Exploration of morbidity, suicide and all-cause mortality in a Scottish forensic cohort over 20 years

Forensic mental health: envisioning a more empirical future

Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.

Long-term outcomes of the recovery approach in a high-security mental health setting: a 20 year follow-up study

Background

This study examined the outcomes of a descriptive, longitudinal cohort consisting of 241 patients initially examined in a population study at the high secure State Hospital for Scotland and Northern Ireland in 1992-93. A partial follow-up focusing on patients with schizophrenia was conducted in 2000-01, followed by a comprehensive 20 year follow-up that began in 2014.

Aims

To explore what happens to patients who required high secure care during a 20 year follow-up period.

Method

Previously collected data were amalgamated with newly collected information to examine the recovery journey since baseline. Various sources were employed, including patient and keyworker interviews, case note reviews, and extraction from health and national records, and Police Scotland datasets.

Results

Over half of the cohort (56.0%) with available data resided outside secure services at some point during the follow-up period (mean 19.2 years), and only 12% of the cohort were unable to transition out of high secure care. The symptoms of psychosis improved, with statistically significant reductions observed in reported delusions, depression, and flattened affect. Reported sadness [according to the Montgomery-Åsberg Depression Rating Scale (MADRS)] at baseline, first, and 20 year follow-up interviews was negatively correlated with the questionnaire about the process of recovery (QPR) scores at the 20 year follow-up. However, qualitative data depicted progress and personal development. According to societal measures, there was little evidence of sustained social or functional recovery. The overall conviction rate post-baseline was 22.7%, with 7.9% violent recidivism. The cohort exhibited poor morbidity and mortality, with 36.9% of the cohort dying, primarily from natural causes (91%).

Conclusions

Overall, the findings showed positive outcomes in terms of movement out of high-security settings, symptom improvement, and low levels of recidivism. Notably, this cohort experienced a high rate of deaths and poor physical morbidity, along with a lack of sustained social recovery, particularly among those who had negotiated a path through services and who were current residents in the community. Social engagement, enhanced during residence in low secure or open ward settings, diminished significantly during the transition to the community. This is likely a result of self-protective measures adopted to mitigate societal stigma and the shift from a communal environment. Subjective depressive symptoms may impact broader aspects of recovery.

Investigating 'treat culture' in a secure care service: a study of inpatient NHS staff on their views and opinions on weight gain and treat giving for patients in a forensic secure care service

BACKGROUND

Obesity is a significant health inequality within forensic secure care mental health/learning disability inpatient settings. Patients may be at increased risk of developing preventable long-term conditions/premature death. This study investigated staff views on patient weight gain, how it affects patients and how to better manage patient weight in this setting. Furthermore, the research explored the culture of food being used as a 'treat' and the perceived impact of 'treats' on weight.

METHODS

A two-phase mixed methods approach was taken to explore staff views on patient weight gain and the 'treat' culture on adult forensic secure care inpatient wards in one NHS Mental Health Trust in the north-east of England. Phase one was an online survey, and phase two consisted of semi-structured qualitative interviews. The quantitative survey data were analysed using descriptive statistics. Thematic analysis was used for the open-ended survey questions and interview data.

RESULTS

The survey had 49 responses out of a possible 380 (13%). Ninety-two per cent of staff participants viewed patient weight gain as an area for concern, citing a range of reasons for weight gain. Weight gain was considered a risk to developing long-term health conditions and poor mental health. Nine participants were interviewed. Six themes were identified suggesting why patients might gain weight in forensic secure care, for example, patient history, staff behaviours, the surrounding 'treat' culture in this environment, along with suggestions of what could be improved to manage patient weight.

CONCLUSIONS

People detained in forensic secure care may be more at risk of weight gain due to their history, the secure care environment and the 'treat' culture adopted in these environments.

Models of care in forensic psychiatry

Forensic psychiatry services have grown and become more complex in structures, processes and pathways. Legacy customs, practices and changing policy are now organised into formal models of care. These are written accounts of how a health service is delivered, outlining best practice and services for patients progressing through the stages of their condition and the care and treatment available. This article explores the four key elements of a model of care: goals; pathways and processes; treatment programmes; and systematic evaluation. It describes the most common model of care in forensic services, which builds on structures of stratified therapeutic security. It also considers variations on this basic or standard model matched to needs arising from the complex interrelationship with other parts of the mental health service for the population served and with criminal justice, primary care and physical health, housing and welfare agencies.