Factors Influencing Length of Stay of Forensic Patients: Impact of Clinical and Psychosocial Variables in Medium Secure Setting

The violence profile of male mentally disordered offenders in a high secure unit in Turkiye

Our knowledge of the severity and reoffending is limited for mentally disordered offenders, and studies generally evaluate without separation between different diagnostic groups. It was aimed to determine the general profile of mentally disordered offenders who are inpatients in a high secure psychiatry unit from Turkiye and to evaluate the factors associated with violence profiles among different diagnostic groups. According to the results the schizophrenia patients committed the most severe crimes, and intellectual disability patients had some different features from schizophrenia and bipolar disorder patients. History of substance misuse in the intellectual disability group (p = 0,045) and comorbid antisocial personality disorder in the bipolar disorder group (p = 0,015) were associated with increased crime severity. Substance misuse history, history of substance use during the crime, and the existence of comorbid antisocial personality disorder were associated with increased offenses in each of the three diagnosis groups. Living alone (p = 0,004) and having a suicide history (p= 0,052) were associated with the high number of offenses in the schizophrenia group. This study is the first study that compares three diagnostic groups to involve a large patient group. We believe that clinicians must evaluate these parameters for the violence risk assessment of patients.

The role of Qatar's first forensic community team in reducing recidivism and re-admission of mentally unwell offenders

Introduction: Qatar established its Community Forensic Mental Health Team (CFMHT) in 2019 as part of the region's first comprehensive forensic psychiatry service. We present here the data on clinical and offending outcomes since its establishment and compare this with data from before the service was established. Objectives: To compare clinical and offending outcomes in mental health patients with criminal offending histories in Qatar before and after the establishment of CFMHT. Methods: This is a retrospective study comparing the socio-demographical characteristics, clinical outcome and recidivism measures of forensic patients, under the CFMHT for the last 2 years with data from a similar period before the services were in place. Results: Data for 85 patients under the active care of forensic community team were matched with a comparable group before the establishment of the services. The re-admission and reoffending rates after the establishment of the service over 2-year follow-up were 17.6% and 12.9%, respectively, compared with 40% and 32% before the service. Conclusions: Since its inception, the CFMHT has made a significant positive impact on quality of life, mental well-being and safety of patients under its care. Close working relationships with the criminal justice system, families and carers have helped fight stigma and promote safer communities.

Factors influencing the length of stay in forensic psychiatric settings: a systematic review

BACKGROUND

Forensic psychiatry is often associated with long admissions and has a high cost of care. There is little known about factors influencing length of stay (LOS), and no previous systematic review has synthesised the available data. This paper aims to identify factors influencing the LOS in forensic psychiatry hospitals to inform care and interventions that may reduce the length of admissions.

METHODOLOGY

A systematic review was conducted by searching major databases, including PubMed, EMBASE and PsycInfo, from inception until May 2022. Observational studies conducted in forensic hospitals that examined associations between variables of interest and LOS were included. Following data extraction, the Newcastle‒Ottawa Scale was used for quality appraisal. No meta-analysis was conducted due to heterogeneity of information; a quantitative measure to assess the strength of evidence was developed and reported.

RESULTS

A total of 28 studies met the inclusion criteria out of 1606 citations. A detailed quantitative synthesis was performed using robust criteria. Having committed homicide/attempted homicide, a criminal legal status with restrictions, and a diagnosis of schizophrenia-spectrum disorders were all associated with longer LOS. Higher Global Assessment of Functioning (GAF) scores were associated with a shorter LOS.

CONCLUSION

High-quality research examining factors associated with LOS in forensic psychiatry is lacking, and studies are heterogeneous. No modifiable characteristics were identified, and thus, practice recommendations were not made. There is an increasing necessity to understand the factors associated with longer admissions to inform care and increase success in reintegration and rehabilitation. This paper provides recommendations for future research.

Court-ordered inpatient psychiatric care in Switzerland: determinants of length of stay and treatment outcome

Introduction

In several European countries, offenders with decreased or abolished responsibility and high risk of recidivism due to long-lasting mental disorders are compulsory admitted for court-ordered treatments (COT) that take place in high and medium-security hospitals. As a rule, length of stay in these structures is very long implying major restrictions for the inmate and high societal cost. Despite intensive research, the predictors of length of stay and treatment outcome in long stay forensic services is still matter of debate.

Methods

We report here a detailed analysis of the demographic, psychiatric and offense predictors of length of stay and discharge locations of 204 mentally disordered offenders convicted to COT in a new medium-security forensic psychiatry clinic in Geneva, Switzerland. Kaplan-Meier survival estimates were performed to determine time to release. Length of stay was predicted by Cox regressions, and discharge locations were predicted by multinomial logistic regressions.

Results

The typical inpatient was a 35-age single male re-offender, submitted to COT after a conviction for physical violence (78.9%) or property violation (64.2%), with drug trafficking (52.9%), in relation to psychotic (67.2%), antisocial or borderline personality disorder (35.8%) with comorbid substance use disorders (60.3%). Sex offenses were found in 24.5% of cases and were associated with Cluster B personality disorders. The median length of stay was of 2.5 years and was independent of demographic variables, severity of crime recidivism and psychiatric diagnosis. Longer COT at admission, and type of offense (in particular drug traffic and sexual violence) predicted longer stays. At discharge, 32.8% of cases were transferred to sheltered educational housing, 23.1% to open low-security wards, while 30.6% returned to regular prisons and 9.7% to their country of origin.

