Characteristics and outcomes of insanity acquittees in Oklahoma

Are symptoms assessed differently for schizophrenia and other psychoses in legal insanity evaluations of violent crimes?

BACKGROUND

Forensic evaluations of legal insanity include the experts' assessment of symptoms present at the mental state examination (MSE) and the mental state at the time of offense (MSO). Delusions and hallucinations are most important. We explored how often symptoms were recorded in written forensic reports.

DESIGN

This exploratory, cross-sectional study included 500 reports of legal insanity written in 2009-2018 from cases of violent crimes in Norway. The first author read all reports and coded symptoms recorded from the experts' assessments of the offenders. Two co-authors repeated this procedure for 50 randomly selected reports. Interrater reliability was calculated with Gwet's AC1. Generalized Linear Mixed Models with Wald tests for fixed effects and Risk Ratios as effect sizes were used for the statistical analyses.

RESULTS

Legal insanity was the main conclusion in 23.6% of the reports; 71.2% of these were diagnosed with schizophrenia while 22.9% had other psychotic disorders. Experts recorded few symptoms from MSO, but more from MSE, although MSO is important for insanity. We found a significant association between delusions and hallucinations recorded present in the MSO and legal insanity for defendants with other psychotic disorders, but no association for defendants with schizophrenia. The differences in symptom recordings between diagnoses were significant.

CONCLUSION

Few symptoms were recorded from the MSO. We found no association between presence of delusions or hallucinations and legal insanity for defendants with schizophrenia. This may indicate that a schizophrenia diagnosis is more important to the forensic conclusion than the symptoms recorded in the MSO.

Use of assessment instruments in forensic evaluations of criminal responsibility in Norway

OBJECTIVES

Assessment instruments are often used to enhance quality and objectivity in therapeutic and legal settings. We aimed to explore the use of instruments in Norwegian reports of forensic evaluations of criminal responsibility; specifically, whether this use was associated with diagnostic and forensic conclusions.

METHODS

Our study has an exploratory cross-sectional design. We examined 500 reports filed with the Norwegian Board of Forensic Medicine in 2009-2018 regarding defendants indicted for the most serious violent crimes. The first author coded data from all reports according to a registration form developed for this study. Two co-authors then coded a random sample of 50 reports, and inter-rater reliability measures were calculated. The first author coded 41 reports for calculation of intra-rater reliability. Descriptive statistics are presented for the use of assessment instruments, and a generalized linear mixed model (GLMM) was used to estimate associations between the use of instruments and diagnostic and forensic conclusions.

RESULTS

Instruments were used in 50.0% of reports. The Wechler's Adult Intelligence Scale (WAIS), Historical Clinical Risk-20 (HCR-20), and the Structured Clinical Interview for DSM disorders (SCID I), were used in 15.8, 13.8, and 9.0% of reports, respectively. The use of instruments increased from 36% in 2009 to 58% in 2015; then decreased to 49% in 2018. Teams of two experts wrote 98.0% of reports, and 43.4% of these teams comprised two psychiatrists. In 20.0% of reports, the diagnostic conclusion was schizophrenia, and in 8.8% it was other psychotic disorders. A conclusion of criminal irresponsibility was given in 25.8% of reports. Instruments were more often used in reports written by teams that comprised both a psychiatrist and a psychologist, compared to reports by two psychiatrists. The use of instruments was strongly associated with both diagnostic and forensic conclusions.

CONCLUSION

Instruments were used in 50% of reports on forensic evaluations of criminal responsibility in Norway, and their use increased during the study period. Use of instruments was associated with diagnostic and forensic conclusions.

Absconsion in forensic psychiatric services: a systematic review of literature

While serious concerns are often raised when patients abscond or leave unauthorized from psychiatric services, there is limited knowledge about absconsion in forensic psychiatric services. Following the preferred reporting items for systematic reviews and meta-analyses guideline, we searched Medline/PubMed, PsycINFO, EMBASE, CINAHL, Scopus, and Web of Science through May 2020 for eligible reports on absconsion in forensic patients with no language limits. The search string combined terms for absconsion, forensic patients, and psychiatry in various permutations. This was supplemented by snowball searching for additional studies. Of the 565 articles screened, 25 eligible studies, including two interventional, seven cross-sectional, and 16 case-controlled studies spanning five decades were included. Absconsion and re-absconsion rates ranged from 0.2% to 54.4% and 15% to 71%, respectively, albeit higher rates trended with less secure psychiatric units. Previous absconsion, aggression, substance use, high Historical Clinical Risk Management-20 score, anti-sociality, psychiatric symptoms, sexual offending, and poor treatment adherence were the factors reported with a degree of predictive value for absconsion. However, the construct of absconsion was heterogeneous in the included studies and the quality of evidence on the predictors of absconsion was limited. Serious risky behaviors including re-offending, violence, self-harm, suicide, rape, and manslaughter were perpetrated by patients during unauthorized leave. Nevertheless, the rates of re-offending were generally low in the included studies (highest recidivism rate = 0.11). There is need for standardized assessment and documentation of absconsion to improve risk analysis and management. Furthermore, it is necessary to develop a structured guideline for defining absconsion, and to create a protocol that operationalizes all absconsion-related behaviors/events to promote reliable assessment and comparative analysis in future studies.

