Forensic mental health in Europe: some key figures.

PURPOSE: While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. METHODS: Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. RESULTS: The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. CONCLUSION: The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators.

Longer than prison? A comparison of length of stay in a medium security hospital and prison for perpetrators of violent crimes other than homicide or attempted homicide.

BACKGROUND: Concerns have been raised that people detained in secure hospitals after a criminal act spend longer in a locked institution than people sent to prison for similar offending, but research evidence is scarce and conflicting. AIMS: To compare the length of secure hospitalisation of people convicted of crimes for which flexible sentencing is allowed with length of time in prison for people serving a prison sentence for similar crimes who were not found mentally ill. METHODS: A records-based, retrospective study was conducted comparing length of stay of all inpatients in one medium security hospital in Poland, hospitalised between 2014 and 2018, who had been convicted of any interpersonal crime other than homicide or attempted homicide, and data on all sentenced prisoners in Poland on 09.05.2018 convicted of a similar range of offences. Homicide was excluded because, in Poland, it usually attracts a fixed sentence-a life sentence until the 1970s and currently a 25-year imprisonment-so disrupting comparisons. RESULTS: Eighty-two patients completed their secure hospital stay within the study period or were still hospitalised at the census point 09.05.2018, only 10 of them women. Male patients convicted of stalking or similar threatening offence or 'mistreatment' spent, on average, almost twice as long confined to hospital than men sentenced to imprisonment spent in prison (28.8 months, respectively). By contrast, men hospitalised after sex offences were confined for over three years less than those sentenced to prison. Only bodily harm offences attracted comparable lengths of stay in hospital and prison. CONCLUSIONS: Our findings confirm significant disparities in length of time spent in a closed institution after offences of serious interpersonal violence, according to whether that institution was prison or hospital, but not all in the same direction. Next steps should explore reasons for this and relative longer-term outcomes.

Procedural justice and forensic mental health: An introduction and future directions.

This article advocates for integrating procedural justice principles into forensic mental health services to enhance patient engagement and autonomy. Procedural justice, broadly defined as fair decision-making processes, is introduced and key principles including voice, neutrality, respect and trustworthiness are described. Evidence suggestive of positive outcomes following procedural justice experiences, such as improved satisfaction, collaboration and reduced perceptions of coercion is outlined. Practical applications are suggested, including staff training and reflective practices using procedural justice principles. The article then calls for further research to explore patients' and staff members' experiences of procedural justice in forensic settings, develop measurement tools, undertake intervention studies and establish causal links between procedural justice and outcomes important for forensic patients.

Variations in services and intervention pathways for traumatic stress in Welsh prisons: A national survey.

Both Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder are prevalent in prison settings. Both often go undetected and untreated, while prisoners who already suffered previous trauma may be re-traumatised upon imprisonment. The current study aimed to conduct a national survey of all Welsh prisons to gather information about existing services and treatments for traumatic stress. The survey identified variation within Welsh prisons with regard to NICE-recommended evidence-based therapies. It is therefore recommended that there needs to be development of a pathway of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in the prison system which should be achieved through a consensus process of both frontline staff and experts in the field.

Mandatory substance use treatment for justice-involved persons in Germany: a systematic review of reoffending, treatment and the recurrence of substance use outcomes.

Many jurisdictions implement mandatory substance use treatment for justice-involved persons. Germany is one such country; however, debates about the appropriateness and effectiveness of this disposal abound. Very little attention has been paid in the international literature to patients receiving mandatory treatment in Germany. This systematic review synthesises research on patients receiving substance use treatment in forensic hospitals under §64 of the German Penal Code with regard to three primary outcomes: treatment completion, reoffending, and the recurrence of substance use. Forty-five publications reporting on 36 studies were reviewed; publication dates ranged from 1988 to 2023. On average, 47% of patients did not successfully complete treatment, compared to 45% who did. Average follow-up reconviction rates were higher than in mentally ill and general offender populations as reported elsewhere. Approximately half of all patients reused substances during treatment. Suggestions for future research, including a focus on strength- and recovery-based indicators, and harmonising routine outcomes measurements, are given.

Quality of life, wellbeing, recovery, and progress for older forensic mental health patients: a qualitative investigation based on the perspectives of patients and staff.

