Positive and negative syndrome scale in forensic patients with schizophrenia spectrum disorders: a systematic review and meta-analysis.

Among forensic patients with schizophrenia spectrum disorders, the association between symptomatology and violence is still not entirely clear in literature, especially because symptoms shift both during the acute phase of the illness and after. The aims were to investigate the level of symptomatology in forensic patients and to evaluate if there are differences in the level of symptoms between forensic and non-forensic patients. According to PRISMA guidelines, a systematic search was performed in PubMed, Web of Science, and ProQuest, using the following key words: "forensic" AND "Positive and Negative Syndrome Scale" OR "PANSS". A total of 27 studies were included in the systematic review, while only 23 studies in the meta-analysis. The overall sample included a total of 1702 participants, most commonly male and inpatients in forensic settings. We found that studies with an entirely male sample had significantly lower Positive PANSS ratings than studies with mixed samples. Although both forensic and non-forensic patients were affected by mild psychopathological symptoms, forensic patients presented higher ratings in all four PANSS scales. This meta-analysis shows that forensic patients reported a mild level of symptomatology, as assessed with the PANSS, and therefore might be considered as patients in partial remission. Among patients with schizophrenia, the association between symptoms and violence is very complex: many factors might be considered as key mediators and thus should be taken into account to explain this association. Further studies are needed.Trial registration all materials and data can be found on the OSF framework: https://osf.io/5ceja (date of registration: 8 September 2021).

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.

Women and men of mafia between traditional cultural contexts and new social roles.

The Italian mafia organizations represent a subculture with values, beliefs, and goals that are antithetical to and undermining of the predominant society. The conduct of individual members includes such extreme violence for material gain, it may at least superficially suggest a severe personality disorder. Since the first edition of the DSM and into the 21st century, various terms have been used, sometimes interchangeably, but over time inconsistently, to designate the mentality and practices of mafia members. Only recently has the psychology of mafia members become a focus of serious scientific study. For the first time, investigators for the present study applied instruments, including the PCL-R, to examine for character psychopathology and specifically degrees of psychopathy in male and female mafia members, 20 female and 21 male members. Results showed some gender difference with the women having a higher score on Factor 1, in contrast to men who showed a lower score. Psychopathy and personality disorder were not found to be associated with membership in the mafia for either gender. Some psychopathic traits and gender differences warrant further research. Meanwhile these findings are consistent with a mentality characterized by beliefs and practices determined by a deviant culture rather than psychopathology.

Is non-completion of treatment related to security need?

BACKGROUND: Treatment completion difficulties are common in forensic mental health settings and may have a profound impact on recidivism rates. AIMS: To test for associations between measures of risk and of security needs on the one hand and treatment non-completion on the other among male offender-patients in one medium security hospital. METHODS: We conducted a retrospective file study in a Flemish medium security hospital. A random sample of 25 treatment non-completers was compared to a random same-size sample of completers, each rated, blind to outcome, on the DUNDRUM-1 security needs scale from data recorded at the time of admission to the unit. 'Non-completion' was defined as any failure to complete treatment, whether staff-terminated or self-terminated; in Flanders, failure to comply with the judicial conditions of placement can result in re-imprisonment. We used binary logistic regression to test relationships between treatment completion/non-completion and security need, measured with the DUNDRUM-1, together with a range of possible confounding variables. RESULTS: Most patients had psychosis and/or personality disorder and often substance use disorders also. Treatment non-completion was invariably staff ordered because of security breaches. DUNDRUM-1 and PCL-R Facet 4 scores at the time of admission and HCR-20 scores during admission were significantly higher among non-completers than completers, but after binary logistic regression, only the DUNDRUM-1 rating was independently associated with non-completion. CONCLUSIONS: Our study showed that an admission DUNDRUM-1 rating, indicating levels of security need, co-varies only to a small extent with the historical items of the HCR-20, so may be regarded as measuring complementary domains. While conditions in Flanders at the time of the study complicated it in that medium security hospital units offered the highest level of hospital security available, the finding that non-completion of treatment was particularly likely when the DUNDRUM-1 indicated a higher security need than facilities could provide may have implications for all secure hospital services.

A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders).

BACKGROUND: Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. METHODS: In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. RESULTS: A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours. CONCLUSION: Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.

A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder.

