Perspectives on Recruitment and Representativeness in Forensic Psychiatric Research

Intervening factors between risk of violence and aggressive behaviours among forensic inpatients: a scoping review

BACKGROUND

Risk of violence is closely associated with aggression propensity. However, there is a lack of research to explain the mechanisms behind this association, especially among the patients of forensic secure facilities. This review aimed to identify and synthesize the available literature concerning the intervening factors (mediating or moderating factors) in the relationship between the risk of violence and aggressive behavior in forensic secure facilities.

METHODS

Two electronic academic databases were searched: Scopus and Web of Science (WoS) using specific keywords as search terms derived from the PCC framework with no specific time limit. The search strategy was developed based on the JBI Manual for Evidence Synthesis and utilised the PRISMA-ScR guidelines. Data on the risk of violence, intervening factors, and aggressive behavior were extracted from the included studies. Further analysis was performed whereby similar data were grouped and synthesised together.

RESULTS

The initial search produced 342 studies. However, only nine studies fulfilled the inclusion criteria. The nine studies included 1,068 adult forensic inpatients from various psychiatric hospitals. Only mediation studies reported significant mechanisms of influence between the risk of violence and aggressive behavior. It is postulated that the human agency factor may be the underlying factor that influences a person's functioning and the subsequent series of events between the risk of violence and aggression.

CONCLUSIONS

In light of the paucity of evidence in this area, a generalised conclusion cannot be established. More studies are warranted to address the gaps before conclusive recommendations can be proposed to the relevant stakeholders.

Virtual reality-assisted assessment of paranoid ideation in forensic psychiatric inpatients: A mixed-methods pilot study

Background

Reliable and valid assessment of paranoia is important in forensic psychiatry for providing adequate care. VR technology may add to current assessment procedures, as it enables observation within realistic (social) situations resembling the complexity of everyday life. VR constitutes a promising tool within forensics, due to the restricted nature of forensic psychiatric hospitals and ethical challenges arising from observing potentially dangerous behaviors in real life.

Objective

To investigate the feasibility of VR assessment for paranoid ideation in forensic psychiatric inpatients qualitatively by assessing the experiences of patients and a clinician, and to explore how the VR measures relate to established clinical measures.

Methods

One clinician (experienced psychiatrist) and 10 forensic psychiatric inpatients with a history or suspicion of paranoid ideation were included. Patients participated in two immersive VR scenarios (bus and supermarket) during which paranoia was assessed by the clinician. Qualitative interviews were performed with patients and the clinician performing the assessment to investigate experiences and feasibility. Further, measures of paranoia, social anxiety, and positive symptoms were obtained.

Results

Nine out of 10 participants with varying levels of paranoid ideation completed the assessment. Manifest inductive content analyses of the interviews revealed general experiences, advantages such as enabling observing participants from a different perspective, and challenges of the VR assessment, such as a lack of objectivity and the laboriousness of the assessment for the clinician. Although more paranoia was experienced during the supermarket scenario, correlates with classical measures were only significant for the bus scenario.

Discussion

The VR assessment was appreciated by most patients and the clinician. Based on our results short, standardized VR assessment scenarios are feasible, however, they do not appear reliable or objective for assessing paranoia. The clinical usefulness is most likely as a collaborative tool and add-on measure to existing methods.

Forensic psychiatry patients, services, and legislation in Nunavut and Greenland

Circumpolar regions face unique challenges in establishing and maintaining mental health care systems, including forensic psychiatry services. The scarcity of data and lack of evidence concerning the forensic psychiatry patient (FPP) populations of Nunavut and Greenland exacerbates the challenges of informing best practices and healthcare planning. By comparing the prevalence of forensic psychiatry patients, the mental health care services, and the legislation in these two relatively similar but unique regions, insight may be gained that can help inform healthcare planning. This cross-sectional study includes all forensic psychiatry in- and outpatients in one year from Nunavut (2018) and on February 29, 2020, in Greenland. The Greenland sample (n = 93) was nearly four times larger than the Nunavut sample (n = 15) at the population level. Despite considerable differences in forensic legislation and service supply, the forensic psychiatry patients in the two areas share several similarities. A total of 87% (n = 13) in the Nunavut sample were diagnosed with a DSM-5 schizophrenia spectrum disorder or other psychotic disorder. In Greenland, 82% (n = 76) were diagnosed with an ICD-10 F2 diagnosis (schizophrenia, schizotypal and delusional disorders). Approximately 2/3 of the patients in both populations were diagnosed with substance use disorder, and 60% of the Nunavut FPP received long-acting antipsychotic injections versus 62% in Greenland. Nearly half of the FPPs in both populations had never been convicted prior to entering the forensic psychiatry system; Nunavut 45% versus Greenland 47%. A substantial proportion of Greenlandic FPPs were outpatients compared to Nunavut (83% versus 47%). This study is an essential first step toward describing a Model of Care for forensic psychiatry patients in circumpolar regions; furthermore, the clinical similarities between the two populations provide support for future joint Arctic research and the inclusion of artic forensic patients in international studies.

