Factors associated with recommitment of NGRI acquittees to a forensic hospital

Assessing symptom exaggeration of psychopathology in incarcerated individuals and mentally ill offenders within forensic contexts

In forensic contexts, there is a high probability that offenders may exaggerate illness to avoid legal punishment. Since very few empirical studies presently exist on this matter in Thailand, the objectives are to explore the prevalence rate of the exaggeration of psychopathological symptoms and to examine the detection strategy response styles for Thai version of the Symptom validity test (SVT-Th). An analysis of the factors that influence symptom exaggeration would also be included. Mixed participants included 608 individuals consisting of 528 Incarcerated individuals and 80 Mentally Ill Offenders (MIOs). SVT-Th indicated the prevalence rates of feigned psychopathology among overall offenders were 8.88%, 3.20% for incarcerated individuals, and 46.30% for MIOs. As expected, the endorsed average scores of the psychopathological symptoms using the Amplifier and Unlikely response style were recorded at similar amounts. Offenders with a history of mental illness exaggerated their symptoms to a greater degree than those without a history of mental illness. With regard to the type of crime and the number of offenses, no discrepancies of statistical significance were found. Interestingly, offenders who committed violent crimes, and with more than four times the number of offenses, were more likely to exaggerate their symptoms than the other subjects.

Conditional release and cannabis use: Concerns and challenges for community reintegration

This article, which serves as a perspective review, delves into the complexities of cannabis use among individuals preparing for or already on conditional release (CR). These complexities include an association between cannabis use and mental illness and dealing with the fact that the use of illicit substances, such as cannabis, is against CR rules, leading to potential revocation. A focus of this article is the deleterious effects cannabis and synthetic derivatives of cannabis can have for individuals on CR. The article concludes with six-specific recommendations for managing cannabis use in this population with a focus on careful and detailed risk assessments that considers the relationship between substance use and dangerousness, the role of protective factors, the need for a detailed conditional release plan, inpatient and community-based interventions aimed at increasing individual autonomy, and education on the dangers of cannabis use for both the treatment team and the insanity acquittee.

Differences Between Readmitted and Non-readmitted Women in an Italian Forensic Unit: A Retrospective Study

The main objective of this study was to compare readmitted (RW) and non-readmitted (NRW) female psychiatric patients after being conditionally or unconditionally released from Italian inpatient forensic psychiatry services, in order to identify variables that were significantly linked with readmission. This study included all patients who were discharged from the female Residences for the Execution of the Security Measure (REMS) of Castiglione delle Stiviere from January 2008 to June 2015 who were not readmitted until December 31, 2018 (48). In addition, data were collected on female patients who were discharged from the same REMS before 2008 and readmitted from January 2008 to December 2018 (42). A key finding of our study was that the readmission into a female REMS was positively associated with the presence of substance use disorders (SUD) and a primary diagnosis on Axis II. To a lesser extent, younger age, being unconditionally discharged when first released, having had a shorter length of inpatient stay and having committed a crime against property for the first REMS admission was also variables that were apparently linked with readmission. The present research continues the previous research on gender-specific mentally ill offenders. Hence, the decision to proceed separately with a sample of men only and one of women only. For all these reasons, young female patients with personality disorder and SUD perhaps should remain longer in REMS and be released with conditions. In most European countries, the length of stay depends on the clinical condition and risk assessment, with some exceptions where the courts set a maximum length of stay at the outset, as in Italy. All the factors listed above influence the risk assessment. Finally, from integrating these findings into the increasing international literature on conditional release and considering the recent changes in the Italian forensic treatment model, we recommend continuing research on individual risk and protective factors as well as risk assessment instruments on conditionally and unconditionally released inpatients with genders studied separately.

Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Factors associated with referrals to high security forensic services among people with severe mental illness and receiving inpatient care in prison

BACKGROUND

Prison mental health care is a significant topic which has been already studied and described in literature, particularly because of important implications both in the prison and in the health care system. It's not uncommon that inmates suffering from mental disorders are referred to high security forensic services (HSFS) but, to date, studies assessing factors associated with relevant referrals to these services are missing. So, the aim of our study is to investigate socio-demographic, criminological, psychopathological and toxicological variables among those who were referred to HSFS as compared to their non-referred counterpart.

METHODS

We conducted a cross-sectional study recruiting 159 subjects receiving prison inpatient care in an Italian jail, between January 2010 and August 2015. No subjects were excluded from the study. The mean age was 39.

