Factors influencing the length of stay in forensic psychiatric settings: a systematic review.

BACKGROUND: Forensic psychiatry is often associated with long admissions and has a high cost of care. There is little known about factors influencing length of stay (LOS), and no previous systematic review has synthesised the available data. This paper aims to identify factors influencing the LOS in forensic psychiatry hospitals to inform care and interventions that may reduce the length of admissions. METHODOLOGY: A systematic review was conducted by searching major databases, including PubMed, EMBASE and PsycInfo, from inception until May 2022. Observational studies conducted in forensic hospitals that examined associations between variables of interest and LOS were included. Following data extraction, the Newcastle‒Ottawa Scale was used for quality appraisal. No meta-analysis was conducted due to heterogeneity of information; a quantitative measure to assess the strength of evidence was developed and reported. RESULTS: A total of 28 studies met the inclusion criteria out of 1606 citations. A detailed quantitative synthesis was performed using robust criteria. Having committed homicide/attempted homicide, a criminal legal status with restrictions, and a diagnosis of schizophrenia-spectrum disorders were all associated with longer LOS. Higher Global Assessment of Functioning (GAF) scores were associated with a shorter LOS. CONCLUSION: High-quality research examining factors associated with LOS in forensic psychiatry is lacking, and studies are heterogeneous. No modifiable characteristics were identified, and thus, practice recommendations were not made. There is an increasing necessity to understand the factors associated with longer admissions to inform care and increase success in reintegration and rehabilitation. This paper provides recommendations for future research.

Clinicians' perspectives of forensic rehabilitation.

Having sought 22 clinicians' views of how rehabilitation was practised in a forensic mental health service, this study explores whether or not these views are consistent with claims that forensic rehabilitation can be hampered by the lack of a coherent rehabilitation framework. Two major, mutually influencing themes emerged from the participants' narratives, the first of which delineates the culture and functioning of individuals and systems in a forensic service and the underlying philosophies and beliefs guiding professional behaviour. The second theme outlines the participants' views of the ways in which client needs are assessed and how clients are subsequently provided with the skills and opportunities required for their rehabilitation. The results indicate that while the participants perceived that there were positive aspects to the forensic mental health care that was provided; they also stated that systematicity in the formulation and provision of forensic mental health clients' needs was lacking. These findings reinforce previous claims that there needs to be a theoretically sound means of embedding and systematising effective rehabilitation practice in forensic services.

Unfit offenders in NSW: paying the price for gaps in service provision.

The Mental Health (Forensic Provisions) Act 1990 (NSW) was amended in 2013 to include section 54 A, enabling an application to be made for the extension of a forensic patient's status. Thirteen patients were subject to an extension order between 2014 and 30 June 2018. Shared characteristics of these forensic patients were considered with a view to identifying the types of patients involved in these applications and the gaps in service provision that this might reflect. Nine out of the 13 patients subject to an extension order had a background of sexual offences, and all patients had either an intellectual disability and/or complex comorbid disorders, such as severe personality disorder. The extension orders coincide with gaps in the service provision in relation to the management of certain complex mental disorders, intellectual disability and problematic behaviours that lead to justice system involvement. The authors discuss the potential implications that these findings have for future resource allocation, legislative reform and service provision.

"Moving on" through the locked ward system for women with intellectual disabilities.

BACKGROUND: The move to community support for all people with intellectual disabilities is an aspiration with international significance. In this article, we draw on rich accounts from women with intellectual disabilities detained under the Mental Health Act (E&W) 1983 and staff at an National Health Service secure setting in England to explore how "moving on" is defined and perceived. METHODS: The study reports on an ethnographic study using the field-notes and the 26 semi-structured interviews with detained women and staff on three wards. RESULTS: We first explore staff conceptions of moving on, which include behavioural change and utilizing coping strategies. Then, we discuss the areas of analysis that women discussed: taking back responsibility, success in arranged relationships, acceptance of regime and resistance to progression. CONCLUSION: The concepts of moving on were not determined by the women but by the service. We recommend further research which explores women's own rehabilitation requirements.

New Zealand Youth Fitness to Stand Trial: The Impact of Age, Immaturity and Diagnosis on Evaluator Opinions and Court Determinations.

