Evolution of forensic psychiatry in Italy over the past 40 years (1978-2018)

Vox clamantis in deserto: a survey among Italian psychiatrists on defensive medicine and professional liability

Due to recent events, professional liability for psychiatrists in Italy is currently a matter of lively debate. Specifically, overwhelming pressure on psychiatrists' duties has been brought by regulatory developments, such as the closure of forensic psychiatric hospitals, with the consequent return of offenders to community-based care, and the mental health consequences of the pandemic. According to Italian courts, psychiatrists are not only responsible for diagnostic and therapeutic appropriateness but also for the effects of their interventions on patients, and their behaviors. The aim of this study was to explore the attitude and behaviors of Italian psychiatrists regarding defensive medicine and professional liability. A total sample of 254 psychiatrists was surveyed by means of a quantitative online questionnaire. Most psychiatrists reported practicing defensive medicine (no. 153/254, 60.2%) and felt that their position of guarantee compromised their work in healthcare for patients (no. 138/253, 54.3%). Age correlated inversely with acknowledgment of defensive practices (r = -0.245, p < 0.001), with younger physicians more prone to defensive medicine (p = 0.013), particularly for patients at risk of suicide or violence. Psychiatrists in 'closed' settings (hospital wards, residential and rehabilitation centers, mental health service units in prison) reported more malpractice claims (p = 0.037) and complaints (p = 0.031), as well as a greater propensity to act defensively. In the treatment of patients with violent behavior, suicidal ideation, dual diagnoses, and criminal convictions, defensive practices were associated more with perceived legal risks (r = 0.306, p < 0.001) than actual legal involvement (p > 0.05). Anxiety, anger, and restlessness were common reactions to legal complaints, involving no. 50/254 (19.7%) respondents, with 40% reporting impaired functioning. Most psychiatrists (no. 175/253, 68.9%) were concerned about both civil and criminal laws regarding their professional responsibility, but many were not fully informed about recent legislative regulations and younger physicians resulted scarcely trained in risk management (p < 0.001). In conclusion, our findings suggest that defensive medicine is a common phenomenon among psychiatrists and their position of guarantee drives this attitude. Education on legal implications and risk management should be provided starting from the university and continuing over time, to improve the knowledge of young and senior doctors on professional liability and inform their decision-making processes. This would also reduce defensive practices and improve the quality of healthcare. Considering the concerns of younger physicians, as well as of professionals working in acute and high-intensity medical care facilities, there is also an urgent need for a revision of the medical liability to ensure the sustainability of the National Health Service.

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project

BACKGROUND

There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries.

AIMS

In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe.

METHODS

Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed.

RESULTS

Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others.

CONCLUSIONS

Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Highly varying concepts and capacities of forensic mental health services across the European Union

Introduction

There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed.

Methods

From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data.

Results

Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous.

Discussion

Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

An Innovative Approach to the Dismantlement of a Forensic Psychiatric Hospital in Italy: A Ten-year Impact Evaluation

Aims

This study aimed to evaluate the impacts of a pilot project concerning the closure of a Forensic Psychiatric Hospital (FPH) inspired by Human Development Theory and the Capability Approach.

Background

The dismantlement of the FPH of Barcellona Pozzo di Gotto (Sicily Region in Italy) began in 2010 with the pilot project Luce é Libertà and ended in 2017. With the closure of six FPHs, Italy officially became the first country worldwide to close such institutions. After the closure of FPHs, some critical issues emerged, and the debate shifted to developing small-scale facilities and residences for the execution of security measures (RESM). However, few studies have provided results on the cohort of patients discharged from FPHs.

Objective

Following are the objectives of this study: a) Assessing the effectiveness of the pilot project in terms of better functioning accordingly to the Classification of Functioning of Disability and Health (ICF) framework, social and labour insertion, health conditions, level of dangerousness to other, rate of readmission in forensic services, b) cost analysis, and c) describing how the CA has been applied and translated into methodological and administrative devices and concrete intervention strategies.

Methods

A pre-post evaluation design was performed with a comparison between the intervention and the control group for the healthcare cost analysis. Data were collected from 2010 to 2019 at three points: T0) as a baseline, T1 and T2) for the follow-up. The instruments are a structured questionnaire, the Scale HoNOS Secure, 4 sub-scales of ICF (Activity and participation dimensions: sociality, culture, and knowledge, daily life, income, and work) (Cronbach's Alpha from 0.76 to 0.94), and n.20 interviews with key stakeholders and beneficiaries.

Results

Main results include a) the discharge of 55 patients through the use of a person-centered approach and the Personal Capability Budget (PCB), b) the expansion of substantial freedom of choice and the improvement of ICF score (t-test Sig. <, 02), c) the reduction of the risk for others and themselves (Mean Diff. -2,15 Sig. .000), d) at T2 42% of beneficiaries achieved a job placement and 36% were living in one's own home, e) at T2 the need of security measures has reduced from the initial 70% to 6.8%, and f) reduction of the healthcare costs from the fourth year onwards.

