Risk tools for the prediction of violence: 'VRAG, HCR-20, PCL-R'

Visual perspective taking neural processing in forensic cases with high density EEG

This EEG study aims at dissecting the differences in the activation of neural generators between borderline personality disorder patients with court-ordered measures (BDL-COM) and healthy controls in visual perspective taking. We focused on the distinction between mentalizing (Avatar) and non-mentalizing (Arrow) stimuli as well as self versus other-perspective in the dot perspective task (dPT) in a sample of 15 BDL-COM cases and 54 controls, all of male gender. BDL-COM patients showed a late and diffuse right hemisphere involvement of neural generators contrasting with the occipitofrontal topography observed in controls. For Avatars only and compared to controls, the adoption of Self perspective involved a lower EEG activity in the left inferior frontal, right middle temporal cortex and insula in BDL-COM patients prior to 80 ms post-stimulus. When taking the Other-perspective, BDL-COM patients also showed a lower activation of superior frontal, right inferior temporal and fusiform cortex within the same time frame. The beta oscillation power was significantly lower in BDL-COM patients than controls between 400 and 1300 ms post stimulus in the Avatar-Other condition. These results indicate that BDL-COM patients display both altered topography of EEG activation patterns and reduced abilities to mobilize beta oscillations during the treatment of mentalistic stimuli in dPT.

Forensic criteria, clinical and theoretical issues of the indication of court-ordered treatment: A comparative survey among experts in forensic psychiatry and sentencing judges in France

Following the French law n° 98-468 of 17 June 1998 relative to the prevention of sexual offenses and the protection of minors, social and judicial follow-up and court-ordered treatment were introduced with the aim of reinforcing the prevention of recidivism. Court-ordered treatment is one of the possible obligatory measures provided for by social and judicial follow-up. However, there is no consensus between the different professionals concerning the criteria of indication and the final purpose of this measure. Most of the few available studies are retrospective. Only rare studies have assessed the influence of criminological factors on the indication of court-ordered treatment. We carried out a nation-wide qualitative comparative study in two populations, psychiatric experts and sentencing judges, by means of e-mail questionnaires. The aim was to determine the criteria for court-ordered treatment according to psychiatric experts and to sentencing judges, to identify the criteria that gave rise to differences in appreciation between these professionals, and to attempt to explain these differences. The secondary aim of the study was to determine the methods and tools used in expert practice to evaluate dangerousness and risk of recidivism. We obtained 20 responses in each of the two populations. The great majority of psychiatric experts and sentencing judges considered that court-ordered treatment was appropriate when the offender presented with psychiatric dangerousness, and so with an underlying mental disorder. When a subject had no identified mental disorder, the psychiatrists were divided in their opinion, whereas the majority of sentencing judges were in favor of court-ordered treatment. Opinions differed particularly significantly between the two populations in four circumstances: a subject with an antisocial/psychopathic personality disorder, a subject who denied the alleged acts, the influence of precarious social circumstances and the influence of instability in intimate relationships. The majority of experts used international classifications (DSM-5 and ICD-10) as a basis for their psychiatric diagnosis. Just under half of those surveyed used structured or semi-structured interview guides and only a few stated that they used standardized actuarial tools to assess risk of recidivism. The concepts of care, dangerousness and mental disorder are associated with multiple representations that certainly play a part in the disagreements between the different professionals. It is of prime importance to define these concepts more clearly in order to encourage the use of a common language and to clarify the indications and purpose of court-ordered treatment. We also hypothesize that disagreements between professionals regarding the criteria for court-ordered treatment may be related to certain difficulties raised by the management of the convicted person. The development of guidelines that could be used by all professionals would help to reduce some of these difficulties. Psychiatric experts remain attached to clinical evaluation. Their limited use of assessment tools may relate to the material constraints and time constraints involved. The issue at stake in court-ordered treatment and social and judicial follow-up is to promote cooperation between the various professionals by creating a space for exchange of ideas where the fundamental questions raised by these measures can be discussed, fears shared and knowledge pooled.

Development of a Pediatric Behavioral Early Warning Scale (Pedi-BEWS) for Children

Background and Purpose: The prevention of aggressive behavior in child and adolescent inpatient settings is essential. However, it can be difficult to prompt a quick appropriate intervention without an early warning scale for the prevention and management of behavioral emergencies in a psychiatric inpatient adolescent unit. Behavioral emergencies often result in restraint/seclusion and/or administration of psychotropic medications. The objectives are to develop and evaluate the Pediatric Behavioral Early Warning Scale (Pedi-BEWS) as a screening tool to prompt quick appropriate interventions and to decrease incidents of restraint/seclusion and/or administration of psychotropic medications. Methods: A two-phase methodological design was applied. A total of 447 inpatients and 21 nurses were used to test internal consistency reliability and validity. Results: Receiver operating characteristic curve areas for the developed instrument were calculated to be 0.890 (cognition), 0.959 (affect), and 0.951 (behavior). The overall Pedi-BEWS indicated high reliability (Cronbach's alpha = .98). Conclusions: The Pedi-BEWS shows high internal consistency and validity. The use of the newly developed tool may reduce or eliminate episodes of seclusion and restraint for pediatric patients with a behavioral problem. In addition, the tool has the potential to enhance psychiatric nurses' assessment skills and competencies. The use of the newly developed Pedi-BEWS can promote an appropriate and timely nursing assessment and intervention before the deterioration in psychiatric nursing practice.

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.

Risk Assessment in Mental Health Practice: An Integrative Review

Although risk assessment in mental health practice can influence and measure treatment outcomes and level of care provision, risk assessment practices are not standardised and different screening tools are used. The aim of this integrative review was to review the literature on risk assessment in mental health practice to promote evidence-based care. Electronic databases were searched for articles available in English and published from 2013 to 2019. The findings from 12 articles evaluated the evidence for risk assessment tools utilised and discussed the justification, barriers and enabling factors for risk assessment. Lastly, recommendations were made to improve risk assessment.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol

BACKGROUND

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.

METHODS

The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.

DISCUSSION

Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.

TRIAL REGISTRATION

Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

Violence risk-assessment screening tools for acute care mental health settings: Literature review

BACKGROUND

Violence is a large concern for mental health professionals: 90% of physicians and nurses working in mental health areas have been subject to violence from patients. Approximately 80% of violent acts from patients are directed toward nurses.

OBJECTIVE

The purpose of this integrative literature review was to identify violence risk-assessment screening tools that could be used in acute care mental health settings.

DESIGN

The Stetler model of evidence-based practice guided the literature search, in which 8 violence risk-assessment tools were identified, 4 of which were used for further examination.

RESULTS

The Brøset Violence Checklist and Violence Risk Screening-10 provided the best assessment for violence in the acute care mental health setting.

CONCLUSIONS

Using a violence risk assessment screening tool helps identify patients at risk for violence allowing for quick intervention to prevent violent episodes.