BACKGROUND: Evidence is accumulating that Cognitive Remediation Training (CRT) is effective for ameliorating cognitive deficits experienced by patients with schizophrenia and accompanying functional impairment. There has been no randomized controlled trial of CRT using a nationally representative population of forensic patients, despite the significant cognitive deficits frequently present within this group. METHODS: Sixty-five patients with schizophrenia or schizoaffective disorder were enrolled in a single blind randomized controlled trial of CRT versus treatment as usual (TAU); representing 94% of those eligible within a national forensic cohort. The primary outcome measure was the composite score of the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcome measures included neurocognitive and social cognitive domains, symptoms, and 'real world' functioning. Patient satisfaction was examined using an exit interview. Participants were reassessed at 8 months follow up. All data were analyzed using an intention to treat design (ITT). RESULTS: For the primary outcome measure, the MCCB composite score, there were significant differences between those who participated in CRT and those receiving TAU at both end of treatment and 8 months follow up (Cohen's d = 0.34. Significant improvements were observed in visual and working memory. Mediation analysis found that those who cognitively benefited from CRT had corresponding improved functioning, and more net positive therapeutic moves i.e. moves to units with lower security within the hospital. Ninety-six percent believed their cognitive gains positively affected their daily lives. CONCLUSIONS: CRT may be an acceptable and efficacious intervention for forensic patients with schizophrenia or schizoaffective disorder. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02360813 . Trial registered Feb 4th 2015, last updated May 1st 2015.

Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study.

BACKGROUND: People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence. METHOD: We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence. RESULTS: Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence. CONCLUSIONS: Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

An evaluation of functional mental capacity in forensic mental health practice: the Dundrum capacity ladders validation study.

BACKGROUND: Because of the potential gravity of finding a person incompetent, assessment of mental capacity is challenging for clinicians. We aimed to test validity of a new structured professional judgement tool designed to assess functional mental capacity in three domains - finances, welfare and healthcare. METHODS: Fifty-five male forensic psychiatric patients with Schizophrenia were interviewed using the Dundrum Capacity Ladders - a new semi-structured interview, and scores were assigned on a stratified scoring system, measuring ability to understand, reason, appreciate the personal importance of the decision at hand and communicate a decision. Data were also gathered pertaining to level of therapeutic security at the time of interview, diagnosis, neurocognitive function and a validated measure of real world function. RESULTS: The results show that internal consistency and inter-rater reliability were high for all items. There were correlations between higher scores of functional mental capacity, neurocognitive function and measures of real world function in this population. Correlations were in the range 0.358 to 0.693, effect sizes that were moderate to high. CONCLUSIONS: The DUNDRUM Capacity Ladders appear to be a valid measure of functional mental capacity in this population. Further prospective studies of functional mental capacity as a measure of recovery are now required.

Prospective observational cohort study of 'treatment as usual' over four years for patients with schizophrenia in a national forensic hospital.

BACKGROUND: We evaluated change in response to multi-modal psychosocial 'treatment as usual' programs offered within a forensic hospital. METHODS: Sixty nine patients with a diagnosis of schizophrenia or schizoaffective disorder were followed for up to four years. Patient progress was evaluated using the DUNDRUM-3, a measure of patient ability to participate and benefit from multi-modal psychosocial programs and the HCR-20 dynamic items, a measure of violence proneness. We report reliable change index (RCI) and reliable and clinically meaningful change (RMC). We assessed patients' cognition using the MCCB, psychopathology using the PANSS. The effect of cognition and psychopathology on change in DUNDRUM-3 was examined using hierarchical multiple regression with age, gender, and baseline DUNDRUM-3 scores. RESULTS: The DUNDRUM-3 changed significantly (p < 0.004, d = 0.367, RCI 32% of 69 cases, RMC 23%) and HCR-20-C (p < 0.003, d = 0.377, RCI 10%). Both cognition and psychopathology accounted for significant variance in DUNDRUM-3 at follow up. Those hospitalized for less than five years at baseline changed more than longer stay patients. Mediation analysis demonstrated that the relationship between cognition and change in violence proneness (HCR-20-C) was both directly affected and indirectly mediated by change in DUNDRUM-3. CONCLUSIONS: Change in response to multi-modal psychosocial programs (DUNDRUM-3) reduced a measure of violence proneness over four years. Forensic in-patients' ability to benefit from psychosocial treatment appears to be a function of the outcome measure used, unit of measurement employed, degree of cognitive impairment, psychopathology, and length of stay. Lower risk of re-offending may be partially attributable to participation and engagement in psychosocial interventions.

Study protocol: a randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder.

BACKGROUND: Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder. METHODS: An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction. DISCUSSION: Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02360813. Trial registered Feb 4th 2015 and last updated May 1(st) 2015.

Recovery and concordance in a secure forensic psychiatry hospital - the self rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales.

