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Tully J, Hafferty J, Whiting D, Dean K, Fazel S. Forensic mental health: envisioning a more empirical future. Lancet Psychiatry 2024:S2215-0366(24)00164-0. [PMID: 38945145 DOI: 10.1016/s2215-0366(24)00164-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 07/02/2024]
Abstract
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.
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Affiliation(s)
- John Tully
- Academic Unit of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK; Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK.
| | | | - Daniel Whiting
- Academic Unit of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK; Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | | | - Seena Fazel
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
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2
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McLaughlin P, Brady P, Carabellese F, Carabellese F, Parente L, Uhrskov Sorensen L, Jeandarme I, Habets P, Simpson AIF, Davoren M, Kennedy HG. Excellence in forensic psychiatry services: international survey of qualities and correlates. BJPsych Open 2023; 9:e193. [PMID: 37828908 PMCID: PMC10594163 DOI: 10.1192/bjo.2023.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development. AIMS To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security. METHOD A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire. RESULTS Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score. CONCLUSIONS Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.
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Affiliation(s)
- Patrick McLaughlin
- National Forensic Mental Health Service, Central Mental Hospital, Portrane, Dublin, Ireland; and DUNDRUM Centre for Forensic Excellence, Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Philip Brady
- National Forensic Mental Health Service, Central Mental Hospital, Portrane, Dublin, Ireland; and DUNDRUM Centre for Forensic Excellence, Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Felice Carabellese
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari ‘Aldo Moro’, Puglia, Italy
| | - Fulvio Carabellese
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari ‘Aldo Moro’, Puglia, Italy
| | - Lia Parente
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari ‘Aldo Moro’, Puglia, Italy
| | - Lisbeth Uhrskov Sorensen
- Department for Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark; and Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Ingeborg Jeandarme
- Knowledge Centre for Forensic Psychiatric Care (KeFor), OPZC Rekem, Rekem, Belgium; and KU Leuven, Leuven, Belgium
| | - Petra Habets
- Knowledge Centre for Forensic Psychiatric Care (KeFor), OPZC Rekem, Rekem, Belgium; and Tilburg University, Tilburg, The Netherlands
| | - Alexander I. F. Simpson
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; and Department of Psychiatry, Temerty School of Medicine, University of Toronto, Toronto, Canada
| | - Mary Davoren
- National Forensic Mental Health Service, Central Mental Hospital, Portrane, Dublin, Ireland; DUNDRUM Centre for Forensic Excellence, Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland; and Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari ‘Aldo Moro’, Puglia, Italy
| | - Harry G. Kennedy
- DUNDRUM Centre for Forensic Excellence, Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland; Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari ‘Aldo Moro’, Puglia, Italy; and Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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3
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Stewart AC, Cossar RD, Quinn B, Dietze P, Romero L, Wilkinson AL, Stoové M. Criminal Justice Involvement after Release from Prison following Exposure to Community Mental Health Services among People Who Use Illicit Drugs and Have Mental Illness: a Systematic Review. J Urban Health 2022; 99:635-654. [PMID: 35501591 PMCID: PMC9360359 DOI: 10.1007/s11524-022-00635-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 01/31/2023]
Abstract
Illicit drug use and mental illness are common among people in prison and are associated with higher rates of reoffending and reimprisonment. We conducted a systematic review, searching MEDLINE, Embase, and PsycINFO to January 10, 2022, for studies reporting criminal justice involvement following exposure to community mental health services among people released from jail or prison who use illicit drugs and have mental illness. Our search identified 6954 studies; 13 were eligible for inclusion in this review. Studies were separated into three broad categories based on community mental health service type. Eleven of 13 studies reported a reduction in criminal justice involvement among participants exposed to community mental health services compared to a comparison group. Findings indicate a need to expand and improve integration and referral mechanisms linking people to community mental health services after jail or prison release, alongside a need for tailored programs for individuals with complex illicit drug use and mental health morbidities.
