Die forensisch-psychiatrische Versorgung in Mitgliedstaaten der Europäischen Union - Versorgungskonzepte und Kapazitäten

Determinants of clinical outcome and length of stay in acute care forensic psychiatry units

Criminological and sociodemographic variables, such as previous criminal convictions, increased risk of violence, early onset of mental disorder, antisocial personality, psychosis and low social support, have all been related to longer length of stay (LoS) and poorer outcome in long stay forensic services. The factors impacting on LoS and clinical response in acute care specialized units are poorly documented. To address this issue, we examined the psychiatric records of all cases admitted between January 1st and December 31th 2020 in the sole acute ward for detained persons located in the central prison of the Geneva County, Switzerland. Information on judicial status included pre-trial versus sentence execution, previous incarcerations, and age of the first incarceration. Sociodemographic data included age, gender, marital status, and education attainment. Previous inpatient stays prior to incarceration were recorded. All of the ICD-10 clinical diagnoses were made by two independent, board-certified psychiatrists blind to the scope of the study. The standardized assessment was based on the HoNOS (Health of Nation Outcome Scales) at admission and discharge, HONOS-secure at admission, HCR-20 (Historical Clinical Risk 20) version 2, PCL-R (Psychopathy Checklist Revised), and SAPROF (Structured Assessment of Protective Factors). Stepwise forward multiple linear regression models predicting the LoS and delta HONOS respectively were built with the above mentioned parameters. The selected variables were then used in univariate and multivariable regression models. Higher HCR-scores (mainly on clinical items), and longer LoS were related to higher delta HONOS scores. In contrast, cases in pre-trial detention showed a worst clinical outcome. In multivariable models, all three variables remained independent predictors of the clinical outcome and explained 30.7% of its variance. Only education and diagnosis of borderline personality were related to the LoS and explained 12.6% of its variance in multivariable models. Our results suggest that the use of acute wards specialized in forensic psychiatry are mainly useful for patients with prior inpatient care experience, and higher violence risk during sentence execution. In contrast, they seem to be less performant for persons in pre-trial detention that could benefit from less restrictive clinical settings.

Status of mandatory treatment of mentally ill offenders without criminal responsibility in China: Information from 5,262 mandatory treatment judgments

Background

To avoid public health risks, all governments ensure monitoring and treatment of mentally ill persons if they offend and assess their level of criminal responsibility. The Criminal Procedure Law of the People's Republic of China (2013) instituted special procedures. However, there are few articles in English which explain the implementation of mandatory treatment procedures in China.

Methods

We collected 5,262 qualified documents from 2013 to 2021 from the China Judgments Documents Online. We analyzed social demographic characteristics, trial-related information as well as the mandatory treatment-related content, to investigate the mandatory treatment of China's mentally ill offenders without criminal responsibility, from 2013 to 2021. Simple descriptive statistics and chi-square tests were used to compare differences among several types of documents.

Results

There was an overall change trend of the number of documents: increasing year by year from 2013 to 2019 after the implementation of the new law, but with sharp decrease in 2020 and 2021 during covid-19 pandemic. From 2013 to 2021, a total of 3,854 people had applications made for mandatory treatment, of whom 3,747 (97.2%) were given mandatory treatment, 107 (2.8%) had applications rejected. "Schizophrenia and other psychotic disorders" was the most common diagnosis in both groups and all offenders receiving mandatory treatment (3,747, 100.0%) were considered to have no criminal responsibility. A total of 1,294 patients had applications made for relief of mandatory treatment, of whom 827 (63.9%) were subsequently approved for relief, 467 (36.1%) were rejected. A total of 118 patients had applications for relief two or more times, and 56 (47.5%) were finally relieved.

Conclusion

Our study presents the Chinese model of a criminal mandatory treatment system to the international community which has been in operation since the implementation of the new law. Legislatory changes and covid-19 pandemic can have effect on the number of mandatory treatment cases. Patients, their close relatives and mandatory treatment institutions have the right to apply for relief from mandatory treatment, but the final decision in China is taken by the court.

Factors Affecting Length of Inpatient Forensic Stay: Retrospective Study From Czechia

OBJECTIVES

The length of forensic stay (LoS) is a subject to country-specific legal and service systems. Therefore, the identification of common factors targetable by treatment is at the forefront of forensic psychiatric research. In this study, we present the first reports of forensic characteristics of patients from the Czechia.

METHODS

We conducted a retrospective analysis of data from 260 inpatients discharged from the Bohnice Hospital (Prague) and obtained a set of sociodemographic and clinical variables as well as the Health of the Nation Outcome Scale (HoNOS) and HoNOS-secure scores.

RESULTS

The following variables were identified as significantly associated with a longer LoS: older age, length of previous psychiatric hospitalization, olanzapine equivalent, clozapine treatment, psychosocial dysfunction, psychotic or paraphilic disorder diagnosis, and sexual offense. A shorter LoS was associated with being in a relationship, being employed before hospitalization, receiving personal support, and committing an index offense under the influence of substance. While the HoNOS score and HoNOS symptom subscale predicted a longer LoS, the HoNOS-secure subscale predicted a shorter stay.

CONCLUSION

In the European context, our hospital has a relatively low LoS. The results are consistent with findings linking psychotic disorders and paraphilia with a longer LoS in forensic treatment. Higher doses of antipsychotic medication or clozapine prescriptions were associated with a longer LoS. The results show a high level of unmet needs in this population, highlighting the importance of the availability of follow-up service.

Policies on sexual expression in forensic psychiatric settings in different European countries

BACKGROUND

Sexual expression by forensic psychiatric patients is poorly researched.

METHODS

Forensic experts representing 14 European countries were interviewed to explore the diverse ways in which sexual expression within forensic settings is handled.

RESULTS

No country had a national policy, although many had local policies or shared practices. Progressive approaches to patient sexuality were evident in nine of the countries sampled. The UK appeared the most prohibiting and excluding, its protocols apparently based on risk aversion and lack of emphasis or consideration of patients' sexual needs.

CONCLUSIONS

Uniform national policy supporting patients' sexual expression would provide significant improvements.

Coercion in psychiatry

PURPOSE OF REVIEW

This paper highlights issues in the field of coercion in psychiatry which have gained importance in 2007.

RECENT FINDINGS

Reviews on 'involuntary hospital admission' demonstrated negative and positive consequences on various outcome domains. Papers on 'coercion and the law' identified cross-national differences of legal regulations, or addressed justice and equality issues. Studies on the 'patient's perspective', and 'family burden of coercion' showed that involuntariness is associated with feeling excluded from participation in the treatment. A review on 'outpatient commitment' recommended the evaluation of a range of outcomes if this specific legislation is introduced. 'Coercion in special (healthcare) settings and patient subgroups' needs to be assessed in detail. This refers to somatic hospitals, establishments for mentally retarded patients, prisons, forensic settings, and coercion mechanisms for addiction treatment, eating disorders, and minors. Empirical findings in other areas focused on attitudes towards involuntary treatment; decision variables for involuntary commitment; guidelines on the use of coercive measures; and intervention programs for staff victims of patient assaults.

SUMMARY

Coercion in psychiatry is an important area for future clinical and research initiatives. Because of the linkages with legal, human rights and ethical issues, a huge number of individual questions needs to be addressed.