Indefinite Detention of Sex Offenders and Human Rights: The Intervention of the Human Rights Committee of the United Nations

In 2010 The Human Rights Committee of the United Nations (the UNHCR) made rulings on two “communications” submitted by Australian citizens, Robert Fardon and Ken Tillman, about what they contended was the unlawfulness of their preventive detention in Queensland and New South Wales respectively. The UNHCR upheld their applications and declared their detention unlawful by virtue of its constituting a breach of Article 9, paragraph 1, Article 14, paragraph 1, and Article 15, paragraph 1, of the International Covenant on Civil and Political Rights. The decision has major ramifications for the preventive detention systems in Queensland, New South Wales, Victoria, and Western Australia. It provides a fillip for a new rehabilitative, non-penitential focus for such regimes and raises ethical issues for mental health practitioners currently functioning in and advising in relation to such systems.     

The Cogency of Risk Assessments

Preventive detention schemes rely on assessments of risk carried out by forensic practitioners. Corrective services departments and other organs of the state inevitably present the approaches they adopt and the tools they employ in this endeavour as being “best practice” and “evidence based”. Typically these assessments are conducted according to a bureaucratic template and are based on a selected suite of tests that are heavily biased towards actuarial assessment. The validity of this approach is gravely suspect as is the failure of many forensic professionals to properly identify the diagnostic accuracy/inaccuracy of the tests and methods they rely upon in conducting risk assessments. This article iterates the methodological and evidentiary problems with risk assessment of sexual offenders. It is concluded that common extant approaches lack scientific objectivity and fail to provide the courts with cogent evidence. As a result of these errors in investigatory processes miscarriages of justice are inevitable.     

The Human Genome Project: considerations for people with intellectual disabilities

The paper discusses the impact which recent advances in gene technology may have for people with intellectual disabilities. It highlights a conflict between the apparent benefits of advances in genetics for the population in general and the negative effects on persons with intellectual disabilities in particular. This conflict is illustrated in the paper through the use of examples, including the implications of a person's lack of capacity to consent to investigations and treatment; the issue of individual responsibility for antisocial behaviour when this is considered to have a genetic component; and the issue of life and death decisions about treatment in the face of a progressive, genetically determined, disorder. The authors adopt a human rights perspective to discuss these examples because it provides a richness to articulate and justify moral concerns in this area which is lacking in much of the current debate as this is dominated by the primacy of autonomy.     

Psychological and Legal Aspects of Dangerous Sex Offenders: A Review of the Literature

The purpose of this article is to review legislation on ‘dangerous sex offenders’ critically. Most modern legislation determines an individual to be ‘dangerous’ if he or she is at unacceptably high risk of committing further sexual violence. While the decision is judicial in practice, clinical testimony is utilised to inform courts’ decision-making. Dangerousness may be a normative (legal) construct, but it is reliant on clinical assessment. Offenders are not at risk only due to historical factors; the possibility of committing sexual violence in the future is likely affected by temporal factors such as response to therapy, substance misuse, and proximity to victims. It is not clear that mental illness would place an offender at risk, although certain personality disorders are considered to be risk factors. In reporting actual risk, clinicians need to consider a range of variables, and not exclusively use actuarial measures or unstructured clinical interviews.     

Assessing the Risk of Australian Indigenous Sexual Offenders Reoffending: A Review of the Research Literature and Court Decisions

The assessment of offenders’ risk of reoffending, particularly sexual reoffending, is a core activity of forensic mental health practitioners. The purpose of these assessments is to reduce the risk of harm to the public, but they are controversial and become more contentious when Australian practitioners who want to undertake such assessments in an ethically responsible way must use reliable validated instruments, disclose the limitations of their assessment methods, instruments and data to judicial decision-makers and understand how decision-makers might use their reports. The purpose of this systematic literature review was to explore the practices of Australian practitioners and courts in respect of the assessment of Australian Indigenous male sexual offenders’ risk of reoffending. We could not identify an instrument that has been developed for the assessment of this population group. Australian courts differ in whether they admit and give weight to practitioners’ evidence and opinions based on data obtained with non-validated instruments. We could only identify three possible predictor variables with enough quantitative support to justify including them in an instrument that could be used to assess Indigenous sexual offenders. There is a need for research regarding the validity of the instruments that practitioners use.     