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Affiliation(s)
- Ashleigh C Stewart
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Reece D Cossar
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia.,Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia
| | - Brendan Quinn
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Paul Dietze
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Drug Research Institute, Curtin University, Melbourne, Victoria, Australia
| | - Lorena Romero
- Ian Potter Library, Alfred Health, Melbourne, Australia
| | - Anna L Wilkinson
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark Stoové
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Davoren M, O'Reilly K, Mohan D, Kennedy HG. Prospective cohort study of the evaluation of patient benefit from the redevelopment of a complete national forensic mental health service: the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST) protocol. BMJ Open 2022; 12:e058581. [PMID: 35868830 PMCID: PMC9315909 DOI: 10.1136/bmjopen-2021-058581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Secure forensic mental health services are low volume, high cost services. They offer care and treatment to mentally disordered offenders who pose a high risk of serious violence to others. It is therefore incumbent on these services to systematically evaluate the outcomes of the care and treatment they deliver to ensure patient benefit in multiple domains. These should include physical and mental health outcomes, as well as offending related outcomes. The aim of Dundrum Forensic Redevelopment Evaluation Study (D-FOREST) is to complete a structured evaluation study of a complete national forensic mental health service, at the time of redevelopment of the National Forensic Mental Health Service for the Ireland. METHODS AND ANALYSIS D-FOREST is a multisite, prospective observational cohort study. The study uses a combination of baseline and repeated measures, to evaluate patient benefit from admissions to forensic settings. Patients will be rated for physical health, mental health, offending behaviours and other recovery measures relevant to the forensic hospital setting at admission to the hospital and 6 monthly thereafter.Lagged causal model analysis will be used to assess the existence and significance of potential directed relationships between the baseline measures of symptomatology of schizophrenia and violence risk and final outcome namely length of stay. Time intervals including length of stay will be measured by median and 95% CI using Kaplan-Meier and Cox regression analyses and survival analyses. Patient related measures will be rated as changes from baseline using general estimating equations for repeated measures, analysis of variance, analysis of covariance or logistic regression. ETHICS AND DISSEMINATION The study has received approval from the Research Ethics and Effectiveness Committee of the National Forensic Mental Health Service, Ireland. Results will be made available to the funder and to forensic psychiatry researchers via international conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05074732.
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Affiliation(s)
- Mary Davoren
- Dundrum Centre for Forensic Excellence, Trinity College Dublin School of Medicine, Dublin, Ireland
- Health Service Executive, National Forensic Mental Health Service, Dundrum, Ireland
| | - Ken O'Reilly
- Dundrum Centre for Forensic Excellence, Trinity College Dublin School of Medicine, Dublin, Ireland
- Health Service Executive, National Forensic Mental Health Service, Dundrum, Ireland
| | - Damian Mohan
- Dundrum Centre for Forensic Excellence, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Harry G Kennedy
- Dundrum Centre for Forensic Excellence, Trinity College Dublin School of Medicine, Dublin, Ireland
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Carabellese F, Parente L, Kennedy HG. Reform of Forensic Mental Health Services in Italy: Stigma and Blaming the Messenger: Hermenoia. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2022:306624X221113531. [PMID: 35861358 DOI: 10.1177/0306624x221113531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
About 40 years after the reforms leading to the closure of psychiatric hospitals (Ospedale Psichiatrico [OP]) in Italy in favor of a widespread model with a strong rehabilitation emphasis, Italy has chosen to close High Security Hospitals as well (Ospedale Psichiatrico Giudiziario [OPG]). The new forensic treatment model is expected to be more respectful of the person, including the perpetrators of violent crimes, and aims to be less stigmatizing and more rehabilitative. Despite the favorable premises of the reform (Law n. 81/2014), Italian psychiatrists are now obliged to answer calls to give evidence on strictly legal issues such as the social dangerousness of the mentally ill offender drawing on evidence or paradigms that many believe do not belong to medical knowledge. Psychiatrists must now learn to communicate about the relationship between psychiatry and society as required by law. This public expression engages with the cultural climate of society. Otherwise, the risk is of increasing the level of complexity leading to real misunderstandings that paradoxically may feed the stigma. The Italian reform provides an opportunity for reflection on some issues concerning psychiatric action, on how the public perceives the mentally ill and their psychiatrists, on the relationship between psychiatry and the world of law, on clinical methodologies for structured professional judgment, on public communication regarding severe mental illness, and the risk that psychiatrists may inadvertently be blamed for conveying an unwelcome message about mental illness and social dangerousness-we have called this social sensitivity against psychiatrists "hermanoia," blaming the messenger. The authors do not provide certain solutions but propose good practices.
