HCR-20 Risk Profiles of Patients Referred to Forensic Mental Health Services in New South Wales

The present study aimed to consider the HCR-20 risk profiles of forensic and civil (i.e. general psychiatric) patients referred to forensic mental health services (FMHS), in the state of New South Wales (NSW), Australia. It was hoped that by better understanding patient risk, based on HCR-20 ratings, more could be understood about the differing needs of the two patient groups.

Data gathered from comprehensive assessments undertaken by trained clinicians across two service settings, a medium secure forensic facility and the NSW Community Forensic Mental Health Service (CFMHS) was utilised. Data from 129 forensic patients and 105 civil patients were included. T-tests indicated significant differences between means of civil and forensic patients on the HCR-20 and odds ratios (ORs) indicated civil patients referred to FMHS were approximately six times more likely to fall into the high-risk category on the HCR-20 (i.e. score 25 or >) than forensic patients.

The nature and level of risk evident between forensic and civil patients referred to FMHS in NSW highlighted two issues: (1) The differing risk/need inherent in two patient groups accessing FMHS; and (2) The level of risk observed in civil patients referred to FMHS and therein the challenges faced by generalist mental health services in managing this patient group. The need for generalist mental health services to be better supported and the need for structured, evidence-based risk management practice to be extended to civil psychiatric patient care was indicated.     

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label

Objective:

To examine the psychosocio-criminological characteristics of not criminally responsible on account of mental disorder (NCRMD)–accused people and compare them across the 3 most populous provinces. In Canada, the number of people found NCRMD has risen during the past 20 years. The Criminal Code is federally legislated but provincially administered, and mental health services are provincially governed. Our study offers a rare opportunity to observe the characteristics and trajectories of NCRMD–accused people.

Method:

The National Trajectory Project examined 1800 men and women found NCRMD in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 to April 2005, followed until December 2008.

Results:

The most common primary diagnosis was a psychotic spectrum disorder. One-third of NCRMD–accused people had a severe mental illness and a concomitant substance use disorder, with British Columbia having the highest rate of dually diagnosed NCRMD–accused people. Most accused people (72.4%) had at least 1 prior psychiatric hospitalization. Two-thirds of index NCRMD offences were against the person, with a wide range of severity. Family members, followed by professionals, such as police and mental health care workers, were the most frequent victims. Quebec had the highest proportion of people with a mood disorder and the lowest median offence severity. There were both interprovincial differences and similarities in the characteristics of NCRMD–accused people.

Conclusions:

Contrary to public perception, severe violent offenses such as murder, attempted murder or sexual offences represent a small proportion of all NCRMD verdict offences. The results reveal a heterogeneous population regarding mental health and criminological characteristics in need of hierarchically organized forensic mental health services and levels of security. NCRMD–accused people were well known to civil psychiatric services prior to being found NCRMD. Risk assessment training and interventions to reduce violence and criminality should be a priority in civil mental health services.     

A follow-up study of persons found not criminally responsible on account of mental disorder in British Columbia.

OBJECTIVE: To describe the characteristics of individuals found not criminally responsible on account of mental disorder (NCRMD) after the 1992 Criminal Code amendments and to track their movement through the forensic system, as well as to unveil the changes to British Columbia's forensic psychiatric system that resulted from Bill C-30. METHOD: Profile information relating to persons found NCRMD between February 4, 1992, and February 4, 1998, in British Columbia was collected and analyzed. Community follow-up data was collected and analyzed for a 24-month period following a subject's discharge from hospital. RESULTS: A substantially greater number of individuals entered the forensic psychiatric system in British Columbia after Bill C-30 was implemented. The post-1992 forensic psychiatric population contained fewer persons charged with serious index offences and a greater number of persons charged with relatively minor offences. The length of hospitalization for the NCRMD cohort decreased substantially after the 1992 Criminal Code amendments. CONCLUSION: The Bill C-30 provisions have made the NCRMD defence an attractive option for defendants and legal counsel.     

The impact of primary mental health care in a prison system in Brazil.