BACKGROUND: Detention in a secure forensic psychiatric hospital may inhibit engagement and recovery. Having validated the clinician rated DUNDRUM-3 (programme completion) and DUNDRUM-4 (recovery) in a forensic hospital, we set out to draft and validate scales measuring the same programme completion and recovery items that patients could use to self-rate. Based on previous work, we hypothesised that self-rating scores might be predictors of objective progress including conditional discharge. We hypothesised also that the difference between patients' and clinicians' ratings of progress in treatment and other factors relevant to readiness for discharge (concordance) would diminish as patients neared discharge. We hypothesised also that this difference in matched scores would predict objective progress including conditional discharge. METHOD: In a prospective naturalistic observational cohort study in a forensic hospital, we examined whether scores on the self-rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales or differences between clinician and patient ratings on the same scales (concordance) would predict moves between levels of therapeutic security and conditional discharge over the next twelve months. RESULTS: Both scales stratified along the recovery pathway of the hospital, but clinician ratings matched the level of therapeutic security more accurately than self ratings. The clinician rated scales predicted moves to less secure units and to more secure units and predicted conditional discharge but the self-rated scores did not. The difference between clinician and self-rated scores (concordance) predicted positive and negative moves and conditional discharge, but this was not always an independent predictor as shown by regression analysis. In regression analysis the DUNDRUM-3 predicted moves to less secure places though the HCR-20 C & R score dominated the model. Moves back to more secure places were predicted by lack of concordance on the DUNDRUM-4. Conditional discharge was predicted predominantly by the DUNDRUM-3. CONCLUSIONS: Patients accurately self-rate relative to other patients however their absolute ratings were consistently lower (better) than clinicians' ratings and were less accurate predictors of outcomes including conditional discharge. Quantifying concordance is a useful part of the recovery process and predicts outcomes but self-ratings are not accurate predictors.

Factors affecting length of stay in forensic hospital setting: need for therapeutic security and course of admission.

BACKGROUND: Patients admitted to a secure forensic hospital are at risk of a long hospital stay. Forensic hospital beds are a scarce and expensive resource and ability to identify the factors predicting length of stay at time of admission would be beneficial. The DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale are designed to assess need for therapeutic security and urgency of that need while the HCR-20 predicts risk of violence. We hypothesized that items on the DUNDRUM-1 and DUNDRUM-2 scales, rated at the time of pre-admission assessment, would predict length of stay in a medium secure forensic hospital setting. METHODS: This is a prospective study. All admissions to a medium secure forensic hospital setting were collated over a 54 month period (n = 279) and followed up for a total of 66 months. Each patient was rated using the DUNDRUM-1 triage security scale and DUNDRUM-2 triage urgency scale as part of a pre-admission assessment (n = 279) and HCR-20 within 2 weeks of admission (n = 187). Episodes of harm to self, harm to others and episodes of seclusion whilst an in-patient were collated. Date of discharge was noted for each individual. RESULTS: Diagnosis at the time of pre-admission assessment (adjustment disorder v other diagnosis), predicted legal status (sentenced v mental health order) and items on the DUNDRUM-1 triage security scale and the DUNDRUM-2 triage urgency scale, also rated at the time of pre-admission assessment, predicted length of stay in the forensic hospital setting. Need for seclusion following admission also predicted length of stay. CONCLUSIONS: These findings may form the basis for a structured professional judgment instrument, rated prior to or at time of admission, to assist in estimating length of stay for forensic patients. Such a tool would be useful to clinicians, service planners and commissioners given the high cost of secure psychiatric care.

Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder.

BACKGROUND: There is a broad literature suggesting that cognitive difficulties are associated with violence across a variety of groups. Although neurocognitive and social cognitive deficits are core features of schizophrenia, evidence of a relationship between cognitive impairments and violence within this patient population has been mixed. METHODS: We prospectively examined whether neurocognition and social cognition predicted inpatient violence amongst patients with schizophrenia and schizoaffective disorder (n = 89; 10 violent) over a 12 month period. Neurocognition and social cognition were assessed using the MATRICS Consensus Cognitive Battery (MCCB). RESULTS: Using multivariate analysis neurocognition and social cognition variables could account for 34 % of the variance in violent incidents after controlling for age and gender. Scores on a social cognitive reasoning task (MSCEIT) were significantly lower for the violent compared to nonviolent group and produced the largest effect size. Mediation analysis showed that the relationship between neurocognition and violence was completely mediated by each of the following variables independently: social cognition (MSCEIT), symptoms (PANSS Total Score), social functioning (SOFAS) and violence proneness (HCR-20 Total Score). There was no evidence of a serial pathway between neurocognition and multiple mediators and violence, and only social cognition and violence proneness operated in parallel as significant mediators accounting for 46 % of the variance in violent incidents. There was also no evidence that neurocogniton mediated the relationship between any of these variables and violence. CONCLUSIONS: Of all the predictors examined, neurocognition was the only variable whose effects on violence consistently showed evidence of mediation. Neurocognition operates as a distal risk factor mediated through more proximal factors. Social cognition in contrast has a direct effect on violence independent of neurocognition, violence proneness and symptom severity. The neurocognitive impairment experienced by patients with schizophrenia spectrum disorders may create the foundation for the emergence of a range of risk factors for violence including deficits in social reasoning, symptoms, social functioning, and HCR-20 risk items, which in turn are causally related to violence.

