTION The increasing public concern for the violence committed by people with mental disorders has imposed the need for more subtle ways to assess and manage risk of violent or general offending. Furthermore, because of the strong criticism previously raised related to the mental health professionals' inability to correctly assess dangerousness, many legal systems currently require that the assessment procedures are structured, transparent, and empirically validated to be admissible as expert evidence in court. (1) At the beginning, the risk assessment was based solely on the unstructured clinical judgment, then on the actuarial instruments, and, recently, it relies more on structured professional judgment (SPJ) model which combines the two previous models. (2) Most recently there are discusses about a next generation of tools for assessing the risk for violent or general offending, which include protective factors. (3) Most professionals are currently leaning towards the SPJ model and the HCR-20 is the best known, and the most researched guide to risk assessment, developed as SPJ. The HCR-20 (Webster et al., 1997) is a structured professional guideline which was developed for the assessment of risk for general violence. It comprises static and dynamic items, and the assessor reviews past (Historical), concurrent (Clinical), and future-oriented (Risk Management) risk factors.(4) The HCR-20 is widely used in European forensic psychiatry, most UE Member States using a risk assessment tool, although it is not legally required except for the Netherlands (from July 2005) (2,5). Numerous studies have reported positive results on the predictive value for violence (and general offending) of the HCR-20 in prisons (6), psychiatry hospitals (7,8) and in the community (2,9,10), for forensic patients and for non-forensic patients (11,12,13). Beside the clinical interview, the information required for quoting HCR-20 items are collected, preferably from multiple sources and through multiple methods: interviews with family and friends, psychological assessments, occupational therapist reports, police reports, juridical files.(4) The risk judgment depends not only on the simple summation of item s (subscale H,C,R or total), but also on specific combinations of factors or other considerations. Aside from the 20 items, the HCR-20 offers the possibility to code other considerations, that is, case-specific risk factors that do not fit within the item descriptions (3). The essential difference between the actuarial and the SPJ approach is in how the final risk judgments are arrived at; in actuarial instruments by a fixed algorithm and in SPJ guidelines by (structured) human decisionmaking. It need a discussion of at least 2 experienced assessors (members of the therapeutic team or without knowing the patient) on each item quotation and integrating all available information that the final risk judgment has to be judged as low, moderate, or high and is valid for a specific time period, for instance, during a specific treatment phase or for a given context (inpatient versus outpatient) (3,4). The HCR-20 authors believe that the goal of riskassessment is to prevent violence by guiding risk management activities (4). The risk assessment will need to focus particularly on static risk factors that change slowly and risk management will focus on dynamic factors. Historical items are static, basically unaffected while the clinical and risk management items can be influenced by therapeutic interventions, therefore the risk of violence assessed based on the HCR-20 is not stable for a person and can be modified, in time, by treatment. Pyott (2005) supports the call to incorporate the HCR-20 into standard risk assessment procedures because it may be useful in stratifying services according to the level of risk they should manage and, also, may be useful in demonstrating to those who fund forensic services that expensive services such as assertive outreach or intensive case management are being directed to an appropriately 'forensic' andhigh-risk client group (14). METHODS Participants The study was an observational prospective follow-up study of the mentally ill assisted with medical safety measures discharged from psychiatry and for safety measures hospital Sapoca, Buzau (PSMH) between 01.01.2008 and 28.02.2009. The participants change the compulsory hospitalization with compulsory outpatient treatment in accordance with the Penal Code; they lived in Buzau county and the psychiatric outpatient treatment was provided by mental health centre Buzau (unit of PSMH Sapoca). Procedure The participants were followed for one year since discharge. If a mentally ill person