PURPOSE: There is a lack of research informing service requirements for older (aged≥55 years) forensic mental health patients. The aim of this research was to increase knowledge about older forensic mental health patients' quality of life, wellbeing, recovery, and progress, in order to make recommendations of how to facilitate and enhance these factors. METHODS: In-depth interviews with patients (N = 37) and staff (N = 48) were undertaken; data were analysed using thematic analysis. RESULTS: Environmental (e.g., physical, structural and facilities), relational (staff, family and friends) and individual (characteristics, feelings, behaviours) factors were identified as enablers and/or obstacles to wellbeing, recovery, progress and quality of life. CONCLUSIONS: The physical and psychological environment of services needs to be adapted to meet the needs of patients. Therapeutic relationships with staff should be encouraged and a person-centred and individual recovery approach adopted. Prosocial relationships with peers, friends and family need to be fostered to enable positive recovery outcomes. Older patients should be empowered to develop a sense of autonomy to enable quality of life, wellbeing, and recovery, and progress.

Care for older forensic mental health patients: A consensus guidance document.

BACKGROUND: It is important to investigate the needs, experiences, and outcomes of older forensic mental health inpatients. In this consensus document, we offer practitioners working with older forensic inpatients recommendations to meet the unique older-age-related needs of this group. METHOD: We report on the findings of a scoping review of service provision and age-responsive interventions for this population. We complement this with a review of qualitative studies investigating staff and patient views on age-responsive inpatient care. RESULTS: The guidance synthesizes this evidence into sections on: epidemiological studies of demographic, clinical, and legal profiles; qualitative studies; investigations of patient need; evidence for interventions tailored to this patient group; future directions for research; and finally, recommendations for practice. Forensic patients over the age of 50 years have a different set of psychological and physical health needs from their peers. There is a dearth of dedicated interventions and support to assist patients through secure services and into the community. CONCLUSIONS: We suggest service providers involve older patients in treatment and service organization decisions, adapt interventions to be responsive to this group, train staff to recognize physical vulnerabilities and cognitive decline, and embrace methods of communication developed in other areas of care, such as dementia Care.

Implementation and evaluation of participatory advisory boards in mental health research: a research protocol of the 'PART-Beirat' project.

BACKGROUND: The use of participatory research approaches in the field of dementia and forensic mental health research has been on the rise. Advisory board structures, involving people with lived experience (PWLE), have frequently been used for guiding and leading research. Yet, there has been limited guidance on the establishment, retention and use of advisory boards in the field of dementia and forensic mental health research. OBJECTIVE: This project outlined in this research protocol will investigate the benefits and challenges of establishing three patient advisory boards, involving PWLE, practitioners and researchers with the purpose to guide research. Data will be used to develop guidelines for best practice in involving PWLE in dementia and forensic mental health research through advisory boards. METHODS: The research project will be divided into three phases: Phase I will involve two topic-specific systematic reviews on the use of participatory research with PWLE, followed by an initial study exploring PWLE's, practitioners' and researchers' expectations on research involvement. Phase II will consist of the establishment of three advisory boards, one focusing on dementia, one on forensic mental health and one overarching coordinating advisory board, which will involve PWLE from both fields. Phase III, will consist of interviews and focus groups with advisory board members, exploring any challenges and benefits of involving PWLE and practitioners in advisory boards for guiding research. To capture the impact of involving PWLE in different research phases and tasks, interviews and focus groups will be conducted at four different points of time (0, 6, 12, 18 months). Reflexive thematic analysis will be used for the analysis of data. DISCUSSION: The project aims to explore the involvement of PWLE and practitioners in guiding research and aims to develop guidelines for best practice in establishing and using patient advisory boards in dementia and forensic mental health research and involving PWLE and practitioners in research.