Suicide Risk Assessment and Management in the Psychiatry Emergency Service: Psychiatric Provider Experience and Perceptions

The objective of this study was to explore suicide risk identification and flow of patients with differing suicide risk through the Psychiatric Emergency Service (PES) to their clinical dispositions. 3 focus groups (N?=?15 psychiatric providers working in the PES of a large urban teaching hospital) discussing suicide risk assessment in the PES were conducted, followed by thematic analysis. A total of 7 themes were identified in 624 coded passages. In focus groups conducted to explore suicide risk assessment, discussions shifted to broader matters, e.g., frustrations with the system in which the providers worked. 4 main messages emerged: screening tools cannot replace clinical judgment; the existing electronic health record is not efficient and sufficiently informative; competing demands challenge PES psychiatrists; and post-discharge patient outcome data are needed. These concerns suggest directions for improving patient care.     

The factors affecting end‐of‐life decision‐making by physicians of patients with intellectual disabilities in the Netherlands: a qualitative study

Background The aim of this study was to investigate the process of end‐of‐life decision‐making regarding people with intellectual disabilities (ID) in the Netherlands, from the perspective of physicians. Methods This qualitative study involved nine semi‐structured interviews with ID physicians in the Netherlands after the deaths of patients with ID that involved end‐of‐life decisions. The interviews were transcribed verbatim and analysed using Grounded Theory procedures. Results Four main contributory factors to the physicians decision‐making process were identified, three of which are related to the importance of relatives' wishes and opinions: (1) Involving relatives in decision‐making. As they had assessed their patients as lacking capacity, the physicians gave very great weight to the opinions and wishes of the relatives and tended to follow these wishes. (2) Delegating quality of life assessments to relatives. Physicians justified their end‐of‐life decisions based on their medical assessment, but left the assessment of the patients' quality of life to relatives, despite having their own implicit opinion about quality of life. (3) Good working relationships. Physicians sought consensus with relatives and paid care staff, often giving greater weight to the importance of good working relationships than to their own assessment of the patient's best interest. (4) Knowledge of the patient's vulnerabilities. Physicians used their intimate, long‐standing knowledge of the patient's fragile health. Conclusions In order to take a more balanced decision, physicians should seek possibilities to involve patients with ID themselves and other stakeholders which are important for the patients. Physicians who have known the patient over time should rely more on their own knowledge of the patient's needs and preferences, seek the input of others, and openly take the lead in the decision‐making process.     

The Role of Context in the Evaluation of Reinforcer Efficacy: Implications for the Preference Assessment Outcomes

Highly preferred stimuli were identified via two preference assessments (based on Fisher et al., 1992), the second of which included stimuli that were ranked low in the initial preference assessment. Following the preference assessments, a subset of stimuli was evaluated as reinforcers in single- and concurrent-operant arrangements. In general, stimuli that were identified as highly preferred in the initial preference assessment functioned as more effective reinforcers. These results are discussed in terms of how the context in which stimuli are evaluated may play a role in the identification of effective positive reinforcers for individuals with autism and related developmental disabilities.     

The Challenge for Australian Jurisdictions to Guarantee Free Qualified Representation Before Mental Health Tribunals and Boards of Review: Learning from the Tasmanian Experience

A mentally ill citizen whose case is listed for hearing before a Mental Health Tribunal or Board of Review has a statutory right to be represented, although in nearly all Australian jurisdictions relatively few individuals are represented. An examination of the annual reports of mental health legal services demonstrates a consensus view that the low number of represented people is due to the lack of sufficient government funding and consequentially the too limited resources of the services. This article reviews the legislation and explores concepts such as the “more well” person and “qualified representation” behind the existing representational system that does not meet Australia's human rights obligations. It questions the continued reliance on the traditional, once clear distinction between that which is legal representation and that which is lay representation in light of the Mental Health Tribunal Representation Scheme which has been operating in Tasmania since 2003. It suggests that this type of representation scheme is a cost-effective alternative that will guarantee every Australian appearing before a mental health board or tribunal the ability to exercise their right to free, competent representation.     