assisted with medical safety measure in community committed violence or other crime, he/she was involuntary hospitalized or had a criminal record or was examined by psychiatric medico-legal commission, so the data was collected from only file records from PSMH Sapoca database (admissions, outpatient treatment), Medico- Legal Department Buzau (psychiatric medico-legal expertise) and Police Department (criminal records). Methodology was approved by Ethics Board of PSMH Sapoca. Measures At discharge we collected data about sociodemographic condition, diagnosis, length of hospitalization, initial offense and rated HCR-20. HCR- 20 was rated by two independents assessors who evaluated the final risk for violence or general offending only for research purpose because the safety measure proposed by psychiatric medico-legal commission was established in accordance with the current methodology. They rated HCR-20 during psychiatric medico-legal expertise or based on file records without any additional request to patient. At the end of the follow-up period, the general outcome measure was the compliance of compulsory outpatient treatment (regular 6-12 visits/year, irregular 3-5 visits/year, failure of compulsory treatment 0-2 visits/year) and the occurrence or not of one of the following: violence (self-reported or officially detected), general offending, non-voluntary admissions (as a result of violence) and voluntary admissions (proof of a good insight and treatment compliance). We considered relapse any violent behavior or general offending. Data analysis The standard SPSS 17 (Statistical Package for Social Sciences) program was used in all statistical 81

, Monica D. Moºescu, Roxana Chiriþã Magdalena Dragu, Alina V. Ungureanu, Vasile Chiriþã : Hcr-20: Predicting Relapse In Patients Discharged From Forensic Psychiatry Hospital (Sommer's index) to track association between HCR-20 and relapse, re-admissions and treatment compliance; Mann-Whitney U test was used for comparison of two samples and ROC analysis and survival analysis (Kaplan- Meier, Cox regression) to examine the validity of the prediction. Sample The final sample was 22 subjects (18 men, 4 women) aged between 24 and 58 years (mean age 42.1 years, SD = 9.8), coming from rural areas (59%) and urban (41%), being single (81.8%), unemployed (40%) and pensioners (54.5%). Offense index was committed with violence in 63.6% of cases. The participants was diagnosed especially with schizophrenic spectrum disorders (63.6%) followed by bipolar disorders and personality disorders (13.6% each), organic disorder and related disorders alcohol (4.5% each). Final risk was assessed as low (31.8%), medium (40.9%) and high (27.3%). The mean s of HCR-20 are presented in table 1 and we noticed that those with relapse, comparative with those without, had bigger s and they were younger (39.8 years compared to 43.7 years) and stay longer in hospital before discharge (as medical safety measure): 1.54 to 3.56 years (table 1). One third (31.8%) had failure to compulsory outpatient treatment, 41% relapsed and 27.3% were voluntarily readmitted in psychiatry wards. The mean time to relapse was 36.4 weeks (SD = 20.3). Sam ple N= 22 W ith relap se N =9 No relaps e N= 13 M ean SD M ean M ea n H -sc ore 11.1 3.0 9 1 3 9.85 C - 4.9 1.2 4.33 3.85 R -sc ore 6.05 1.7 7.11 5.31 T otal sc ore 21.2 5.2 2 4.4 19 Table 1. Mean s of HCR-20: subscales and total Among those that were assessed with low-risk (7 cases) there was no relapse and from those with medium risk (9 cases) only 33% relapsed, while all of the six with high-risk (100%) relapsed. RESULTS Spearman Correlation Analysis Table 2 showed the correlations following this analysis: statistically significant correlations were observed between relapse and H, R and total s as well as for the HCR-20 final risk judgment but not for C-. Also significant correlation were observed between the outpatient treatment compliance and relapse. No correlations observed between HCR-20 and failure to compulsory treatment or readmissions (table nr 2). Relapse Voluntary readmissions Compulsory outpatient treatment Correlation Coefficient H- subscale C- subscale R - subscale HCR-20 total Final risk judgment Compulsory outpatient treatment -,550** -,085 -,518* -,511* -,611** - 0,711 Sig. (2-tailed),008,706,013,015,002,000 Correlation Coefficient -,194 -,060 -,114 -,137 -,087 Sig. (2-tailed),386,791,612,543,702 Correlation Coefficient,584** -,045,442*,464*,609** Sig. (2-tailed),004,843,040,030,003 * Significant correlation at 0,05 level (2-tailed) ** Significant correlation at 0,01 level (2-tailed) Table 2. Spearman's rho Correlations between HCR-20 and relapse, voluntary