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Ryland H, Davies L, Kenney-Herbert J, Kingham M, Deshpande M. Advancing research in adult secure mental health services in England. MEDICINE, SCIENCE, AND THE LAW 2022; 62:225-229. [PMID: 34907815 PMCID: PMC9198389 DOI: 10.1177/00258024211066981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Forensic mental health services in high income countries are typically high cost and low volume, providing care to people with mental illness, personality disorders, learning disability and autism deemed to pose a risk to others. Research into how forensic mental health services work as a whole system is limited. Such research is urgently needed to guide policy makers and ensure that services operate effectively.
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Affiliation(s)
| | - Louise Davies
- Adult Secure Clinical Reference Group, NHS England and NHS Improvement
| | | | | | - Mayura Deshpande
- Adult Secure Clinical Reference Group, NHS England and NHS Improvement
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Geheran B, Kumar S, Ma’u E. Care pathways in forensic mental health services in New Zealand. PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2022; 30:553-564. [PMID: 37484510 PMCID: PMC10360999 DOI: 10.1080/13218719.2022.2059030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
On entering forensic mental health services (FMHS) patients progress along forensic care pathways (FCP) that aim to maximise well-being and reduce risk of reoffending. They progress through high-, medium-, and low-secure psychiatric units with changing care and security needs. There is minimal literature examining FCP or their efficacy. This retrospective study describes the characteristics of patients admitted to an acute FMHS and explores the clinical, sociodemographic, and legal factors that influence FCP progression. Most patients were referred from prison (65.1%) and presented with violent index offending (62.4%) and psychotic disorder (80.6%). Young Maori men with psychosis predominated the forensic population. Logistic regression revealed violent index offending and diagnosis were determinants of following FCP, while violent offending and longer duration of stay were predictive of FCP progression. This study found no reduction in re-hospitalisation rates or inpatient length of stay over a three year follow-up for patients that completed the FCP.
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Affiliation(s)
- B. Geheran
- Psychiatry, Auckland District Health Board, Auckland, New Zealand
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
| | - S. Kumar
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
- Psychiatry, The University of Auckland Waikato Clinical School, Hamilton, New Zealand
| | - E. Ma’u
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
- Psychiatry, The University of Auckland Waikato Clinical School, Hamilton, New Zealand
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Crocker AG, Leclair M, Bélanger FA, Livingston J. Survol de l’organisation des services de santé mentale forensique à travers le monde : vers un modèle hiérarchisé-équilibré. SANTÉ MENTALE AU QUÉBEC 2022. [DOI: 10.7202/1094150ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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9
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Askola R, Louheranta O, Seppänen A. Factors Affecting Treatment Regress and Progress in Forensic Psychiatry: A Thematic Analysis. Front Psychiatry 2022; 13:884410. [PMID: 35903640 PMCID: PMC9314742 DOI: 10.3389/fpsyt.2022.884410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/23/2022] [Indexed: 11/27/2022] Open
Abstract
International variability and shifting trends in forensic psychiatry lead to gaps in national service provision and needs for service development. This study explores these needs through the subjective narratives of those involved in Finnish forensic services, either as forensic psychiatric patients, their parents, or service providers. Data was gathered by means of thematic interview and subjected to thematic analysis. Three main themes emerged: (1) pre-treatment challenges, (2) institutional/treatment-related concerns about therapeutic security and (3) adapting and recovery. The research highlights the need to develop forensic psychiatric services at three levels. First, it calls for increased risk awareness and risk assessment skills at the general psychiatric level. Second, it emphasizes the need for increased therapeutic engagement throughout the rehabilitative process. Third, it calls for structured and meaningful post-discharge aftercare. At all three levels, gradated security-aware standardization and patient triage in forensic services would help to develop and maintain an intact care pathway. This would decrease offending, marginalization, and suffering. Only then can we begin to meet the requirements of the WHO European Mental Health Action Plan. These findings can contribute to the development of international, standardized treatment models for clinical forensic psychiatric practices.