OBJECTIVE: To analyze the impact of a psychiatric service in a prison general hospital that refers prisoners with mental disorders to a separate forensic psychiatric hospital (FPH). METHOD: Analysis of data on prison population and referrals to the FPH. RESULTS: Despite a 10.9% increase in the overall prison system population over 3 years, referrals from the prison general hospital with the new psychiatric service to the FPH were reduced by 36.5%, whereas referrals from other prisons increased by 120.4%. CONCLUSION: Our results demonstrate the efficiency of the new primary health care approach.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

A Social-Learning Approach to the Rehabilitation of Individuals with Severe Mental Disorders who Reside in Forensic Facilities

Abstract

With steadily growing populations of individuals with severe mental illnesses in forensic hospitals and correctional institutions, there is a need for effective rehabilitation services in these facilities. Individuals in such facilities have many of the same rehabilitation needs as people with severe mental illnesses in other settings. This paper describes the use of a comprehensive social-learning approach to rehabilitation that has been implemented in forensic facilities with documented success. The effectiveness of the social-learning approach has been well established for individuals with the most severe mental illnesses in public psychiatric hospitals. The application of this approach within the Forensic Services of the Missouri Department of Mental Health is outlined, and some of the challenges associated with implementing psychosocial rehabilitation technologies within highly secure facilities are discussed.     

Association of cigarette smoking and depressive symptoms in a forensic population

The link between mental health issues and smoking has been an important area of investigation. However, little is known about this association in a general adult, male forensic population. The aim of this study was to identify demographic and clinical (depression and anxiety) variables that predict smoking in a forensic population. A large cohort of 353 inmates in a high-security prison underwent a psychiatric interview, including administration of the Montgomery-Asberg Rating Scale for Depression (MADRS) and Hamilton's Rating Scale for Anxiety (HAM-A). Multiple regression analysis suggested that younger age and higher depression scores might predict the amount of daily smoking in this population. In contrast, anxiety symptoms were not an independent predictor for smoking in our study. These findings support the need for additional research to focus on those factors associated with smoking in forensic populations. Psychiatric screening for younger male individuals in forensic settings and targeted cognitive-behavioral interventions to treat depressed smokers may ameliorate the smoking abstinence rate in prisons.     

The Short- to Medium-Term Predictive Validity of Static and Dynamic Risk-of-Violence Measures in Medium- to Low-Secure Forensic and Civil Inpatients

The prediction and subsequent management of aggression by psychiatric inpatients is a crucial role of the mental health professional. This retrospective cohort study examines the predictive validity of 10 static and dynamic risk-of-violence measures and subscales in 37 forensic and 37 civil inpatients residing in a medium- to-low security psychiatric facility for a period of up to 6 months. Retrospective file records were sourced to conduct an AUC analysis of the ROC curve for short- and medium-term follow-up periods. The hypothesis that dynamic measures would be better predictors than static measures over the short term was supported. Albeit to a lesser extent, dynamic measures were still better predictors than static measures over the medium term. This result was seen in both civil and forensic groups. Three previously untested measures were found to predict aggression within the sample. It is recommended that mental health services employ the use of dynamic measures when making short-term risk-of-violence predictions for civil and/or forensic inpatients.     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders

Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.     

Psychopathology in adolescent and young adult criminal offenders (15–21 years) in Sweden

Background This study examined rates of psychopathology among adolescent and young adult serious offenders referred to pre-sentence forensic psychiatric services and compared patterns of psychiatric morbidity with adult forensic referrals and age-matched general psychiatric inpatients. Methods In Sweden, criminal offenders can be referred for an extensive court-ordered pre-sentence inpatient forensic psychiatric examination (FPE). Data on all 3,058 of these offenders (90% male, mean age = 35.3 years) during 1997–2001 were obtained from the National Board of Forensic Medicine. We compared DSM-IV psychiatric diagnoses across age bands 15–17 years (N = 60), 18–21 years (N = 300) and 22 years and older (N = 2,698). Comparative data by age bands were also obtained for inpatient diagnoses among individuals admitted to general psychiatric hospitals. Results Compared with the adult forensic psychiatric examinees, those aged 15–17 years and 18–21 years had higher rates of depression, and childhood and developmental disorders but lower rates of psychosis, bipolar disorder, and substance use disorders. Compared with general psychiatric inpatients, offenders aged 15–17 years had higher prevalences of depression and attention-deficit or disruptive disorders and lower ones of alcohol and drug misuse disorders. Conclusions There are significant differences in patterns of psychiatric morbidity in adolescent and young adult offenders that come into contact with psychiatric services compared with older offenders and adolescent psychiatric inpatients. This suggests that the development of health services addressing the psychiatric needs of younger offenders needs to draw on information on their specific mental health needs.     