Conclusion

Indications emerge to support processes of deinstitutionalisation and capabilities expansion through innovative models, a person-centered approach supported by PCBs, social finance, and social impact investments.

Psychometric properties of the Parma Scale for the treatment evaluation of offenders with mental disorder: A new instrument for routine outcome monitoring in forensic psychiatric settings

PURPOSE

Routine Outcome Monitoring (ROM) is still poorly implemented in the routine forensic psychiatric practice. As reliable ROM instruments are lacking, the aims of this research was to assess the psychometric properties of the Parma Scale (Pr-Scale) and its sensitivity to measure scores' longitudinal changes.

METHODS

Interrater and test-retest reliability, internal consistency and concurrent validity were investigated in offenders with mental disorder. Scores' longitudinal changeability was examined after a 3-month period using the Wilcoxon test for repeated measure.

RESULTS

Sixty male adult patients were recruited in this study. Our findings showed good to excellent interrater and test-retest reliability, concurrent validity and internal consistency for the Pr-Scale. Pr-Scale scores also display a moderate to large changeability over time.

CONCLUSIONS

Our results support the clinical use of the Pr-Scale in forensic psychiatric settings as reliable ROM instrument.

Impact of Legal Traditions on Forensic Mental Health Treatment Worldwide

BACKGROUND

Forensic psychiatry is a subspecialty dealing with the diagnosis and treatment of mentally ill offenders. However, forensic treatment standards vary. Differences arise among forensic treatment standards, due to variations in either the legal framework, the general psychiatric treatment standards, or the forensic training standards. Thus, to date there is no evidence-based pattern for how forensic services should be organized and provided.

AIMS

The aim of this article is to compare forensic services in various countries in order to contribute to the current debate on international forensic treatment standards, by informing about existing differences in available policies.

METHODS

This scoping review was conducted by reviewing the academic literature regarding forensic treatment around the world. Studies were identified from Pub-Med and Google-Scholar. Keywords for the search included "forensic psychiatry," "mentally ill offenders," "legal framework," "jurisdiction," and the names of geographical regions.

RESULTS

Forensic treatment admission varies significantly around the world. There are countries that do not recognize forensic psychiatry as a subspecialty, whereas other countries apply insufficient forensic training. Most countries provide inpatient treatment for mentally ill offenders. However, service organization varies, including where the services are delivered (prisons, high-security hospitals, and general psychiatric departments). Forensic services are mainly centralized, although the need for outpatient care is emerging.

DISCUSSION

Differences may originate mainly from variations in the legal tradition. These differences combined with the limited evidence on the effectiveness of the intervention imply the need for the optimization of forensic treatment standards on an international level. Therefore, further follow-up studies are needed.

Mental Health in Prison: Integrating the Perspectives of Prison Staff

(1) Background: The Italian Constitutional Court’s decision n. 99/2019 abolished the distinction between physical and psychological health care in the Italian prison system. However, this and other changes to the penitentiary system present challenges to prison staff, which may vary based on their roles and backgrounds; (2) Purpose: To create a process of dialogue and collaboration that include different points of view, needs, and proposals regarding mental health in prisons, this study collects and integrates the perspectives of 91 prison staff who work in various capacities in eight prisons in northeast Italy. (3) Methods: Each participant was involved in either a focus group or a semi-structured interview, and thematic analysis was used to process the resulting transcripts; (3) Results: Through this process, 10 themes were derived that highlight the difficulties of working with prisoners with psychiatric disorders or psychological distress, including lack of human and economic resources, lack of positive communication between prisoners and society and a sense of professional incompetency; (4) Conclusions: Based on these themes, the need for increased points of view, dialogue, and collaboration between prison professionals and between prison and society is discussed, and the current feasibility of treating psychiatric disorders in prison is considered.

Factors Influencing Length of Stay of Forensic Patients: Impact of Clinical and Psychosocial Variables in Medium Secure Setting

OBJECTIVES

Forensic psychiatric care has two, often contradictory, aims-the treatment of mentally ill offenders and the isolation of the perpetrators to ensure public safety. It is essential to ensure that any periods of liberty deprivation do not last longer than necessary to provide appropriate treatment. Therefore, identifying the factors affecting the length of stay (LoS) is one of the most important research areas in the forensic psychiatry. The literature on this subject is scarce and to date there no data available on LoS for patients in Eastern or Central European patients.

METHODS

We conducted a retrospective analysis of data for 150 inpatients in a medium secure unit. Based on a literature review and clinical experience, variables potentially influencing LoS were identified and included in the analysis.

RESULTS

The variables that were significantly associated with LoS included duration of mental illness; severity of index offense; whether a crime was committed as a result of hallucinations or during drug treatment discontinuation; if the index offenses was a continuous crime (crimes committed over an extended period of time); persistent psychosis; multiple antipsychotic treatments; as well as a diagnosis of schizophrenia and schizoaffective disorder.

