Post-discharge pharmacological treatment discontinuation of forensic psychiatric patients in Sweden

Introduction

Most forensic psychiatric patients have chronic psychiatric disorders that require long-term pharmacological treatment even after discharge from care. However, the prevalence and correlates of post-discharge medication discontinuation in this patient group remain unclear.

Objective

The aim of this study was to investigate the prevalence and correlates of post-discharge discontinuation of pharmacological treatment in forensic psychiatric patients in Sweden.

Methods

Data on individuals discharged from forensic psychiatric care between 2009 and 2018 (n = 1,142) with ongoing pharmacological treatment at the time of discharge (n = 856) were identified from the Swedish National Forensic Psychiatric Register. Cox regression models were used to estimate the association between patient characteristics and medication discontinuation.

Results

Of the 856 individuals with pharmacological treatment at discharge, 488 (57%) discontinued treatment within 2 years of discharge. Factors associated with an increased risk of treatment discontinuation varied between different types of psychotropic medications: the most important correlate was comorbidity between psychosis and personality disorder. Higher age at discharge, longer length of stay, having a history of several psychiatric care episodes, having a trustee, having a limited guardian, and a residing in a supported living accommodation at the time of discharge were associated with a decreased rate of medication discontinuation. This applied for antipsychotics, antidepressants, antiepileptics, and any psychotropic medication, but not for psychostimulants or drugs used in addictive disorders.

Conclusion

For many former forensic psychiatric patients, there are situational factors associated with medication discontinuation. This insight holds significance for professionals who are involved in pre-discharge planning within forensic psychiatric care and those who interact with this cohort of former patients post-discharge.

Mortality among male forensic and non-forensic psychiatric patients: matched cohort study of rates, predictors and causes-of-death

Background: The mortality of forensic psychiatric (FP) patients compared to non-forensic psychiatric (non-FP) patients has been sparsely examined.Methods: We conducted a matched cohort study and compared Danish male FP patients (n = 490) who underwent pre-trial forensic psychiatric assessment (FPA) 1980-1992 and were subsequently sentenced to psychiatric treatment with matched (on year of birth, marital status, and municipality of residence) male non-FP patients (n = 490) and male general population controls (n = 1716). FP and non-FP patients were also matched on major psychiatric diagnostic categories. To determine mortality and identify potential predictors of mortality, we linked nationwide register data (demographics, education, employment, psychiatric admission pattern and diagnoses, cause of death) to study cohorts. Average follow-up time was 19 years from FPA assessment/sampling until death/censoring or 31 December 2010 and risk factors were studied/controlled with Cox proportional hazard analysis.Results: Overall, psychiatric patients had significantly higher mortality compared to matched general population controls (medium to large effects). Among patients, 44% (213) of FP vs. 36% (178) of matched non-FP patients died during follow-up (p = 0.02). When we used Cox regression modeling to control for potential risk factors; age, education, immigrant background, employed/studying at index, length of psychiatric inpatient stay/year, and ever being diagnosed with substance use disorder (SUD), FP patient status was no longer significantly associated with increased mortality, whereas SUD and longer inpatient time per year were independently associated with increased mortality.Discussion: This study suggests that SUD and longer inpatient time per year are independent risk factors for increased mortality in psychiatric patients.

A Thorn in the Flesh? Forensic Inpatients in General Psychiatry

PURPOSE

To illuminate whether and how taking care of forensic inpatients is experienced as a burden among staff and managers in general psychiatry.

DESIGN AND METHODS

Qualitative analytical strategies based on interviews and questionnaires.

FINDINGS

The interplay between physical environment, bottlenecks, poor information exchange, lack of knowledge and competences, complex psychopathology, and a vague and therefore uncomfortable task of nursing leads to a focus on criminal offenses rather than mental disorders and an increased risk of brutalization and stigmatization in nursing practices. Members of staff identify the care of mentally disordered offenders in general psychiatric units as either "a parking space" or a very difficult or frightening course, where staff members tend to behave like pleasers in order to avoid risks of conflict or physical violence. Either way, it seems hard to provide sufficient mental health care.

PRACTICE IMPLICATIONS

Nationwide training and teaching as well as knowledge exchange between specialized forensic psychiatry and general psychiatry are recommended. Further exploration is needed on patient perspectives and on avenues to increase efficiency and decrease bottlenecks throughout the clinical pathways. Furthermore, we need additional knowledge of the impact on general patient populations' resources for treatment and their safety.

Women's secure hospital services: national bed numbers and distribution

A mapping exercise as part of a pathway study of women in secure psychiatric services in the England and Wales was conducted. It aimed to (i) establish the extent and range of secure service provision for women nationally and (ii) establish the present and future care needs and pathways of care of women mentally disordered offenders (MDO) currently in low, medium and enhanced medium secure care. The study identified 589 medium secure beds, 46 enhanced medium secure beds (WEMSS) and 990 low secure beds for women nationally. Of the 589 medium secure beds, the majority (309, 52%) are in the NHS and under half (280, 48%) are in the independent sector (IS). The distribution of low secure beds is in the opposite direction, the majority (745, 75%) being in the IS and 254 (25%) in the NHS. Medium secure provision for women has grown over the past decade, but comparative data for low secure provision are not available. Most women are now in single sex facilities although a small number of mixed sex units remain. The findings have implications for the future commissioning of secure services for women.

Prevalence of criminal thinking among state prison inmates with serious mental illness

To examine the prevalence of criminal thinking in mentally disordered offenders, incarcerated male (n = 265) and female (n = 149) offenders completed measures of psychiatric functioning and criminal thinking. Results indicated 92% of the participants were diagnosed with a serious mental illness, and mentally disordered offenders produced criminal thinking scores on the Psychological Inventory of Criminal Thinking Styles (PICTS) and Criminal Sentiments Scale-Modified (CSS-M) similar to that of non-mentally ill offenders. Collectively, results indicated the clinical presentation of mentally disordered offenders is similar to that of psychiatric patients and criminals. Implications are discussed with specific focus on the need for mental health professionals to treat co-occurring issues of mental illness and criminality in correctional mental health treatment programs.