Older men and older women remand prisoners: mental illness, physical illness, offending patterns and needs.

BACKGROUND: Older prisoners are the fastest growing group of prisoners in most countries. They have high rates of physical and psychiatric co-morbidity, compared to community dwelling older persons and also compared with other prisoner groups. Very high rates of mental illness have been found in remand (pre-trial) prisoners when compared with other prisoner groups; however to date there have been no studies examining older male and female remand prisoners. METHODS: A retrospective chart review was conducted of all remands, to a male and a female prison, over a six and half-year period. Demographic data were collected pertaining to psychiatric and medical diagnoses and seriousness of offending. RESULTS: We found rising numbers of older prisoners amongst male remand prisoners. Older remand prisoners had very high rates of affective disorder and alcohol misuse. They had rates of psychotic illnesses and deliberate self-harm comparable to younger remand prisoners. High rates of vulnerability were found among older prisoners and older prisoners had a greater need for general medical and psychiatric services than younger prisoners. We also found comparable offending patterns with younger prisoners and high rates of sexual offending among the older male prisoner group. CONCLUSIONS: Given the ageing population of many countries it is likely the numbers of older prisoners will continue to grow and given their high levels of both physical and psychiatric illness this will have implications for future service delivery.

Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services.

BACKGROUND: The START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. The DUNDRUM-3 and DUNDRUM-4 also measure positive factors, programme completion and recovery in forensic settings. METHODS: We compared these instruments with other validated risk instruments (HCR-20, S-RAMM), a measure of psychopathology (PANSS) and global function (GAF). We prospectively tested whether any of these instruments predict violence or self harm in a secure hospital setting (n = 98) and whether they had true protective effects, interacting with and off-setting risk measures. RESULTS: SAPROF and START-strengths had strong inverse (negative) correlations with the HCR-20 and S-RAMM. SAPROF correlated strongly with GAF (r = 0.745). In the prospective in-patient study, SAPROF predicted absence of violence, AUC = 0.847 and absence of self-harm AUC = 0.766. START-strengths predicted absence of violence AUC = 0.776, but did not predict absence of self-harm AUC = 0.644. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales also predicted in-patient violence (AUC 0.832 and 0.728 respectively), and both predicted in-patient self-harm (AUC 0.750 and 0.713 respectively). When adjusted for the HCR-20 total score however, SAPROF, START-S, DUNDRUM-3 and DUNDRUM-4 scores were not significantly different for those who were violent or for those who self harmed. The SAPROF had a significant interactive effect with the HCR-dynamic score. Item to outcome studies often showed a range of strengths of association with outcomes, which may be specific to the in-patient setting and patient group studied. CONCLUSIONS: The START and SAPROF, DUNDRUM-3 and DUNDRUM-4 can be used to assess both reduced and increased risk of violence and self-harm in mentally ill in-patients in a secure setting. They were not consistently better than the GAF, HCR-20, S-RAMM, or PANSS when predicting adverse events. Only the SAPROF had an interactive effect with the HCR-20 risk assessment indicating a true protective effect but as structured professional judgement instruments all have additional content (items) complementary to existing risk assessments, useful for planning treatment and risk management.

Prospective study of factors influencing conditional discharge from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4 recovery structured professional judgement instruments and risk.

