Risk Factors for Problematic Behaviors among Forensic Outpatients under the Medical Treatment and Supervision Act in Japan

Assessing attribution in the criminal behavior of mentally disordered offenders: Developing a Japanese version of the Gudjonsson Blame Attribution Inventory-Revised

Aim

Treating individuals with a mental disorder and a history of criminal behavior (mentally disordered offenders [MDOs]) aims to enable patients to maintain their health and facilitate social rehabilitation while preventing adverse outcomes, such as violent recidivism or suicide. Understanding and responding to their own insight on their criminal behavior is crucial to achieving this goal. This article aims to develop a Japanese version of the Gudjonsson Blame Attribution Inventory-Revised (GBAI-R) and investigate the reliability and validity of the scale for MDOs in Japan.

Methods

In addition to developing the Japanese version of GBAI-R (GBAI-RJ), psychological data relevant to the Japanese study were collected and analyzed. Factor analysis was employed.

Results

Seventy-seven Japanese native participants were recruited from forensic psychiatric inpatients, outpatients, and medical prison inmates between 2020 and 2022. The results demonstrated that the dimensions on the GBAI-RJ had a similar factor structure to those reported in previous studies. The GBAI-RJ has both test/retest reliability and internal consistency.

Conclusion

The three dimensions Guilt Factor, External Factor, and Mental Element Factor from the original version in English are applicable to the Japanese version for assessing attribution and comparing the findings with those of the previous studies.

Validity of Short-Term Assessment of Risk and Treatability in the Japanese Forensic Probation Service

This study aimed to evaluate the predictive validity and reliability of the Short-Term Assessment of Risk and Treatability (START) in the context of the Japanese forensic probation service. START is a structured professional judgement guide for risk domains concerning negative behaviors such as violence, self-harm, suicide, substance abuse, unauthorized leave, victimization, and self-neglect. In this study, rehabilitation coordinators evaluated community-dwelling patients who were treated under the Medical Treatment and Supervision Act at baseline and followed-up for 6 months. The results revealed that START vulnerability scores significantly predicted self-harm, suicide, physical aggression, substance abuse, and self-neglect. START strength scores predicted physical violence and unauthorized leave. Specific risk estimates predicted physical violence and self-neglect. Risk judgement for future substance use may require adjustments for cultural differences, because of the lower prevalence in Japan. These results suggest that START offers a feasible and valid tool that allows clinicians to plan treatment and promote recovery of forensic patients in Japan.

The Perspective of Forensic Inpatients With Psychotic Disorders on Protective Factors Against Risk of Violent Behavior

Background: Little is known about the opinions of forensic inpatients with psychotic disorders like schizophrenia on factors likely to prevent or decrease future violent behavior. Aims: To understand the perspectives of forensic inpatients with psychotic disorders on protective factors against risk of violent behavior and compare them to factors identified by professional staff. Method: Using the Structured Assessment of Protective Factors (SAPROF) checklist for self-appraisal of violence risk, we conducted semi-structured interviews with 32 inpatients of the Medical Treatment and Supervision Act Ward and compared the results with those of professionals. Results: Inpatients scored higher in the SAPROF total score, the motivational factors of "life goals" and "motivation for treatment," and the protective level in general. Inpatients scored themselves lower in risk level than professionals. The degree of agreement between service users' and professionals' evaluations was low for all categories except external factors. Inpatients prioritized "life goals," "self-control," and "medication" as the top three key strengths currently preventing violent behavior, whereas the professionals selected "life goals" less often. The top three important future goals for preventing future violence selected by inpatients were "work," "intimate relationships," and "life goals," with the former two being selected significantly less often by the professionals. Conclusions: This is the first study to shed light on Japanese forensic inpatients' perspectives about preventing future violent behavior. Despite professionals' underestimation, inpatients viewed themselves as having high motivation for treatment and positive life goals. Inpatients prioritized personal values such as life goals, work, and intimate relationships, whereas professionals prioritized understanding, treating, and observing the disease. Our findings are consistent with past reports on patients' and clinicians' perspectives. Awareness of such gaps in perceptions can help build fruitful therapeutic alliances. We discuss the implications in terms of treatment, how to address the gap therapeutically, and how to design treatment accordingly. Directions for future research are also discussed.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan

BACKGROUND

Japanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan.

METHODS

Participants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants' prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model.

RESULTS

The participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]).

CONCLUSION

The all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.

Mentally disordered offenders discharged from designated hospital facilities under the medical treatment and supervision act in Japan: Reoffending and readmission

BACKGROUND

Current Japanese forensic mental health legislation (Medical Treatment and Supervision Act [MTSA]) was enacted in 2003. Little is known, however, about the actual outcomes for the offender patients detained within hospitals under this provision.

AIM

This study aimed to quantify reoffending and readmission following patients' discharge from forensic psychiatric hospital units across Japan and explore related risk factors.

METHODS

We followed up 526 offenders with mental disorder who had been detained under the MTSA and who were subsequently discharged from any of the 28 hospitals nationwide between 2007 and 2015.

RESULTS

The total cumulative reoffence rate was found to be 2.5% (1.1-3.9%) after 1 year and 7.5% (4.6-10.4%) after 3 years. The rate of serious reoffending was 0.4% (-0.18% to 0.99%) after 1 year and 2.0% (0.4-3.6%) after 3 years. The cumulative admission rate to local psychiatric hospitals following a discharge was 21.8% after 6 months and 37.6% after 1 year. Patients who had been discharged from their MTSA order but transferred to a general psychiatric hospital before open community residence-because it was necessary to build community supports-were more likely to reoffend than those discharged directly to the community. Patients who had been diagnosed with a substance use disorder (F10-F19) and had one subsequent admission were at higher risk of further readmissions.

CONCLUSIONS

The low reoffending rates could be attributed to the intensive treatment and care plans required by the MTSA. The high rate of readmission to psychiatric hospitals may indicate shortcomings in community mental health services in Japan.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders

PURPOSE

Employment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment.

PATIENTS AND METHODS

The study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients' social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment.

RESULTS

The mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220-0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment.

CONCLUSION

The employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.

Post-traumatic stress disorder in parents of patients with schizophrenia following familial violence

The present study conducted in Japan aimed to clarify the relationship between violence directed towards parents by patients with schizophrenia and parents’ risk of post-traumatic stress disorder (PTSD). Questionnaire data from 353 parents were analyzed. In total, 84 of the 353 parents (23.8%) reported the Impact of Event Scale-Revised (IES-R) score ≥ 25 (high-IES-R), indicative of a high risk of developing PTSD. The rate of high-IES-R scores was significantly higher among parents who had experienced an act of violence that was likely to result in severe injury by their adult child with schizophrenia (OR = 2.03; 95% CI 1.09–3.80; using “never experienced” as a reference) and in parents of patients who were hospitalized at the time of the survey (OR = 2.47; 95% CI 1.01–6.06; using “regularly visited a psychiatrist” as a reference). Therefore, parents experiencing violence by their adult child with schizophrenia are at a risk of developing PTSD. Parents of patients with schizophrenia, who are at a high risk of PTSD, are not usually provided the required support in Japan. To prevent violence and provide support for family members who may develop PTSD, it is necessary to establish crisis intervention programs, especially given the current emphasis on deinstitutionalization policy in Japan.