There is an increasing involvement of people with mental health issues in research, especially in the form of advisory boards. So far People With Lived Experience [PWLE] of mental health issues acquired either from first person experience or through family members, and mental health practitioners' involvement in research has been found to benefit research and society. This is because it increases reach and quality of research, whilst raising the voice of people commonly excluded from decision making (e.g. research, care provision). This research protocol describes the design of a three-year research project. The project aims to establish and use patient advisory boards, involving PWLE, practitioners and researchers, to guide research. The project will consist of three phases: (1) a review of previous studies on the use of participatory research with PWLE of dementia and forensic mental health care, followed by an initial study exploring PWLE's, practitioners' and researchers' expectations in research involvement, (2) the establishment of three advisory boards, one focusing on dementia, one on forensic mental health and one overarching coordinating advisory board, and (3) an exploration of challenges, barriers and benefits of involving PWLE of dementia/forensic mental health care and practitioners in advisory boards for research through interviews and focus groups. Interviews with PWLE and practitioners involved in the advisory boards will be conducted at four different points of time (0, 6, 12, 18 month). At the end, we aim to develop guidelines for establishing advisory board structures, involving PWLE and practitioners in research.

Protocol for the CONNECT Study: A National Database and Prospective Follow-Up Study of Forensic Mental Health Patients in Germany.

In Germany, the most frequently used legal section to order forensic mental health treatment is § 63 of the Penal Code (Strafgesetzbuch; StGB). This disposition is primarily aimed at individuals with major mental illnesses who are not fully responsible for a criminal act they committed. Despite evaluation and follow-up studies being conducted within individual hospitals or federal states we lack key epidemiological data on this patient group across the whole country. The present study aims to fill this gap by conducting an annual survey of all eligible forensic mental health hospitals to develop a database of basic clinical, legal and demographic data. Staff at participating hospitals will complete an online survey answering questions about individual patients using routinely collected hospital records. Over the duration of the study, eight-and-a-half years, we aim to collect data on approximately N = 6,450 patients. Alongside important clinical data, we will use official reconviction data at 3- and 6-year follow-ups to investigate the number and types of crimes committed by discharged patients. We aim to extend the scientific literature on factors associated with reconviction in the Risk-Needs-Responsivity model by also measuring the extent to which treatment engagement and programme completion during care predicts reconviction. This study protocol describes the background and theoretical framework for this study, its methods of data collection and analysis, and steps taken to ensure compliance with ethical and data protection principles.

Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study.

OBJECTIVES: There is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this. METHODS: Semi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis. RESULTS: Two global themes 'What works' and 'What doesn't work' were identified comprising themes representing environmental, interpersonal and individual factors. 'What works' included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. 'What doesn't work' included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments. CONCLUSIONS: For older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient's needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.

Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life.

Background: Older individuals (e.g., 55 years and over) constitute a growing proportion of the forensic mental health patient population. As a group, they are vulnerable to health outcomes similar to other individuals with serious mental disorders of the same age; however, these concerns can be compounded by complex forensic-related care backgrounds and clinical presentations, lengthy periods of time spent in prison or psychiatric hospitals, substance use histories, and crime perpetration or victimisation. The healthcare needs and strengths of this group are not well understood.The aim of this study was to identify and describe the demographic, physical health, mental wellbeing, cognitive ability, and quality of life profiles of older forensic patients in community, low, medium, and high security settings in England. Methods: A cross-sectional quantitative study design was used. N=37 forensic patients aged 55 years and over completed six questionnaires. Data were also collected from patient records. Results: Most patients were male and were diagnosed with psychosis. The most frequently committed index offence types were violent offences. Patients were prescribed 7.6 medications on average and had average anticholinergic effect on cognition scores of 2.4. Nearly half the sample had diabetes, with an average BMI score of 31.7 (indicating obesity). Possible cognitive impairment was identified in 65% of the sample. Patients' assessments of their recovery-related quality of life and mental wellbeing were comparable to published UK general population values. Assessments of quality of life were positively correlated with the ability to undertake everyday activities and cognitive performance. Conclusions: We suggest that forensic services are well-placed to provide holistic mental and physical care to this group but that they should co-develop with patients a greater range of age-appropriate meaningful activities that are mindful of mobility issues and consider implementing more cognition-based and physical health interventions.