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Affiliation(s)
- Riitta Askola
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | | | - Allan Seppänen
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Vanha Vaasa Hospital, Vaasa, Finland
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Ryland H, Cook J, Fitzpatrick R, Fazel S. Ten outcome measures in forensic mental health: A survey of clinician views on comprehensiveness, ease of use and relevance. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2021; 31:372-386. [PMID: 34755402 PMCID: PMC9299034 DOI: 10.1002/cbm.2221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 10/04/2021] [Indexed: 05/12/2023]
Abstract
BACKGROUND Measurement of outcomes in forensic mental health services is essential to ensure that these services are delivering good quality care and treatment. Instruments for outcome measurement should cover all important domains, be easy to implement in a routine clinical context and facilitate transfer of relevant information between clinicians as the patient progresses along a recovery and rehabilitation pathway. AIMS We sought the views of clinicians on 10 common instruments used as outcome measures in forensic mental health services, especially on their perceived comprehensiveness and ease of use. METHODS An online survey was used to gather the views of clinicians from a range of professional backgrounds working in forensic mental health services in the United Kingdom. The selected instruments were identified from a previous systematic review of instruments for measuring outcomes in this context. Questions covered comprehensiveness, ease of use, patient involvement, relevance and use for progressing tracking and care planning. RESULTS Complete responses were received from 229 individuals. The range of respondents either agreeing or strongly agreeing that individual instruments were comprehensive was 6-39%; easy to use 19%-69%; relevant 31%-78%; useful to measure progress 7-70%; and useful for care planning 33-81%. Respondents reported that, for each of the 10 instruments, full involvement of patients varied between 3% and 22%; partial involvement 12-45%, patients informed, but not involved 11%-28%; and patients not involved or informed 21%-64%. CONCLUSIONS The Health of the Nation Outcome Scale Secure, the only instrument designed as an outcome measure, is not regarded by clinicians as useful in that respect and the majority of clinicians do not inform patients they are using it. Clinicians appear most familiar with the Historical Clinical Risk 20 (HCR-20), which some respondents considered potentially useful as a progress measure but with limited patient involvement. Most respondents did not think that the HCR-20 is comprehensive. There is a need for outcome measures that are comprehensive, easy to use and have adequate patient involvement in their development and rating.
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Affiliation(s)
- Howard Ryland
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jonathan Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesUniversity of OxfordOxfordUK
| | - Ray Fitzpatrick
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Seena Fazel
- Department of PsychiatryUniversity of OxfordOxfordUK
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Kennedy HG, Mohan D, Davoren M. Forensic psychiatry and Covid-19: accelerating transformation in forensic psychiatry. Ir J Psychol Med 2021; 38:145-153. [PMID: 32434610 PMCID: PMC7556898 DOI: 10.1017/ipm.2020.58] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 02/07/2023]
Abstract
Swift medically led scientifically informed responses to the Covid-19 epidemic nationally have been demonstrably superior to other, non-scientific approaches. In forensic psychiatry and across all psychiatric services, urgent and clinically led responses have underlined redundancies and confusions in the governance of mental health services and a vacuum in policy makers. For the future, a greater emphasis on services for patients with schizophrenia and other severe, enduring mental disorders must aim at reducing standardised mortality ratios, managing risk of violence and improving hard outcomes such as symptomatic remission, functional recovery and forensic recovery of autonomy. This will require more use of information technology at service level and at national level where Scandinavian-style population-based data linkage research must now become legally sanctioned and necessary. A national research and development centre for medical excellence in forensic psychiatry is urgently required and is complimentary to and different from quality management.
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Affiliation(s)
- H. G. Kennedy
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
- Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - D. Mohan
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
- Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - M. Davoren
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
- Academic Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
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Abstract
SUMMARYForensic 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.
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