Research findings on Greek forensic patients found not guilty by reason of insanity. A juxtaposition of patients who committed a criminal offense during their first psychotic episode with those who did so later in the course of their illness

The aim of this study was to compare the baseline characteristics (demographic, psychiatric-psychopathological and legal) among Greek forensic patients found not guilty by reason of insanity. The first step of this approach being differentiating patients who committed a criminal offense during their first psychotic episode from the ones who did so later in the course of their illness. All patients were hospitalized in the Department of Forensic Psychiatry (DFP) of the Psychiatric Hospital of Thessaloniki (PHT) from January 2015 to January 2020 and were examined in order to be included in the study. The final research sample consisted of 78 patients (70 identifying themselves as males and 8 identifying themselves as females) aged 18 and older, 21 of whom committed a criminal offense during their first psychotic episode (FEP, N = 21) and 57 did so later on in the course of their illness (Course, N = 57). Data were collected from multiple sources and several psychometric tools were used (Mini International Neuropsychiatric Interview-M.I.N·I, Positive And Negative Syndrome Scale-PANSS, Addiction Severity Index-ASI, CAGE Questionnaire, Hostility and Direction of Hostility Questionnaire-HDHQ, Global Assessment of Functioning-GAF and Aggression Questionnaire). Comparing the two groups (FEP vs. Course) we found that patients in FEP were younger, had experienced stressful life events in the last 24 months, committed more serious violent crimes, and more frequently attempted suicide after the crime. Their victims were usually members of their family. The main psychometric disparities between the two groups were found in the "Hostility" score of the Aggression questionnaire, and the items "Criticism of Others" and "Paranoid Hostility" of the HDHQ questionnaire, where patients in FEP scored lower. Patients in FEP scored significantly higher in items P1 (delusions), P4 (excitement), P6 (suspiciousness/persecution) and P7 (hostility) of the PANSS scale. No statistically significant differences were found between the two groups regarding their evaluation with the CAGE, ASI or GAF questionnaires. When comparing the patients' present scores in PANSS scale, the patients in FEP had lower total scores in the Positive and the General Psychopathology subscales. Both groups showed significant improvement during hospitalization in all scales (PANSS & GAF), except for the Negative Subscale of the PANSS scale. Through logistic regression analysis, we found that patients in FEP were younger, more likely to have recently experienced stressful life events and more likely to have assaulted a member of their family. Patients with higher scores in the "Hostility" subscale of the Aggression questionnaire were found to remain at risk for committing a crime during the course of their illness. These findings underline the need to design and develop specialized mental health services in order to identify and treat patients involved in violent crime in a timely and effective manner addressing their multiple needs.

Decriminalizing severe mental illness by reducing risk of contact with the criminal justice system, including for forensic patients

Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness-an observation that many argue reflects a process of "criminalizing" mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis

BACKGROUND

Secure hospitals are a high-cost, low-volume service consuming around a fifth of the overall mental health budget in England and Wales.

AIMS

A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy.

METHOD

We searched for primary studies that followed patients discharged from a secure hospital, and reported mortality, readmissions or reconvictions. We determined crude rates for all adverse outcomes.

RESULTS

In total, 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders. The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175-1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235-415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916-8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679-5287), with lower rates in more recent studies.

CONCLUSIONS

There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.

Characteristics and motivations of absconders from forensic mental health services: a case-control study

BACKGROUND

Absconding from hospital is a significant health and security issue within psychiatric facilities that can have considerable adverse effects on patients, their family members and care providers, as well as the wider community. Several studies have documented correlates associated with absconding events among general psychiatric samples; however, few studies have examined this phenomenon within samples of forensic patients where the perception of threat to public safety in the event of an unauthorized absence from hospital is often higher.