Forensic mental health services provide care for people who have committed a crime or are at risk of harm to themselves or others. This care takes many forms, including mental health support, physical health care, and assistance to re-enter the community after spending time in secure mental health hospitals. Due to changes in the general population, there is a growing number of patients over the age of 55 in care. Despite this, we do not know enough about the healthcare needs of this older patient group and how these needs differ from younger patients. This study aimed to find out more about this patient group. In the current study, thirty-seven forensic patients aged 55 years and older were recruited from low, medium and high security hospitals and community care. These patients completed six questionnaires. Patients were asked about their physical health, mental wellbeing, cognitive ability, and quality of life. Information about medical diagnoses and socio-demographic backgrounds were collected from hospital records. The study found that these patients had complex health needs. Most patients were diagnosed with psychosis (e.g., schizophrenia), were men, and had committed a violent criminal offence. On average patients were prescribed 7.6 medications, many of which carry significant side effects. Nearly half of the patients had diabetes, and most patients were obese or overweight. Quality of life scores were lower for patients who also reported having problems undertaking everyday activities and patients with cognitive impairment. Patients subjectively rated their mental wellbeing and quality of life similarly to the general population's ratings as reported in other studies. We suggest that services should work with patients to develop a greater number of age-appropriate activities and interventions aimed at improving cognitive and physical health.

The climate crisis and forensic mental healthcare: what are we doing?

The climate crisis poses the greatest threat to human health this century. Mental health services will be called on to address the psychological consequences of its effects on peoples' lives, particularly the socially disadvantaged and those on low incomes. However, healthcare systems are also contributors to the climate crisis. This editorial discusses how services can continue to provide care while contributing less to climate change. Specifically, it suggests what services such as forensic mental healthcare, which is constrained by legal, political and resourcing concerns, can do differently.

Psychosocial Support for Healthcare Workers During the COVID-19 Pandemic.

The novel corona virus disease COVID-19 was first diagnosed in humans in Wuhan, China in December 2019. Since then it had become a global pandemic. Such a pandemic leads to short- and long-term mental health burden for healthcare workers. Recent surveys suggest that rates of psychological stress, depression, anxiety, and insomnia and will be high for this group. Numerous organizations have since released guidance on how both healthcare workers and the general public can manage the mental health burden. However, these recommendations focus on specific healthcare workers (e.g., nurses or psychologists), are often not evidence-based, and typically do not situate guidance within a phased model that recognizes countries are at different stages of the COVID-19 pandemic. In this perspective paper we propose a phased model of mental health burden and responses. Building on work by the Intensive Care Society and the Royal College of Psychiatrists in the United Kingdom, we present a model that demonstrates how both staff and organizations might respond to the likely stressors that might occur at preparation-, pre-, initial and core-, and longer-term-phases of the pandemic. Staff within countries at different stages of the COVID-19 pandemic will be able to use this model. We suggest practical tips for both healthcare workers and organizations and embed this within up-to-date scientific literature. The phased model of mental health burden and responses can be a helpful guide for both staff and organizations operating at different stages of the pandemic.

A Comparison of English and Dutch Long-Stay Patients in Forensic Psychiatric Care.

Background: A significant proportion of forensic patients in England are long-stayers. This can be problematic as individuals are kept in restrictive environments at potentially inappropriate levels of security for many years, sometimes decades. Improvements to the current English forensic mental health system to meet the needs of long-stay forensic patients more effectively might be informed by the Dutch service for long-stay forensic patients. Aims: To compare the characteristics of representative samples of long-stay patients in England and in the Netherlands in an attempt to draw conclusions on the degree to which the Dutch service model might be relevant to England. Method: This cross-sectional study explores the relevance of the Dutch service model by comparing the characteristics of representative samples of long-stay patients in England (n = 401) and the Netherlands (n = 102). Descriptive statistics and analyses of differences between groups are presented. The Risk-Need-Responsivity model was used to guide the selection of the study variables and structure the interpretation of the findings. Results: Compared to their English counterparts, the long-stay Dutch patients were less likely to be diagnosed with schizophrenia, but more likely to have personality disorder and have committed sex offences. The English group were younger at first conviction and at first custodial sentence. The total number of offences and the proportion of violent offenders were similar, but the Dutch HCR-20 scores indicated a significantly higher risk of violence. Conclusions: Whilst there may be barriers to adopting the Dutch service model in England, the differences in the characteristics of the two groups studied here do not necessarily preclude this approach.