International research suggests that a proportion of youth facing legal charges are at risk of being unfit (or incompetent) to stand trial. In New Zealand, only a fraction of youth coming before Youth Court are referred for fitness to stand trial evaluations. Amid debate surrounding notions that youth offending could be deterred by providing harsher penalties, it is important to consider fitness to stand trial in youth facing criminal proceedings. This study sought to capture a cross-sectional view of how fitness (competency) to stand trial is addressed in the Youth Court, and how evaluator opinions relate to ultimate court findings. A retrospective review of reports for fitness to stand trial in 79 youth consecutively referred to the Regional Youth Forensic Service from 2010 to 2015 was conducted. Data were combined with Youth Court outcomes obtained from the Ministry of Justice. The mean age is 15.6 years. Intellectual disability is associated with unfit opinions and legal findings (p = .002 and p = .03, respectively), and cases disposed through the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003. Immaturity itself does not appear to have a significant effect on evaluator opinions or court findings of fitness to stand trial. The majority of the referred youth were both opined and found fit.

The role of Qatar's first forensic community team in reducing recidivism and re-admission of mentally unwell offenders.

Introduction: Qatar established its Community Forensic Mental Health Team (CFMHT) in 2019 as part of the region's first comprehensive forensic psychiatry service. We present here the data on clinical and offending outcomes since its establishment and compare this with data from before the service was established. Objectives: To compare clinical and offending outcomes in mental health patients with criminal offending histories in Qatar before and after the establishment of CFMHT. Methods: This is a retrospective study comparing the socio-demographical characteristics, clinical outcome and recidivism measures of forensic patients, under the CFMHT for the last 2 years with data from a similar period before the services were in place. Results: Data for 85 patients under the active care of forensic community team were matched with a comparable group before the establishment of the services. The re-admission and reoffending rates after the establishment of the service over 2-year follow-up were 17.6% and 12.9%, respectively, compared with 40% and 32% before the service. Conclusions: Since its inception, the CFMHT has made a significant positive impact on quality of life, mental well-being and safety of patients under its care. Close working relationships with the criminal justice system, families and carers have helped fight stigma and promote safer communities.

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study.

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: 'Building a Recovery Focused Therapeutic Relationship'; 'Authoritarian Role'; 'Inevitable Imbalance'; 'Rebuilding the Therapeutic Relationship'; plus two sub-themes 'Facilitators to rebuilding' and 'Barriers to rebuilding'. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.

Proposal of a service delivery model for supported living community forensic services.

PURPOSE: Following serious case review, the Transforming Care agenda (DH, 2015) highlights the need for adults with learning disabilities, autism, mental health issues or behaviors that challenge to be supported within communities rather than hospitals. Poor or absent leadership has been identified as contributing to serious cases of abuse in health-care settings [Department of Health (DH), 2012]. This paper aims to focus on identifying the elements required for good leadership and service delivery in community forensic services (CFS). DESIGN/METHODOLOGY/APPROACH: The perspectives of 12 support workers working in CFS were obtained through semi-structured interviews. FINDINGS: Thematic analysis identified two predominant themes, namely, authentic leadership and effective team practice. A culture of trust and learning occurs when teams are well led. This culture leads to consistent practice which benefits services users and reduces risk of poor practice. Analysis suggests a framework for service delivery which is complimented by aspects of the Total Attachment model. RESEARCH LIMITATIONS/IMPLICATIONS: The data set was collected from the same organisation and views may have been aligned to existing organisational policy. However, the sample was taken across different teams and geographical locations to collate more generalised experiences of team dynamics. The lead researcher works for the organisation and this dual role may have affected the candour with which individuals shared information during interviews. PRACTICAL IMPLICATIONS: Using a model to understand the functional dynamics of teams within CFS may support leaders and practitioners to improve service delivery. SOCIAL IMPLICATIONS: Improving service delivery within CFS may increase opportunity to meet the Transforming Care Agenda. ORIGINALITY/VALUE: This paper examines staff perspectives and the application of theoretical frameworks to propose a unique service delivery model for supported living within CFS.

Overview of clinical forensic services in various countries of the European Union.

Examination of a person who has been a victim of a physical or sexual assault may be very important for upcoming legal proceedings. In the context of a clinical forensic examination, physical findings are recorded and biological trace material is gathered and secured. Ideally, all forensic findings are documented in a detailed report combined with photographic documentation, which employs a forensic scale to depict the size of the injuries. However, the integrity of such forensic findings depends particularly on two factors. First, the examination needs to be conducted professionally to ensure that the findings are properly admissible as court evidence. Second, the examination should take place as soon as possible because the opportunity to successfully secure biological samples declines rapidly with time. Access to low-threshold clinical forensic examinations is not evenly provided in all member states of the European Union (EU); in some states, they are not available at all. As part of the JUSTeU! (Juridical standards for clinical forensic examinations of victims of violence in Europe) project, the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria created (in cooperation with its international partner consortium) a questionnaire: the purpose was to collect information about support for victims of physical and/or sexual assault in obtaining a low-threshold clinical forensic examination in various countries of the EU. Our paper provides a summary of the responses and an overview of the current situation concerning provided clinical forensic services.