The state of psychiatry in Greece

Greek psychiatry is presently in a transitional period. Following a large-scale reform effort that started in the mid 1980s, de-institutionalization and establishment of numerous community services has been achieved to a great extent. However, sectorization, development of primary care policies, inter-sectoral communication and long-range planning have not been achieved and deficiencies in the provision of care for children, adolescents, old people, individuals with autism, with intellectual disabilities and with eating disorders as well as deficiencies in forensic psychiatric services have been identified. Thus, the Greek psychiatric reform is an unfinished reform.

The financial crisis that has recently hit the country has had a serious impact on the population and especially on vulnerable groups such as individuals with psychiatric disorders. Continuation of psychiatric reform to its desired extent has become problematic. This situation calls for re-orientation of the national mental health strategy towards more realistic and priority-orientated goals, i.e. securing a satisfactory level of function of the existing services, persisting in the implementation of the basic targets of psychiatric reform, creating the necessary infrastructure but avoiding the creation of expensive facilities of secondary importance.     

The state of psychiatry in Greece

Greek psychiatry is presently in a transitional period. Following a large-scale reform effort that started in the mid 1980s, de-institutionalization and establishment of numerous community services has been achieved to a great extent. However, sectorization, development of primary care policies, inter-sectoral communication and long-range planning have not been achieved and deficiencies in the provision of care for children, adolescents, old people, individuals with autism, with intellectual disabilities and with eating disorders as well as deficiencies in forensic psychiatric services have been identified. Thus, the Greek psychiatric reform is an unfinished reform. The financial crisis that has recently hit the country has had a serious impact on the population and especially on vulnerable groups such as individuals with psychiatric disorders. Continuation of psychiatric reform to its desired extent has become problematic. This situation calls for re-orientation of the national mental health strategy towards more realistic and priority-orientated goals, i.e. securing a satisfactory level of function of the existing services, persisting in the implementation of the basic targets of psychiatric reform, creating the necessary infrastructure but avoiding the creation of expensive facilities of secondary importance.     

The couch and the cloth: the need for linkage

Data from the Epidemiologic Catchment Area study were used to compare the demographic characteristics and psychiatric symptomatology of persons classified into four groups based on source of mental health services: clergy only, mental health specialists only, both clergy and mental health specialists, and neither source. Those receiving services from both clergy and mental health specialists were more likely to have major affective and panic disorders than those who sought services from clergy or mental health specialists only or who sought services from neither. Those in the care of mental health specialists were more likely to have substance abuse disorders. Those in the care of clergy only were as likely as those seeing mental health specialists only to have serious mental disorders. The data make clear the need for formal linkages between clergy and mental health professionals.     

The future of psychosocial treatments for elderly patients.

Geriatric psychiatric disorders usually occur in the context of medical illness, disability, and psychosocial impoverishment. Preliminary evidence suggests that psychotherapy can reduce not only psychopathology but also physical complaints, pain, and disability and that it can improve compliance with medical regimens. Psychotherapy has been found effective in treatment of depression related to bereavement and caregiver burden. Modification of available treatment strategies to address infirmity and life adversity may have a major impact on rehabilitation from psychiatric and medical disorders and may reduce utilization of nonpsychiatric health services. Most elderly patients with psychiatric problems prefer to be treated by their primary care physician. Models need to be developed and tested to integrate psychotherapy and other mental health services in primary care settings so that timely and appropriately targeted interventions can be provided.     

Are the responses of clients with psychiatric and addiction disorders using services for the homeless valid?]

OBJECTIVE: To verify the validity of self-reported data on service use from clients with mental or substance abuse disorders in Montreal and Quebec services for homeless individuals. METHOD: To compare the self-reported data from the Enquête chez les personnes itinérantes (Fournier, 2001) on health service use with official data from Quebec health services (MEDECHO and RAMQ). RESULTS: The analysis shows a moderate-to-high level of concordance between the self-reported and the official data. Almost every item analyzed presents moderate but significant intraclass correlation coefficients for general and psychiatric hospitalization and use of psychiatric medication, but lower and nonsignificant coefficients for medical hospitalization. Participant characteristics such as mental disorders, homeless status, and substance abuse problems do not seem to have an impact on data validity. CONCLUSIONS: The answers on health service use from individuals with mental health problems, homeless status, or substance abuse problems are generally valid in the results presented. Thus the self-reported data from these individiuals seems to be a generally valid source of data and an affordable one for research on service use or other domains.     