RESULTS

About half of included prisoners suffered from personality disorder while one-third from psychotic disorders. >60% of the subjects had comorbid substance use disorders. The odds of being referred to HSFS were related to previous admission (odds ratio [OR] = 5.34, 95% confidence interval [CI] 1.66-17.16), diagnosis of psychosis (OR = 2.79, 95% CI 1.11-7.04) and cannabis use disorder (OR = 2.68, 95% CI 1.14-6.28). Personality disorder was inversely associated to the referral to forensic facilities (OR = 0.37, 95% CI 0.14-0.97).

CONCLUSIONS

Mental health services should improve preventive measures for vulnerable prisoners in order to reduce criminal recidivism and forensic readmission.

An update and expansion on the role of the Violence Risk Appraisal Guide and Historical Clinical Risk Management-20 in United States case law

An individual's risk for future violent behavior may be considered in various legal contexts, including civil commitment, criminal sentencing, or suitability for parole. Among the assessment tools forensic evaluators use to assess violence risk are the Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, ) and the Historical Clinical Risk Managment-20 (HCR-20)/Historical Clinical Risk Management-20, Version 3 (HCR-20^V3 ) (Webster, Douglas, Eaves, & Hart, and Douglas, Hart, Webster, & Belfrage, , respectively). Previous surveys and case law research suggest that these measures are widely used and perceived to be useful in aiding forensic clinicians. This study provides an update to Vitacco, Erickson, Kurus, and Apple () and examines the use of the HCR-20 and VRAG in United States case law. A LexisNexis review revealed 134 cases decided between 1 January 2010 and 21 December 2016 that included the HCR-20, VRAG, or both. Results revealed that these measures are typically introduced by the prosecution to inform opinions regarding general violence risk. In addition, consistent with previous research, these data suggest the introduction of the HCR-20 and VRAG is rarely challenged and, when challenged, these challenges are rarely successful. However, data suggest that courts and parole boards may focus on specific risk factors (e.g., lack of insight) at the expense of other, more objective factors. Finally, we offer suggestions for clinicians who have transitioned to the newest version of the HCR-20.

Reconviction and revocation rates in Flanders after medium security treatment

AIM

To examine the criminal outcome of Flemish forensic psychiatric patients ('internees') after medium security treatment. Also, the effect of conditional release on recidivism of two subgroups (internees under conditional release and internees who received unconditional release) was examined.

METHOD

Reconviction rates and revocation rates were collected for all participants. Kaplan-Meier survival analyses were used to investigate recidivism rates while controlling for time at risk.

RESULTS

During the 10-year period, 502 offenders were discharged from medium security treatment. Over a follow-up period averaging 3.6years, 7.4% of discharged patients were reconvicted or received a new 'not guilty by reason of insanity' (NGRI) verdict for a violent offence. One-quarter of the population had their conditional release revoked. Part of the study population was granted unconditional release. Reconviction rates were higher after unconditional release in comparison to conditional release.

CONCLUSIONS

The results of this study suggest that the court supervision of NGRI patients in Flanders is effective in protecting the community from further offending.

Methodological development of the Hoeven Outcome Monitor (HOM): A first step towards a more evidence based medicine in forensic mental health

To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.

Psychosis and Substance Use: Implications for Conditional Release Readiness Evaluations

In Foucha v. Louisiana (1992), the United States Supreme Court ruled that individuals adjudicated not guilty by reason of insanity (NGRI) could not remain in a forensic hospital if they were no longer mentally ill and dangerous. Since this decision, a variety of important questions have arisen related to the insanity defense and what should happen to insanity acquittees post-adjudication. This article provides an analysis of clinical issues confronting forensic examiners when psychosis as a result of substance abuse is the underlying condition supporting an insanity defense. To accomplish this analysis, this article provides the reader with a review of literature showing the complex relationship between psychosis and substance abuse. Second, this article investigates how substance-induced psychosis may impact both insanity opinions and subsequent conditional release decisions. Third, the article aims to provide research-driven information to assist clinicians in conducting conditional release evaluations. Finally, this paper provides a model for evaluating dangerousness in the context of conditional release evaluations. Given the substantial comorbidity between substance abuse and psychosis, it is critical for researchers and clinicians to consider potential effects of substance abuse when evaluating insanity acquittees for conditional release, especially as substance use relates to future dangerousness. Copyright © 2016 John Wiley & Sons, Ltd.