The Philadelphia Brief Assessment of Cognition (PBAC): A Validated Screening Measure for Dementia

The Philadelphia Brief Assessment of the Cognition (PBAC) is a brief dementia-screening instrument. The PBAC assesses five cognitive domains: working memory/executive control; lexical retrieval/language; visuospatial/visuoconstructional operations; verbal/visual episodic memory; and behavior/social comportment. A revised version of the PBAC was administered to 198 participants including patients with Alzheimer's disease (AD) (n?=?46) and four groups of patients with frontotemporal dementia (FTD) syndromes: behavioral-variant FTD (bvFTD; n?=?65), semantic-variant primary progressive aphasia (PPA) (svPPA; n?=?22), non-fluent/agrammatic-variant PPA (nfaPPA; n?=?23), and corticobasal syndrome (CBS; n?=?42), and a group of normal controls (n?=?15). The total PBAC score was highly correlated with the MMSE. The criterion validity of the PBAC was assessed relative to standard neuropsychological test performance. Using standard neuropsychological test performance as a criterion, the total PBAC score accurately identified the presence and severity of dementia. Intra-class correlations between PBAC subscales and standard neuropsychological tests were highly significant. PBAC subscales demonstrated good clinical utility in distinguishing AD and FTD subtypes using receiver operating characteristic analysis and standard diagnostic performance statistics to determine optimal subscale cut scores. The PBAC is a valid tool and able to assesses differential patterns neuropsychological/behavioral impairment in a broad range of neurodegenerative conditions.     

The reliability and validity of the forensic Camberwell Assessment of Need (CANFOR): a needs assessment for forensic mental health service users

No instrument exists that measures the individual needs of forensic mental health service users (FMHSUs). The aim of this study was therefore to develop a valid and reliable individual needs assessment instrument for FMHSUs that incorporated staff and service user views and measured met and unmet needs. The Camberwell Assessment of Need was used as a template to develop CANFOR. Consensual and content validity were investigated with 50 forensic mental health professionals and 60 FMHSUs. Both were found to be satisfactory. Concurrent validity was tested using the Global Assessment of Functioning and a five-point needs scale, and again was found to be satisfactory. Reliability studies were carried out with 77 service users and 65 staff in high and medium security psychiatric services in the UK. Inter-rater reliability, rating whether a need was present or not, was high for service users (0.991) and staff (0.998). Similarly high reliability was found for unmet needs (0.985 and 0.972, respectively). Test-retest reliability was found to be moderately high for service users (0.795) and staff (0.852) when ratings were made two weeks apart. Similar levels were found for ratings of unmet needs (0.813 and 0.699, respectively). The average interview time was 23 minutes. CANFOR has good validity and reliability, and is suitable for further testing with other service user groups.     

The Predictive Ability of the CHADS2 and CHA2DS2-VASc Scores for Bleeding Risk in Atrial Fibrillation: The MAQI Experience

Introduction

Guidelines recommend the assessment of stroke and bleeding risk before initiating warfarin anticoagulation in patients with atrial fibrillation. Many of the elements used to predict stroke also overlap with bleeding risk in atrial fibrillation patients and it is tempting to use stroke risk scores to efficiently estimate bleeding risk. Comparison of stroke risk scores to bleeding risk scores to predict bleeding has not been thoroughly assessed.

Methods

2600 patients followed at seven anticoagulation clinics were followed from October 2009-May 2013. Five risk models (CHADS₂, CHA₂DS₂-VASc, HEMORR₂HAGES, HAS-BLED and ATRIA) were retrospectively applied to each patient. The primary outcome was the first major bleeding event. Area under the ROC curves were compared with C statistic and net reclassification improvement (NRI) analysis was performed.

Results

110 patients experienced a major bleeding event in 2581.6 patient-years (4.5%/year). Mean follow up was 1.0 ± 0.8 years. All of the formal bleeding risk scores had a modest predictive value for first major bleeding events (C statistic 0.66-0.69), performing better than CHADS₂ and CHA₂DS₂-VASc scores (C statistic difference 0.10 - 0.16). NRI analysis demonstrated a 52-69% and 47-64% improvement of the formal bleeding risk scores over the CHADS₂ score and CHA₂DS₂-VASc score, respectively.

Conclusions

The CHADS₂ and CHA₂DS₂-VASc scores did not perform as well as formal bleeding risk scores for prediction of major bleeding in non-valvular atrial fibrillation patients treated with warfarin. All three bleeding risk scores (HAS-BLED, ATRIA and HEMORR₂HAGES) performed moderately well.