Use of a state inpatient forensic system under managed mental health care

OBJECTIVES: One of the goals of managed mental health care has been to lower the use of inpatient psychiatric treatment. In the past, interventions that have limited hospitalization for persons with severe mental illness have led to greater involvement of these individuals with the criminal justice and forensic mental health systems. The authors examined associations between Medicaid managed mental health care in Massachusetts and rates of admission to the inpatient forensic mental health service maintained by the state's mental health department. METHODS: A total of 7,996 persons who were receiving services from the department before and after the introduction of managed care were studied. A logistic regression model based on generalized estimating equations was used to identify associations between Medicaid beneficiary status and forensic hospitalization before and after the introduction of managed care. RESULTS: The overall rate of forensic hospitalization declined in the study cohort in both periods. However, no significant decline was observed in the risk of forensic hospitalization among Medicaid beneficiaries whose care had become managed. CONCLUSIONS: Although the results of this study warrant further exploration, the risk of forensic hospitalization among Medicaid beneficiaries should be considered by policy makers in the design of mental health system interventions.     

Development of a brief screen for violence risk (V-RISK-10) in acute and general psychiatry: An introduction with emphasis on findings from a naturalistic test of interrater reliability

Most violence risk assessment scales were originally developed for use in forensic settings at the time of discharge or release of patients into the community after long-term treatment. However, there is a considerable need for specialized, brief and structured risk assessment tools to inform risk decisions in short-term psychiatric treatment. The present study reports on research findings from the development and implementation of the violence risk screening-10 (V-RISK-10) in two acute psychiatric settings in Norway. The 10-item screen is easy to use, time-saving and may be used for screening of violence risk during hospital stay and after discharge into the community. Prospective validation studies of the screen concerning inpatient and post-release community violence have been conducted. Although data analyses are not yet complete, preliminary findings indicate that the screen has good predictive validity. This suggests that the screen is a promising tool in short-term acute psychiatric settings. However, the importance of reliability in mental health data and tests is well recognized, and a screen with good predictive validity is not worth much if clinicians are unable to agree on the scoring of one and the same patient. In this article we report results from a naturalistic interrater reliability investigation that involved 25 mental health professionals and 73 acute psychiatric patients. V-RISK-10 scoring was accomplished by two raters for each patient. The interrater reliability value for total scores was acceptable. Variations pertaining to the individual V-RISK-10 item, patient characteristics and rater characteristics are discussed.     

Predictors of psychiatric hospitalization for adults with co-occurring substance and mental disorders as compared to adults with mental illness only

Predictors of psychiatric hospitalization, predisposing, enabling and need, of adults with co-occurring mental and substance disorders were compared to predictors for adults with a mental illness only. Research participants were 1613 users of crisis intervention services. Findings using Cox regression show that dually-diagnosed individuals were more likely to be hospitalized. Enabling and need factors were important predictors for both groups. Disruptive behavior was a predictor for dually-diagnosed clients but not for clients with mental illness only. Findings suggest that outpatient mental health services are less well equipped to address a psychiatric crisis when it was accompanied by substance use issues.     

Characteristics of older adults referred to a psychiatric emergency outreach service

Although older adults typically underutilize mental health services, problems associated with dementing illnesses, chronic medical illnesses, affective disorders, social isolation, and multiple medication use, among other phenomena, have increased referrals of the elderly to psychiatric emergency services. The present study reviewed characteristics of elderly adults referred to a psychiatric emergency outreach/screening service. Of all individuals for whom a referral was made, 24% were aged 60 or older. Among those older adults referred, 63% were seen by screening service personnel; 37% did not meet screening criteria or voluntarily sought mental health services. Diagnoses of individuals evaluated included dementia (27%), affective disorders (27%), schizophrenia (16%), psychosis (12%), alcohol abuse (7), and diagnosis deferred (11%). Findings highlight the limited options available for mental health care of the aged.