Improving the stability of bivariate correlations using informative Bayesian priors: a Monte Carlo simulation study

Objective

Much of psychological research has suffered from small sample sizes and low statistical power, resulting in unstable parameter estimates. The Bayesian approach offers a promising solution by incorporating prior knowledge into statistical models, which may lead to improved stability compared to a frequentist approach.

Methods

Simulated data from four populations with known bivariate correlations (ρ = 0.1, 0.2, 0.3, 0.4) was used to estimate the sample correlation as samples were sequentially added from the population, from n = 10 to n = 500. The impact of three different, subjectively defined prior distributions (weakly, moderately, and highly informative) was investigated and compared to a frequentist model.

Results

The results show that bivariate correlation estimates are unstable, and that the risk of obtaining an estimate that is exaggerated or in the wrong direction is relatively high, for sample sizes for below 100, and considerably so for sample sizes below 50. However, this instability can be constrained by informative Bayesian priors.

Conclusion

Informative Bayesian priors have the potential to significantly reduce sample size requirements and help ensure that obtained estimates are in line with realistic expectations. The combined stabilizing and regularizing effect of a weakly informative prior is particularly useful when conducting research with small samples. The impact of more informative Bayesian priors depends on one's threshold for probability and whether one's goal is to obtain an estimate merely in the correct direction, or to obtain a high precision estimate whose associated interval falls within a narrow range. Implications for sample size requirements and directions for future research are discussed.

Adverse childhood experiences do not moderate the association between aggressive antisocial behavior and general disinhibition in a forensic psychiatric inpatient sample

Adverse childhood experiences (ACE) and high levels of disinhibition have been associated with a variety of negative outcomes such as aggressive antisocial behavior (AAB). However, forensic psychiatric populations remain an understudied group in this field of research. This study aimed to fill that gap by investigating associations between ACE, AAB, and disinhibition in a forensic psychiatric sample. Furthermore, we aimed to explore such findings by investigating whether ACE might have a moderating effect on the association between disinhibition and AAB. A sample of forensic psychiatric patients (n = 89) was recruited from a high-security forensic psychiatric facility in Sweden. All study variables were moderately to strongly related to each other, although we found no moderating effect of ACE. Post hoc analysis indicated that our ACE items had differential effects on AAB scores, with placement outside the family home, absent parents, and parental drug abuse producing the largest effect on AAB levels. Our findings are in line with previous research demonstrating a significant and robust relationship between ACE, AAB, and disinhibition. Forensic psychiatric populations are exposed to high levels of both self-reported and documented ACE. This calls for trauma-informed care and highlights the importance of considering ACE in risk assessment, preventive work, and policy making.

Prolonged NoGo P3 latency as a possible neurobehavioral correlate of aggressive and antisocial behaviors: A Go/NoGo ERP study

Aggressive and antisocial behaviors are detrimental to society and constitute major challenges in forensic mental health settings, yet the associated neural circuitry remains poorly understood. Here, we investigated differences in aggressive and antisocial behaviors between healthy controls (n = 20) and violent mentally disordered offenders (MDOs; n = 26), and examined associations between aggressive and antisocial behaviors, behavioral inhibitory control, and neurophysiological activity across the whole sample (n = 46). Event-related potentials were obtained using EEG while participants completed a Go/NoGo response inhibition task, and aggressive and antisocial behaviors were assessed with the Life History of Aggression (LHA) instrument. Using a robust Bayesian linear regression approach, we found that MDOs scored substantially higher than healthy controls on LHA Aggression and Antisocial subscales. Using the whole sample and after adjusting for age, we found that scores on the LHA Aggression and Antisocial subscales were robustly associated with longer NoGo P3 latency, and less robustly with longer NoGo N2 latency. Post-hoc analyzes suggested that healthy controls and MDOs exhibited similar associations. With several limitations in mind, we suggest that prolonged NoGo P3 latency, reflecting decreased neural efficiency during the later stages of conflict monitoring or outcome evaluation, is a potential neurobehavioral correlate of aggressive and antisocial behaviors.