admission, compulsory outpatient treatment Cross-tabulations Since the dependent variables are ordinal we use as a measure of association Sommer's d indicator (asymmetric relationship between variables) which confirms the previous results (table 3): significant association (negative) between H, R and total HCR-20 s and relapse in the sense that the higher means higher risk to relapse. There is no significant association for C-. The association is very strong for the HCR-20 final risk judgment. There are no statistical significance for association between HCR-20 (s and final risk judgment) and readmission or compulsory outpatient treatment compliance (table 3). Applying the same test for the final risk judgment and relapse according to age group shows that high significant association (negative) is preserved for age group 18-35 years (d=0.857, p=0.000) and 36-50 years (d=0.824, p=0.000) but not for the age group over 50 years (d=0.588, p=0.065). Other factors such as residence, marital status (although all four who were married belong 82

Romanian Journal of Psychiatry, vol. XIII, No.2, 2011 to the group without relapse), occupation (the only employee being without relapse), sex, violence, offense index, diagnosis does not significantly influence the association between final risk judgment and probability of relapse. d -In d ica tor A p p r ox. S i g. H S u b s cale -,4 5 5,0 0 0 C S u b scale -,0 7 7,6 8 9 R S u b s cale -,4 4 2,0 0 5 H C R t o tal sco re -,4 1 2,0 0 3 F in al r is k ju d g m en t -,7 1 7,0 0 0 Table 3. Cross-tabulations: Sommer's d indicator: relapse and HCR-20 Mann-Whitney U test We use this test to compare the two samples (with and without relapse) depending the HCR-20 s, final risk judgment based on the HCR-20, socio-demographic data, diagnosis, length of hospitalization. The results confirms the significant differences between samples for H, R and total s, final risk judgment and outpatient treatment compliance (strong effect size about 0.5) but not for C. Of the other variables followed only residence is a significant difference (Z =- 1.998, p = 0.046), meaning that urban areas represent a risk factor for relapse, which confirms in part the results from cross-tabulation (table 4). Mann- Whitney U H- C- R- Total Final risk judgment 21,000 53,000 23,500 23,500 23,000 Z - 2,522 -,390-2,375-2,343-2,554 Asymp. Sig. (2- tailed) p,012,696,018,019,011 Table 4. Results of Mann-Whitney U test: comparison between groups with and without relapse Survival Analysis Using univariate Kaplan-Meier analysis we compared the three groups defined by the final risk judgment at HCR-20 (low, medium, high) depending on the time to relapse and noticed significant differences between them: Log Rank (1.22 ) = 11.207, p =.001 (Figure 1). Considering the factors in the analysis of Kaplan-Meier, the HCR-20 s (Table 5) confirm earlier results (time to relapse is longer when H, R and total s are smaller) and if we consider the other variables (socio-demographic, diagnosis, duration of hospitalization) only length of hospitalization is significant for time to relapse: Log Rank (1.22) = 7.306, p = 0.007. Figure 1. Kaplan-Meier survival curves for relapse depending HCR-20 final risk iudgment We used Cox regression entering s on subscales H, C, R in block 1 and then final risk judgment in block 2 with forward conditional method. At block 1 subscales s produced a properly significant model: 2 (2.22) = 5.487, p = 0.019. In block 2, the risk assessed has produced a significant improvement in the model: 2 change (2.22) = 6.497, p = 0.011. If in step 2, we used the HCR-20, the total didn't confirm significant model (p = 0.064). In conclusion, the risk assessed is a predictive factor for relapse while the HCR-20 total is not, what it claims the value of SPJ compared with actuarial methods of risk assessment. 83

, Monica D. Moºescu, Roxana Chiriþã Magdalena Dragu, Alina V. Ungureanu, Vasile Chiriþã : Hcr-20: Predicting Relapse In Patients Discharged From Forensic Psychiatry Hospital ROC analysis (receiver operating characteristic) The ROC is a statistical method to assess predictive validity of the HCR-20 and produce area under the curve (AUC) which represents the probability which independent variable predict positive results for the dependent variables (relapses, readmissions, failure to compulsory outpatient treatment). Table 6 shows significant results for H, R, total s and final risk judgment (good prediction is above 0.75) but not for C in terms of relapse prediction. (15) (table 6). Test Result Variable (s) Area Std. Errora Table 6. Area Under the Curve Asympto tic Sig.b Asymptotic 95% Confidence Interval Lower Bound Upper Bound C-,547,128,713,297,797 