Factors associated with referrals to high security forensic services among people with severe mental illness and receiving inpatient care in prison.

BACKGROUND: Prison mental health care is a significant topic which has been already studied and described in literature, particularly because of important implications both in the prison and in the health care system. It's not uncommon that inmates suffering from mental disorders are referred to high security forensic services (HSFS) but, to date, studies assessing factors associated with relevant referrals to these services are missing. So, the aim of our study is to investigate socio-demographic, criminological, psychopathological and toxicological variables among those who were referred to HSFS as compared to their non-referred counterpart. METHODS: We conducted a cross-sectional study recruiting 159 subjects receiving prison inpatient care in an Italian jail, between January 2010 and August 2015. No subjects were excluded from the study. The mean age was 39. RESULTS: About half of included prisoners suffered from personality disorder while one-third from psychotic disorders. >60% of the subjects had comorbid substance use disorders. The odds of being referred to HSFS were related to previous admission (odds ratio [OR] = 5.34, 95% confidence interval [CI] 1.66-17.16), diagnosis of psychosis (OR = 2.79, 95% CI 1.11-7.04) and cannabis use disorder (OR = 2.68, 95% CI 1.14-6.28). Personality disorder was inversely associated to the referral to forensic facilities (OR = 0.37, 95% CI 0.14-0.97). CONCLUSIONS: Mental health services should improve preventive measures for vulnerable prisoners in order to reduce criminal recidivism and forensic readmission.

Nivel de satisfacción y factores sociodemográficos de usuarios atendidos en los servicios forenses de la Unidad Médico Legal II Amazonas / Level of satisfaction and sociodemographic factors of users attended in the forensic services of the Medical Legal Unit II Amazonas

Resumen Introducción: La insatisfacción en la atención de los servicios forenses públicos, representa una preocupación de las entidades estatales hacia la atención brindada a los usuarios, siendo necesario su identificación. La investigación determino la relación entre el nivel de satisfacción y factores sociodemográficos de usuarios atendidos en la Unidad Médico Legal II Amazonas. Materiales y métodos: Estudio descriptivo-correlacional, de enfoque cuantitativo y diseño no experimental, en una muestra de 126 usuarios, seleccionados por muestreo probabilístico aleatorio estratificado, se aplicó un cuestionario mediante encuesta, validado por juicio de expertos (V de Alkin, 94.38) y confiabilidad (alfa de Cronbach, 0.824). Resultados: Mediante prueba Chi-cuadrado de Pearson, no se encontró relación entre la variable nivel de satisfacción y características sociodemográficas (p>0.05); al evaluarse por servicios, se encontró en mesa de partes satisfacción indiferente (44.4%) e insatisfacción (27%), en Medicina legal, satisfacción (35%) e indiferente (55%), en Odontología forense, tuvo satisfacción (84.1%) y el servicio de Psicología forense satisfacción (78.6%). Conclusiones: El nivel de satisfacción y los factores sociodemográficos no se relacionan, es decir las variables se disocian; en general los usuarios atendidos mostraron satisfacción (56.6%), insatisfacción (11%) y satisfacción indiferente (32.6%), por ello se requieren de planes de mejora para la atención al usuario.

Abstract Introduction: The dissatisfaction of the attention of the public forensic services, represent a concern of the state entities towards the attention of the users, being necessary their identification. The research determined the relationship between the level of satisfaction and sociodemographic factors of users attended in the Medical Legal Unit II Amazonas. Materials and methods: Descriptive-correlational study, with a quantitative approach and non-experimental design, in a sample of 126 users, selected by stratified random probability sampling, a questionnaire was applied by means of a survey, validated by expert judgment (V de Alkin, 94.38) and reliability (Cronbach's alpha, 0.824). Results: Using Pearson's Chi-square test, no relationship was found between the level of satisfaction variable and sociodemographic characteristics (p> 0.05); When evaluated by services, indifferent satisfaction (44.4%) and dissatisfaction (27%) were found at the party table, in Legal Medicine, satisfaction (35%) and indifferent (55%), in Forensic Dentistry, there was satisfaction (84.1%) and the forensic psychology service satisfaction (78.6%). Conclusions: The level of satisfaction and the sociodemographic factors are not related, that is, the variables are dissociated; In general, the users attended showed satisfaction (56.6%), dissatisfaction (11%) and indifferent satisfaction (32.6%), for this reason improvement plans are required for user service.