CONCLUSIONS

Our findings are highly consistent with observations made by other researchers. However, contrary the majority of previous studies our project incorporates data concerning the clinical presentation of patients. For example, we demonstrate that variables measuring treatment resistance might be one of the crucial determinants of LoS, which is a novel research finding.

Translating clinical findings to the legal norm: the Defendant's Insanity Assessment Support Scale (DIASS)

Insanity definition and the threshold for satisfying its legal criteria tend to vary depending on the jurisdictions. Yet, in Western countries, the legal standards for insanity often rely on the presence of cognitive and/or volitional impairment of the defendant at crime time. Despite some efforts having been made to guide and structure criminal responsibility evaluations, a valid instrument that could be useful to guide forensic psychiatrists' criminal responsibility assessments in different jurisdictions is lacking. This is a gap that needs to be addressed, considering the significant forensic and procedural implications of psychiatric evaluations. In addition, differences in methodology used in insanity assessments may also have consequences for the principle of equal rights for all citizens before the law, which should be guaranteed in the European Union. We developed an instrument, the Defendant's Insanity Assessment Support Scale (DIASS), which can be useful to support, structure, and guide the insanity assessment across different jurisdictions, in order to improve reliability and consistency of such evaluations.

The factors associated with forensic psychiatrists' decisions in criminal responsibility and social dangerousness evaluations

Despite the central role in criminal trials, there is little research on the decision-making processes of experts in forensic psychiatry. We aimed to investigate the role of sociodemographic, psychopathological, and criminological characteristics in forensic psychiatric decisions on criminal responsibility and social dangerousness in criminal trials. We analyzed 302 forensic psychiatric reports provided by 16 forensic psychiatrists from the North, Central and Southern Italy. Defendants' psychiatric symptom severity was evaluated through the 24-item Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression (CGI) scale and the Global Assessment of Functioning (GAF). Defendants judged not criminally responsible (Not-CRDs) presented with more severe psychiatric symptoms (positive symptoms, negative symptoms, manic excitement / disorganization), were more likely to be female, to be affected by a schizophrenia spectrum disorder, or bipolar spectrum disorder and to have had a higher number of previous psychiatric treatments and previous involuntary hospitalizations compared to their criminally responsible counterparts. Not-CRDs affected by a schizophrenia spectrum disorder, personality disorder, with severe psychiatric symptoms and with histories of criminal convictions and more victims were more likely to have received a judgment of social dangerousness. The forensic psychiatric evaluations were carried out on average of 770 days after the time of the crime, which in light of the other results, suggests an effect of the perceptions of the expert on the judgment of responsibility, raising the possibility of time bias on forensic judgments concerning defendants' mental responsibility.

Forensic psychiatric evaluations of defendants: Italy and the Netherlands compared

BACKGROUND

Forensic psychiatric practices and provisions vary considerably across jurisdictions. The diversity provides the possibility to compare forensic psychiatric practices, as we will do in this paper regarding Italy and the Netherlands.

AIM

We aim to perform a theoretical analysis of legislations dealing with the forensic psychiatric evaluation of defendants, including legal insanity and the management of mentally ill offenders deemed insane. This research is carried out not only to identify similarities and differences regarding the assessment of mentally ill offenders in Italy and the Netherlands, but, in addition, to identify strengths and weaknesses of the legislation and procedures used for the evaluation of the mentally ill offenders in the two countries.

RESULTS

Italy and the Netherlands share some basic characteristics of their criminal law systems. Yet, forensic psychiatric practices differ significantly, even if we consider only evaluations of defendants. A strong point of Italy concerns its test for legal insanity which defines the legal norm and enables a straightforward communication between the experts and the judges on this crucial matter. A strong point of the Netherlands concerns more standardized practices including guidelines and the use of risk assessment tools, which enable better comparisons and scientific research in this area.

CONCLUSIONS

We argue that there appears to be room for improvement on both sides with regards to the evaluation of mentally ill offenders. More generally, a transnational approach to these issues, as applied in this paper, could help to advance forensic psychiatric services in different legal systems.

Violence risk and mental disorders (VIORMED-2): A prospective multicenter study in Italy

Background

The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.

Aim

The aim of this study was to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of outpatients with severe mental disorders.

Method

This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with or without a history of violence, were enrolled in four Italian Departments of Mental Health and underwent a comprehensive multidimensional assessment.

Results

The sample included 247 outpatients, for a total of 126 cases and 121 controls. Compared to controls, patients with a history of violence had a greater frequency of lifetime domestic violence, a greater lifetime propensity to misuse substances, and a higher number of compulsory admissions. The forthnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between the two groups. Verbal aggression was significantly associated with aggression against objects and physical aggression. Moreover, outpatients with an history of violence showed statistically significant higher MOAS scores compared to both residential patients with an history of violence, assessed in the first wave of this project, and all controls.

Conclusions

Patients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.