R-,799,107,019,579 1,000 H-,821,090,012,643,998 Total Final risk judgment,799,101,019,601,997 0,923,056,001,000 1,000 DISCUSSION The study shows a good predictive validity of the HCR-20 (in terms of H, R and total s and, especially, of final risk judgment) for relapse but not for failure of compulsory outpatient treatment or readmissions in patients discharged from PSMH with compulsory outpatient treatment order. The results are confirmed by other studies. (16,17,18) Poor predictive validity of C is supported by other studies (16,19) and may be associated with the observation that, using only unstructured clinical judgment to change medical safety measure proposed, 41% of those discharged relapsed. We can argue these results through the dynamism of clinical items which reflect mental status of the patient, variable, sometimes even with treatment compliance. Data from descriptive statistics for this sample regarding age, gender, length of hospitalization or diagnosis are similar to other studies (20,21) and in terms of dependent variables, it was observed that a third of those discharged were not presented to the compulsory outpatient treatment, almost one third have required hospitalization for exacerbation of disease or alcohol use(voluntary admissions) and 41% have relapsed, returning to the compulsory hospitalization as safety measures or the application of compulsory treatment in prison. These results do not necessarily mean that the proposal to change the safety measure was inadequate since, in Romania, neither the health system nor community are not properly prepared to provide forensic psychiatry services appropriate to this category of patients (double-stigmatized persons, once he has a mental disorder and then he committed a crime punished by the Penal Code) for real social reintegration. The risk assessment at discharge would be based on existing and real available outpatient services not on the services which are ideal and desirable and should exist. Descriptive analysis for mean s of HCR-20, by comparison, for samples with or without relapse, corresponds to data presented by other studies. (16,20,22,23) Using the HCR-20 in the forensic psychiatric system in Romania, we meet a few key issues, most important being the difficulty to obtain information on medical or juridical history of the subject and lack of community support for compulsory outpatient treatment disposed by a Court Order. The first problem could be solved more easily in terms of legal provisions which require specialized institutions to provide information and by creating a computerized national registry for patients assisted with the medical safety measures. The solutions to the second problem are not so simple because they involve more institutions and major legislative changes (since the new codes, the Penal and Penal Procedure, are already published). The importance of the HCR-20 usage in routine practice of psychiatric medico-legal expertise, besides its predictive value higher than unstructured clinical judgment, especially for patients assisted with the medical safety measure, is to improve communication with nonmedical structures involved in the implementation of medical safety measures (Police, Prosecutor, Court) and, to also assure a better monitoring of the evolution of mentally ill persons assisted with medical safety measures as part of risk management The findings reported here should be regarded with the study's methodological limitations: the small number of participants, the short follow up period and difficulties to obtain data about participants after discharge. CONCLUSIONS This study confirms the predictive value of the HCR-20 for relapse (violent behavior or offending) but not for failure to compulsory outpatient treatment in patients with compulsory outpatient treatment as medical safety measure disposed by Court sentence. Considering the methodological limitations, future studies are needed to confirm the validity of the prediction and to provide a cross-cultural contribution to the existing research on HCR-20. Using the HCR-20 in the psychiatric medicolegal expertise, especially for mentally ill persons assisted with medical safety measures, would mean a step forward in risk assessment but also the alignment with the European standards. Conflict of interest: none List of abbreviations: HCR-20 - Historical Clinical Risk Management-20 PSMH Psychiatry and Safety Measures Hospital EU European Union SPJ - Structured professional judgment SPSS - Statistical Package for Social Science 84

