Prädeliktische Behandlungswege schizophrener Patienten der forensischen Psychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Prior to admission to a forensic ward, two thirds of schizophrenic patients have been admitted to a general psychiatric institution at least once. Among other factors, forensic admission is seen as a consequence of insufficient pretreatment in general psychiatry. This study aims to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples include 72 male patients from forensic wards and 72 male patients from general psychiatry diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as the outpatient psychiatrists and by analyzing these patients’ medical records.

Results

Both groups showed similar risk factors, however, forensic patients had a higher number of previous convictions and were convicted more often for violent offences. Furthermore, the data indicate that forensic patients are less integrated into psychiatric care and showed a lower rate of treatment compliance prior to admission to a forensic ward.

Conclusions

The results provide support for the arrangement of an intensive outpatient aftercare, especially for schizophrenic patients with comorbid substance abuse disorders and previous convictions for violent offences.     

Forensische Patienten und Patienten der Allgemeinpsychiatrie

BACKGROUND: The aim of this study was to assess the potential for future violent behaviour comparing patients recruited from forensic and general psychiatric wards in Germany. PATIENTS AND METHODS: Fifty patients were recruited from a forensic hospital and 29 from a general psychiatric hospital. In the weeks preceding discharge, structured assessments of the future risk of violent behaviour were completed using the HCR-20. RESULTS: There was little difference in the risk presented by the two groups. Forensic patients presented an elevated risk of violence because of historical factors, while the risk among patients from general psychiatry was due to clinical symptoms. CONCLUSION: Some criminal offences could be prevented if more time and effort were spent in general psychiatric practice in identifying patients at high risk for violence and in reducing symptoms of psychoses before discharge.     

Treatment of offenders with mental disorders: focusing on prison psychiatry

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.     

Treatment, care, and rehabilitation of the chronic mentally ill in Poland

In Poland primary health settings provide about 71 percent of mental health services, particularly to patients with less serious illnesses, while psychiatry provides specialized mental health care for the chronic mentally ill, the mentally retarded, and patients with alcohol or drug dependence. Poland has a large number of outpatient clinics and an extensive network of sheltered workshops. Most inpatient psychiatric beds are located in mental hospitals; few general hospitals have psychiatric units. Deinstitutionalization has been less extensive in Poland than in many other countries; only about 10 percent of the chronic patients treated in mental hospitals were deinstitutionalized between 1970 and 1981. During that period the proportion of patients hospitalized for a year or more decreased, the number of chronic patients treated in nursing homes increased, and the pattern of hospitalization shifted toward multiple readmissions.     

Planning mental health services: I. Background and key issues.

Planning mental health services is a complex task requiring an understanding of background developments and key issues related to mental health services. In Canada, the deinstitutionalization of patients attempted to shift the locus of care from provincial psychiatric hospitals to general hospital psychiatric units. This resulted in the isolation of provincial psychiatric hospitals, general hospital psychiatric units and community mental health programs, with little overall accountability for the services provided--three solitudes. To move toward the creation of responsible, integrated systems a number of issues must be addressed: target population(s); the roles of provincial psychiatric and general hospitals; community support services; continuity of care; co-morbidity; consumerism; and methods of integration. In the development of a comprehensive mental health plan, each issue should be recognized and decisions made which are in keeping with current knowledge. A companion report will survey Canadian initiatives in mental health planning and discuss approaches to many of the issues identified.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

Help seeking behaviour of psychiatric patients before seeking care at a mental hospital.