Corrigendum: The Forensic Restrictiveness Questionnaire: Development, Validation, and Revision.

[This corrects the article DOI: 10.3389/fpsyt.2019.00805.].

Perceptions of Restrictiveness in Forensic Mental Health: Do Demographic, Clinical, and Legal Characteristics Matter?

Where safe, forensic mental health systems should provide care in the least restrictive environment possible. Doing so can maximize patient autonomy and empowerment while minimizing unnecessary social disconnection and stigmatization. This study investigated whether patients' perceptions of restrictiveness were associated with demographic, clinical, and legal characteristics. The Forensic Restrictiveness Questionnaire (FRQ) was used to measure perceptions of restrictiveness in 235 patients in low-, medium-, and high-secure settings in England. The results showed that restrictiveness scores were significantly higher for patients who experienced an adverse event in the past week or were diagnosed with a personality disorder compared to those with a mental illness. A regression analysis suggested that only diagnosis was predictive of FRQ scores when controlling for perceptions of ward atmosphere and quality of life. Age, length of stay, ethnicity, level of security, legal section, and offence type were not associated with FRQ scores. Future research should investigate the roles that individual symptoms, insight into illness, mood, personality, and expectations of care have in influencing perceptions of restrictiveness.

Court sentences to forensic-psychiatric treatment and imprisonment in Germany: Types of crimes and changes from 1995 to 2009.

The management of mentally disordered offenders varies widely across countries. Given the high prevalence of individuals with mental disorders throughout the criminal justice system, it is not always clear why some people receive forensic treatment and others a prison sentence. This project investigated trends in criminal justice sentencing practices in Germany from 1995 to 2009. We analysed officially recorded data taken from 14,100,329 court rulings to describe differences in the index offences committed by individuals sentenced to prison of at least two years and those given a forensic treatment order. The distribution of offence types differed substantially. Forensic patients committed 6.6% of all severe crimes. There was a 50% increase in the number of forensic treatment orders compared to a 11.6% increase in the group of individuals sentenced for crimes of a similar severity. Forensic patients were more likely to have committed a serious offence. This paper provides key epidemiological data and offers a basis for future comparative research. It also concludes that these trends are indicative of a moderate penal policy, without a drift towards penal populism arguably visible in other jurisdictions. Instead, it is argued that the findings are consistent with actuarial social control policies oriented towards risk prediction and crime prevention of high-risk offender groups.

The Forensic Restrictiveness Questionnaire: Development, Validation, and Revision.

Introduction: Forensic psychiatric care is often practiced in closed institutions. These highly regulated, secure, and prescriptive environments arguably reduce patient autonomy, self-expression, and personhood. Taken together these settings are restrictive as patients' active participation in clinical, organizational, community, and personal life-worlds are curtailed. The consequences of patients' experiences of restrictiveness have not been explored empirically. This study aimed to develop a psychometrically-valid measure of experiences of restrictiveness. This paper presents the development, validation, and revision of the Forensic Restrictiveness Questionnaire (FRQ). Methods: In total, 235 patients recruited from low, medium, and high secure hospitals across England completed the FRQ. The dimensionality of the 56-item FRQ was tested using Principle Axis Factor Analysis and parallel analysis. Internal consistency was explored with Cronbach's α. Ward climate (EssenCES) and quality of life (FQL-SV) questionnaires were completed by participants as indicators of convergent validity. Exploratory Factor Analysis (EFA) and Cronbach's α guided the removal of items that did not scale adequately. Results: The analysis indicated good psychometric properties. EFA revealed a unidimensional structure, suggesting a single latent factor. Convergent validity was confirmed as the FRQ was significantly negatively correlated with quality of life (Spearman's ρ = -0.72) and ward climate (Spearman's ρ = -0.61). Internal consistency was strong (α = 0.93). Forty-one items were removed from the pilot FRQ. The data indicate that a final 15-item FRQ is a valid and internally reliable measure. Conclusion: The FRQ offers a novel and helpful method for clinicians and researchers to measure and explore forensic patients' experiences of restrictiveness within secure hospitals.

Experiences of restrictiveness in forensic psychiatric care: Systematic review and concept analysis.

Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.