Romanian Journal of Psychiatry, vol. XIII, No.2, 2011.REFERENCES 1. Cooke D. Report of the Committee on Serious Violent and Sexual O f f e n d e r s, J u n e 2 0 0 0, a v a i l a b l e o n - l i n e. http://www.scotland.gov.uk/maclean/docs/svso-00.asp, cited on march 2010. 2. Vogel V. Structured risk assessment of (sexual) violence in forensic clinical practice. 2005. available on-line. http://www.dare.uva.nl, cited may 2010. 3. Vogel V, Ruiter C, Bouman Y, Vries Robbe M. SAPROF, guidelines for the assessment of protective factors for violence risk, Utrecht: Forum Educatief, english version, 2008. 4. Webster CD, Douglas K, Eaves D, Hart SD. HCR-20: Assessing risk for violence 2nd ed. Vancouver: Mental Health Law and Policy Institute, Simon Fraser University, 1997. 5. Salize HJ, Dreßing H. Placement and Treatment of Mentally Ill Offenders Legislation and Practice in EU Member States. Central Institute of Mental Health, European Commissionfinal report, february 2005. 6. Douglas KS, Webster CD. The HCR-20 violence risk assessment scheme: concurrent validity in a sample of incarcerated offenders. Crim Justice Behav 1999; 26: 3-19 7. Klassen C. Predicting Aggression in Psychiatric Inpatients Using 10 Historical Factors: Validating the "H" of the HCR-20. Unpublished thesis. Vancouver: Simon Fraser University, 1999. Available on-line: http://www.sfu.ca/psychology/groups/faculty/hart/violink.htm, cited march 2010. 8.Belfrage H, Fransson G, Strand S. Prediction of Violence Using the HCR-20: A prospective study in two maximum-security correctional institution. J Forensic Psychiatr 2000; 11:167-175. 9. Douglas KS, Webster CD. Assessing risk of violence in mentally and personality disordered individuals. In: Roesch R, Hart SD, Ogloff JR (eds). Psychology and Law: The State of the Discipline. New York: Plenum, 1999, 175-239. 10. Wintrup MA. Assessing Risk of Violence in Mentally Disordered Offenders with the HCR-20. Vancouver: Simon Fraser University, 1996. a v a i l a b l e o n - l i n e. http://ir.lib.sfu.ca/bitstream/1892/8263/1/b1791856x.pdf, cited on may 2010. 11. Nicholls TL, Ogloff JRP, Douglas KS. Assessing risk for violence among male and female psychiatric patients: The HCR-20, PCL:SV, and VSC. Behav Sci Law 2000; 22:127-158. 12. McNiel, D, Gregory A, Lam J, Binder R, Sullivan G. Utility of decision support tools for assessing acute risk of violence. J Consult Clin Psychol 2003; 71:945-953. 13. Daffern M. The predictive validity and practical utility of structured schemes used to asses risk for aggression in psychiatric inpatient settings. Aggress Violent Beh 2007; 12(1):116-130. 14. Pyott J. Use of HCR-20 in routine psychiatric practice. Psych Bull 2005; 29:352. 15. Douglas KS, Guy LS, Weir J. HCR-20 violence risk assessment scheme: Overview and annotated bibliography. 2005. available on-line. http://www.sfu.ca/psychology/groups/faculty/hart/violink.htm, cited on april 2010. 16. Gray NS, Taylor J, Snowden RJ. Predicting violent reconvictions using the HCR 20. Brit J Psychiat 2008; 192:384-387. 17. Douglas KS, Ogloff JRP, Nicholls TL, Grant I. Assessing risk for violence among psychiatric patients: the HCR-20 violence risk assessment scheme and the psychopathy checklist: screening version. J Consult Clin Psychol 1999; 67: 917 30. 18. Vogel V, Ruiter C, Hildebrand M, Bos B, van de Ven P. Type of discharge and risk of recidivism measured by the HCR-20: A retrospective study in a Dutch sample of treated forensic psychiatric patients. Int J Forensic Ment Health 2004; 3:149-165. 19. Côté G. Violent behaviour, PCL-R and HCR-20 among involuntary inpatients, forensic patients and severely mentally disordered inmates. Paper presented at the First Annual Meeting of the International Association of Forensic Mental Health Services, Vancouver, 2001. available on-line. http://www.sfu.ca/psychology/groups/faculty/hart/violink.htm, cited march 2010 20. Dolan M, Khawaja A. The HCR-20 and post-discharge outcome in male patients discharged from medium security in the UK. Aggressive Behav 2004; 30:469-483. 21. Gray NS, Snowden RJ, MacCulloch S, Phillips H, Taylor J, MacCulloch MJ. Relative efficacy of criminological, clinical, and personality measures of future risk of offending in mentally disordered offenders: A comparative study of HCR-20, PCL:SV, and OGRS. J Consult Clin Psych 2004; 72:523-530. 22. Freese R, Hiscoke U, Hodgins S. The treatment of mentally ill patients with a history of criminality or violence: What works and what doesn't work? Paper presentation at 11th congress of the association of European psychiatrists, Stockholm, Sweden, 2002. Available on-line. http://www.sfu.ca/psychology/groups/faculty/hart/violink.htm. 23. Douglas KS, Ogloff JRP, Hart SD. Evaluation of a model of violence risk assessment among forensic psychiatric patients. Psychiatr Serv 2003; 54:1372-1379. 85