BACKGROUND: A wide range of professionals including psychiatrists, psychologists, general physicians, faith-healers and religious healers cater to the needs of mentally ill patients. Psychiatric facilities are available at general hospitals, office based practice and mental hospitals. Psychiatrists are preferred the least due to stigma. The present work reports on treatment options used by a group of psychiatric patients before visiting a mental hospital. AIM: To study the help seeking behaviour of patients visiting a mental hospital. METHOD: Patients attending psychiatric outpatient service at a mental hospital were asked specifically about various treatment facilities utilized by them before coming to the hospital and the reasons thereof. RESULTS: A wide range of services was used by the subjects varying from professional care to faith healers. Trust, easy availability and accessibility, recommendations by the significant others and belief in supernatural causation of illness were the important reasons for choosing a particular facility. Thus sociocultural factors appeared to influence the help seeking behaviour. CONCLUSION: A substantial number of patients suffering from severe mental disorders seek non-professional care. There is a need of studies in community to assess the help seeking behaviour of psychiatric patients and factors associated with it.     

Psychiatric units in Brazilian general hospitals: a growing philanthropic field

BACKGROUND: Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. OBJECTIVE: To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. METHOD: A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. RESULTS: Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. CONCLUSION: The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.     

Poor sleep quality at baseline is associated with increased aggression over one year in forensic psychiatric patients

ObjectiveIn forensic psychiatric patients, sleep problems as well as impulsivity and aggression are highly prevalent, yet studies on their association over time are lacking. This study investigates the association between sleep quality and changes in impulsivity and aggression in forensic psychiatric patients over one year.MethodsData were drawn from an ongoing prospective observational study in adult forensic psychiatric patients admitted to a forensic treatment facility between October 2006 and January 2018. Validated self-reports and observational instruments were used to assess sleep quality, impulsivity and aggression upon admission to the hospital and after one year. Linear regression analyses were performed to examine the association between sleep quality, impulsivity and aggression. All models were adjusted for baseline values of outcome measures, demographic features and general psychopathology.ResultsData from 83 men (age 37.7 ± 11.7 years) with completed consecutive measurements were analyzed. Poor sleep quality was associated with increased self-reported aggression (β = 1.08; 95% CI, 0.38–1.78). This association was positively confounded by general psychopathology, indicating that sleep quality is specifically related to self-reported aggression instead of being part of general psychopathology (adjusted β = 1.18; 95% CI, 0.39–1.97). Poor sleep quality was not associated with changes in self-reported impulsivity, clinician-rated impulsivity or clinician-rated hostility in this population.ConclusionPoor sleep quality was associated with an increase in self-reported aggression over one year in male forensic psychiatric patients. Early evaluation and treatment of sleep problems in (forensic) psychiatric patients may play an important role in reducing the risk of aggressive behavior.     

Forensic psychiatric services in South‐East Scotland

Forensic psychiatric services in Scotland operate without regional secure units. Despite this, patient turnover is higher and the proportion of patients awaiting transfer from conditions of maximum security is smaller than in England. This is probably a reflection of the Country's small size, the integration of general and forensic psychiatry services and the retention of traditional psychiatric hospitals. Offenders with psychopathic personality disorder are rarely recommended for detention in hospital. There are significant implications for Australia's highly urbanised services when considering the relevance (or otherwise) of secure facilities within local service provision.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

Psychiatric episodes in general hospitals without psychiatric units

Forty percent of inpatient psychiatric episodes are treated in general hospitals without psychiatric units, but little is known about these patients and their treatment. A survey of medical records personnel at 452 hospitals without psychiatric units revealed that the hospitals' psychiatric patients typically lived at home, were admitted through the emergency room because of a substance abuse disorder, received active medical treatment, were discharged back home after about four days, and paid with private insurance. The hospitals that treated primarily substance abusers provided a significantly different mix of treatments than did those that treated primarily patients with traditional diagnoses. The data suggest that general hospitals without psychiatric units may provide appropriate treatment for psychiatric patients, especially those with a substance abuse disorder.     