METHODS

We investigate the frequency, timing, and determinants of absconding events among a sample of forensic psychiatric patients over a 24-month period, and compare patients who abscond to a control group matched along several sociodemographic and clinical dimensions. We explore, in a qualitative manner, patients' motives for absconding.

RESULTS

Fifty-seven patients were responsible for 102 incidents of absconding during the two year study window. Forensic patients who absconded from hospital were more likely to have a history of absconding attempts, a diagnosed substance use disorder, as well as score higher on a structured professional violence risk assessment measure. Only one of the absconding events identified included an incident of minor violence, and very few included the commission of other illegal behaviors (with the exception of substance use). The most common reported motive for absconding was a sense of boredom or frustration.

CONCLUSIONS

Using an inclusive definition of absconding, we found that absconding events were generally of brief duration, and that no member of the public was harmed by patients who absconded. Findings surrounding the motivations of absconders suggest that improvements in therapeutic communication between patients and clinical teams could help to reduce the occurrence of absconding events.

A 21-year retrospective outcome study of New South Wales forensic patients granted conditional and unconditional release

AIM

To retrospectively examine the outcomes of forensic patients found not guilty by reason of mental illness (NGMI) in New South Wales (NSW) and subsequently released into the community, as measured by reoffending, conditional release revocation and psychiatric hospital readmission.

METHOD

Data were collected from the NSW Mental Health Review Tribunal (MHRT) files for all patients who received an NGMI verdict between January 1990 and December 2010, and who were released into the community during this period. The outcome measures of conditional release revocation and psychiatric hospital readmission were extracted from these files. Information about subsequent criminal charges, convictions and penalties were obtained from the Bureau of Crime Statistics and Research's reoffending database.

RESULTS

During the 21-year period studied, 364 offenders received an NGMI verdict and were placed under the supervision of the MHRT. Of these, 197 were released into the community, including 85 who were granted unconditional release. Over a follow-up period averaging 8.4 years, 18% of conditionally released patients reoffended, 11.8% were convicted of a further offence, 8.7% were charged with a violent offence, 3.1% were convicted of a violent offence and 3.7% were sentenced to a term of imprisonment. Five (3.1%) conditionally released forensic patients received a further NGMI verdict. One-quarter of the conditionally released patients had their conditional release revoked and half were readmitted to hospital. Of the forensic patients granted unconditional release, 12.5% were charged with an offence, 9.4% received convictions for an offence, 6.3% were charged with a violent offence and 4.7% were convicted of a violent offence, in a mean follow-up period of 7.6 years. None committed a further serious offence resulting in a term of imprisonment, nor a second NGMI verdict.

CONCLUSIONS

The results of this study suggest that the treatment and rehabilitation of forensic patients in NSW, together with the decision-making procedures of the MHRT, is effective in protecting the community from further offending by forensic patients.

MMPI-2 profiles of NGRI and civil patients

Limited information is available comparing individuals found Not Guilty by Reason of Insanity (NGRI) to other psychiatric patients. This study examined the MMPI-2 profiles of 36 NGRIs and 35 civilly committed inpatients at 3 state psychiatric hospitals. The NGRI and civil patient groups differed in terms of race and gender with more minority individuals and fewer women in the NGRI group. Therefore, these demographic variables were used as covariates in a MANCOVA comparing the MMPI-2 validity and clinical scales for these 2 groups. NGRIs and civil inpatients produced significantly different mean MMPI-2 profiles, with NGRIs reporting less pathology overall compared to civil inpatients. Specifically, NGRIs had lower scores on scales F, 1, 2, 7, 8, and O and higher scores on scale K. Contrary to expectations, NGRIs and civil patients did not differ on scale 4, supplementary scale Re, and content scales ANG, CYN, and ASP, or Harris-Lingoes subscale Pd2. Overall, these results suggest that NGRI patients are functioning at a higher level than civil patients. These findings are considered in terms of previous results and potential selection bias. Implications for treatment and future research are also considered.

Absconding: a literature review

Incidents of absconding from inpatient care are high-risk events which have been linked to serious harm to self and others. This paper brings together for the first time findings from a disparate body of research literature spanning many years. Varied definitions of absconding and methods of calculating the rates of absconding make comparisons between studies difficult. Nevertheless, it is clear that absconders are more often young, male, from disadvantaged groups, and suffering from schizophrenia, compared to admissions generally. Roughly half of the abscondings take place while the patient is temporarily off the ward with permission, the remainder of absconding patients use an assortment of means to make their escape. A large variety of reasons for absconding have been elicited from patients or advanced as possibilities by researchers. Only six evaluative studies of interventions impacting upon absconding have been reported in the literature, but no firm conclusions can be drawn from them.