Discussion

Younger age and conviction for property violation rather than physical violence increased the chances to be discharged to sheltered educational housing. Longer COT at admission, personality disorders, and conviction for sexual offense increased the risk to return to prison. These data suggest that sex offenses determine not only longer stays under COT but also drastically decreases the chance of freedom for inmates with Cluster B personality disorders.

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.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project

BACKGROUND

The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence.

METHOD

Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process.

RESULTS

The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant.

CONCLUSIONS

This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

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.

Perspectives on Recruitment and Representativeness in Forensic Psychiatric Research

Participant representativeness and statistical power are crucial elements of robust research with human participants, both of which relate to the successful recruitment of research participants. Nevertheless, such core features may often not be fully reported or duly considered in psychiatric research. Building on our experiences of collecting data in the context of forensic mental health services, we discuss issues regarding participant recruitment and representativeness in our field with its particular characteristics. A quick sampling and brief overview of the literature in four specialized forensic mental health journals is presented, demonstrating that published manuscripts rarely describe the data in sufficient detail for the reader to assess sample representativeness and statistical power. This lack of transparency leads not only to difficulties in interpreting the research; it also entails risks relating to the already meager evidence base of forensic mental health services being relevant only to a subset of patients. Accordingly, we provide suggestions for increased transparency in reporting and improved recruitment of research participants. We also discuss the balance of ethical considerations pertinent to the pursuit of increased participation rates in forensic mental health research.

Longer than prison? A comparison of length of stay in a medium security hospital and prison for perpetrators of violent crimes other than homicide or attempted homicide

BACKGROUND

Concerns have been raised that people detained in secure hospitals after a criminal act spend longer in a locked institution than people sent to prison for similar offending, but research evidence is scarce and conflicting.

AIMS

To compare the length of secure hospitalisation of people convicted of crimes for which flexible sentencing is allowed with length of time in prison for people serving a prison sentence for similar crimes who were not found mentally ill.

METHODS

A records-based, retrospective study was conducted comparing length of stay of all inpatients in one medium security hospital in Poland, hospitalised between 2014 and 2018, who had been convicted of any interpersonal crime other than homicide or attempted homicide, and data on all sentenced prisoners in Poland on 09.05.2018 convicted of a similar range of offences. Homicide was excluded because, in Poland, it usually attracts a fixed sentence-a life sentence until the 1970s and currently a 25-year imprisonment-so disrupting comparisons.

RESULTS

Eighty-two patients completed their secure hospital stay within the study period or were still hospitalised at the census point 09.05.2018, only 10 of them women. Male patients convicted of stalking or similar threatening offence or 'mistreatment' spent, on average, almost twice as long confined to hospital than men sentenced to imprisonment spent in prison (28.8 months, respectively). By contrast, men hospitalised after sex offences were confined for over three years less than those sentenced to prison. Only bodily harm offences attracted comparable lengths of stay in hospital and prison.

CONCLUSIONS

Our findings confirm significant disparities in length of time spent in a closed institution after offences of serious interpersonal violence, according to whether that institution was prison or hospital, but not all in the same direction. Next steps should explore reasons for this and relative longer-term outcomes.

Treatment resistance and prolonged length of stay among schizophrenia inpatients in forensic institutions

Patients suffering from schizophrenia spectrum disorders are the largest group of forensic inpatients worldwide, therefore the identification of factors that influence how long service users experiencing schizophrenia spend in forensic hospitals is one of the most important research areas in forensic psychiatry. Methods: Analysis of data of 87 schizophrenia inpatients, hospitalized in a medium secure forensic unit. Results: Mental disorders among family members, alcohol or substance dependence diagnosis, the severity of the criminal behavior demonstrated by homicide/homicide attempts and features of treatment resistance as persistent psychotic symptoms and current treatment with >1 antipsychotics was proven to influence the length of stay (LoS).

Polish Experiences of Safety Measures Involving Forensic Psychiatric Inpatients Implemented During the SARS-CoV-2 Pandemic

The SARS-CoV-2 pandemic has made it necessary for us to adapt our healthcare systems to a very different sort of reality. This clearly also applies to psychiatric services. The restrictions and safeguards associated with the pandemic particularly concern adherence to social distancing and medical treatment safety procedures. The implementation of these procedures is generally complicated by conditions of forensic psychiatry where, in line with demands made by courts, the treatment and isolation of mentally unwell offenders must be carefully managed. In most countries, forensic psychiatric treatment is an inpatient service where patients are kept in restricted and cramped spaces, making social distancing difficult to implement as patients participate in compulsory group therapeutic activities. As a result, it is necessary to introduce unique recommendations relating to patient safety and treatment adapted to the realities of forensic psychiatry. All this requires the implementation of additional restrictions, over and above those arising from the essential aspects of forensic psychiatry. In this paper, we present and discuss the Polish guidelines for forensic psychiatric care during the SARS-CoV-2 pandemic, developed as a result of discussions on essential measures introduced to reduce the spread of the virus and the unique needs of the forensic patient population.