Projecting Risk: The Importance of the HCR-20 Risk Management Scale in Predicting Outcomes with Forensic Patients

The present study evaluates data from 116 forensic inpatients who underwent violent risk assessments, which included the Historical, Clinical, Risk-20 (HCR-20), from 2006 to 2013 as part of an opportunity to be conditionally discharged from state forensic facilities. Of the 116 inpatients, 58 were never released, 39 were released and returned to a hospital, and 19 were released and never returned. Results from analyses of variance and multinomial logistic regression found the risk management (R) scale of the HCR-20 successfully predicted group membership in that higher scores were associated with a greater likelihood of not being released from a forensic facility or returning to a forensic facility after release. The results of this study indicate that clinicians should consider community-based risk variables when evaluating forensic patients for potential return to the community. This research demonstrates that clinicians failing to fully consider dynamic risk factors associated with community integration jeopardize the quality and thoroughness of their violence risk assessment with regards to readiness for release. Copyright © 2016 John Wiley & Sons, Ltd.

Conditional Release of Forensic Psychiatric Patients Consistent with or Contrary to Behavioral Experts' Recommendations in the Netherlands: Prevalence Rates, Patient Characteristics and Recidivism After Discharge from Conditional Release

The present study examined a group of 447 Dutch forensic psychiatric patients on conditional release (CR). After a brief overview of the Dutch CR system for forensic psychiatric patients is presented, two sets of factors were studied: factors associated with behavioral experts' recommendations on CR readiness (prevalence rates of recommendations in contrast to or consistent with the judge's decision on CR, written vs. oral recommendations and consensus among parties); and characteristics of forensic psychiatric patients on CR imposed consistent with or contrary to behavioral experts' recommendations (i.e., demographic variables, psychopathology, judicial background and outcomes of violent behavior). Patients on CR consistent with or contrary to the behavioral experts' recommendations did not differ in demographic background variables and psychopathology. Patients on CR contrary to the behavioral experts' recommendations, however, had more prior convictions, and their index offense more often included a sex offense and a property offense (with or without violence) as compared to patients on CR consistent with the behavioral experts' recommendations. In addition, decisions contrary to the behavioral experts' recommendations were more often reached after a 3-month continuation adjournment and after an appeal. Also, patients on CR contrary to the behavioral experts' recommendations were less often found to have been on trial leave before their CR. Finally, recidivism rates were found to be much higher for those on CR contrary to, as compared with those on CR consistent with the behavioral experts' recommendations. However, when corrected for other well-known static predictors of recidivism, this significant difference was no longer prevalent. The implications for evaluators' CR readiness reports and lessons that may be learned from the Dutch forensic psychiatric CR system are discussed. Copyright © 2016 John Wiley & Sons, Ltd.

A Description of the Forensic Monitoring System of the Missouri Department of Mental Health

The Forensic Monitoring System (FMS) of the Missouri Department of Mental Health considers and approves consumers committed under not guilty by reason of insanity (NGRI) status for release. The system extends to the outpatient sector to ensure that such persons maintain their mental stability and do not pose a danger to the community. The process of conditional release and the organization of the FMS are outlined, reasons for the low recidivism rate are discussed, and paternalism in requiring treatment compliance as a condition of individual liberty is explored. Case examples illustrate the success, in terms of revocation and rearrest rates, of the Missouri system, which typically sees an annual return to inpatient custody of only 7%, and a still lower rate of criminal recidivism. Cost-effectiveness is discussed in terms of resources spent so that recovered persons with dangerous mental illnesses may live in safety outside of an institution. Copyright © 2016 John Wiley & Sons, Ltd.

New Frontiers for Conditional Release: Applying Lessons Learned from Other Offenders with Mental Illness

There is relatively little research in the literature on insanity acquittees as compared with the large number of studies focused on the supervision and treatment of probationers and parolees with mental illness. Ideally, the latter literature could be successfully applied to insanity acquittees discharged from an inpatient hospital on "conditional release." This article describes the challenges faced by persons on conditional release as well as the gaps in extant conditional release literature. Then, five evidence-based models for the supervision and/or treatment of probationers and parolees with mental illness are applied to a theoretical conditionally released population (mental health courts, forensic assertive community treatment teams, the risk-need-responsivity model, informed supervision practices, and HOPE probation). Benefits and limitations are noted, and recommendations for such crossover are given. Copyright © 2016 John Wiley & Sons, Ltd.