Medical and psychiatric comorbidity in psychiatric beds in general hospitals: A cross-sectional study in Tokyo

Aims:  Although somatic diseases in psychiatric patients are increasing with the increase of the aged population, psychiatric wards in general hospitals in Japan have progressively been decreasing. The purpose of this cross-sectional study was to clarify whether psychiatric beds in general hospitals play sufficient roles in medical comorbidities of psychiatric patients or not.
Methods:  This was a cross-sectional study performed all over Tokyo during the 2-month period from April to May 2007. The total number of patients who require admission due to both somatic and psychiatric diseases was investigated with their demographic and clinical characteristics.
Results:  The total number of patients admitted to psychiatric beds in general hospitals for the above-mentioned reason was 326, while the number of patients who could not be admitted to them despite the same reason was 88. The rate of surgical diseases in the latter group was higher than that in the former group. In the latter group, diseases requiring orthopedic surgery (22%) and abdominal surgery (22%) were the most frequent, followed by gastrointestinal and hepatic diseases (8%), and gynecological diseases (7%). Patients who had attempted suicide were included more in the latter group than in the former group. Even in the former group, general hospitals could not respond to 34% of requests for emergency admission.
Conclusion:  Psychiatric beds in general hospitals do not necessarily function for medical comorbidities in psychiatric patients, especially in severe and emergency cases. Not only the quantity but also the quality of psychiatric wards in general hospitals should be reconsidered.     

Open wards versus locked wards of general hospitals in the treatment of psychiatric patients with medical comorbidities: A cross-sectional study in Tokyo

Aim:  Treatment of medical comorbidities among psychiatric patients is an expected role of general hospital psychiatric wards. The purpose of this study was to clarify whether locked wards of general hospitals are necessary in the treatment of psychiatric patients with severe medical comorbidities.
Methods:  A cross-sectional study concerning patients who required admission due to both somatic and psychiatric diseases was performed all over Tokyo during a 2-month period. Demographic and clinical characteristics of patients who were admitted to locked wards of general hospitals were compared with those of patients admitted to open wards of general hospitals.
Results:  In locked wards, the rate of organic mental disorders, median Lack of Judgment and Insight from the Positive and Negative Syndrome Scale, and rate of diseases requiring surgery were significantly higher than those in open wards. The rate of patients with medical comorbidities who could not be admitted was significantly higher for open wards than for locked wards. Furthermore, the rate of patients with both medical comorbidities and attempted suicide who could not be admitted was significantly higher for open wards than for locked wards.
Conclusion:  Locked wards may be necessary to treat severe psychiatric patients with severe medical comorbidities.     

Hospitalization for psychiatric illness under Medicare, 1985

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.     

The role of general hospitals in the privatization of inpatient treatment for serious mental illness.

For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated mostly in state hospitals. The extent to which this transfer has taken place and the differences between public and private general hospitals have been unclear. Using data from the 1988 National Mental Health Facilities Study and published data from the 1970s, the authors found that nearly half of all general hospitals providing psychiatric services treat persons with serious mental illness. Significant differences in case and payer mix were observed between public and private general hospitals, although these differences were smaller than in the 1970s. The findings suggest increased involvement by private general hospitals in treating patients reimbursed by public payers, but the findings also indicate that persons with serious mental illness and those using Medicaid are still more prevalent in public general hospitals than in private ones.     

Sleep disturbances in a clinical forensic psychiatric population

Objective

Poor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients.

Methods

In this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital.

Results

Almost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug.

Conclusion

Despite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.     

Prospective payment and psychiatric discharges from general hospitals with and without psychiatric units

For psychiatric patients treated in general hospitals, the prospective payment system does not differentiate between patients treated in medical-surgical wards and patients treated in psychiatric units. In particular, the system uses a single length-of-stay norm for both kinds of patients, even though psychiatric patients in medical-surgical units have shorter stays. The authors document major differences in length of stay and hospital charges for both groups of patients in relation to selected patient and hospital characteristics. They conclude that the current reimbursement procedures systematically overpay for stays in nonpsychiatric units and underpay for stays in psychiatric units, and they suggest mechanisms for partly reducing such inequities.