BACKGROUND: We set out to examine whether structured professional judgement instruments DUNDRUM-3 programme completion (D-3) and DUNDRUM-4 recovery (D-4) scales along with measures of risk, mental state and global function could distinguish between those forensic patients detained in a secure forensic hospital (not guilty by reason of insanity or unfit to stand trial) who were subsequently discharged by a mental health review board. We also examined the interaction between these measures and risk, need for therapeutic security and eventual conditional discharge. METHODS: A naturalistic observational cohort study was carried out for 56 patients newly eligible for conditional discharge. Patients were rated using the D-3, D-4 and other scales including HCR-20, S-RAMM, START, SAPROF, PANSS and GAF and then observed over a period of twenty three months during which they were considered for conditional discharge by an independent Mental Health Review Board. RESULTS: The D-3 distinguished which patients were subsequently discharged by the Mental Health Review board (AUC = 0.902, p < 0.001) as did the D-4 (AUC = 0.848, p < 0.001). Item to outcome analysis showed each item of the D-3 and D-4 scales performed significantly better than random. The HCR-20 also distinguished those later discharged (AUC = 0.838, p < 0.001) as did the S-RAMM, START, SAPROF, PANSS and GAF. The D-3 and D-4 scores remained significantly lower (better) for those discharged even when corrected for the HCR-20 total score. Item to outcome analyses and logistic regression analysis showed that the strongest antecedents of discharge were the GAF and the DUNDRUM-3 programme completion scores. CONCLUSIONS: Structured professional judgement instruments should improve the quality, consistency and transparency of clinical recommendations and decision making at mental health review boards. Further research is required to determine whether the DUNDRUM-3 programme completion and DUNDRUM-4 recovery instruments predict those who are or are not recalled or re-offend after conditional discharge.

Patient perspective on observation methods used in seclusion room in an Irish forensic mental health setting: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Nurses' observation of patients in seclusion is essential to ensure patient safety. Patient observation in seclusion assists nurses in adhering to the requirements of mental health legislation and hospital policy. Direct observation and video monitoring are widely used in observing patients in seclusion. Coercive practices may cause distress to patient-staff relations. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We add detailed information on specific observation methods in seclusion and compare them from the perspective of patients. Nurses communicating with patients ensures relational contact and that quality care is provided to patients even in the most distressed phase of their illness. Providing prior information to patients on observation methods in seclusion and the need for engaging patients in meaningful activities, while in seclusion are emphasized. Observation via camera and nurses' presence near the seclusion room made patients feel safe and gave a sense of being cared for in seclusion. Pixellating the video camera would give a sense of privacy and dignity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The overarching goal is to prevent seclusion. However, when seclusion is used as a last resort to manage risk to others, it should be done in ways that recognize the human rights of the patient, in ways that are least harmful, and in ways that recognize and cater to patients' unique needs. A consistent approach to relational contact and communication is essential. A care plan must include patient's preferred approach for interacting while in seclusion to support individualized care provision. Viewing panels (small window on the seclusion door) are important in establishing two-way communication with the patient. Educating nurses to utilize them correctly helps stimulate relational contact and communication during seclusion to benefit patients. Engaging patients in meaningful activities when in seclusion is essential to keep them connected to the outside world. Depending on the patient's presentation in the seclusion room and their preferences for interactions, reading newspapers, poems, stories, or a book chapter aloud to patients, via the viewing panel could help ensure such connectedness. More focus should be placed on providing communication training to nurses to strengthen their communication skills in caring for individuals in challenging care situations. Patient education is paramount. Providing prior information to patients using a co-produced information leaflet might reduce their anxiety and make them feel safe in the room. When using cameras in the seclusion room, these should be pixelated to maintain patients' privacy. ABSTRACT: Introduction A lack of research investigating the specific role that various observational techniques may have in shaping the therapeutic relations in mental health care during seclusion warranted this study. Aim The aim of the study was to explore patients' experience of different methods of observation used while the patient was in seclusion. Method A retrospective phenomenological approach, using semi-structured interviews, ten patients' experiences of being observed in the seclusion room was investigated. Colaizzi's descriptive phenomenological method was followed to analyse the data. Results Communicating and engaging patients in meaningful activities can be achieved via the viewing panel. The camera was considered essential in monitoring behaviour and promoting a sense of safety. Pixelating the camera may transform patient view on privacy in seclusion. Discussion The mental health services must strive to prevent seclusion and every effort should be made to recognise the human rights of the patient. The study reveals numerous advantages when nurses actively engage in patient communication during the process of observation. Implications for Practice Different observation methods yield different benefits; therefore, staff education in using these methods is paramount. Empowering the patient with prior information on seclusion, engaging them in meaningful activities and proper documentation on patient engagement, supports the provision of individualised care in seclusion.

Excellence in forensic psychiatry services: international survey of qualities and correlates.

BACKGROUND: Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development. AIMS: To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security. METHOD: A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire. RESULTS: Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score. CONCLUSIONS: Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

Ultra high risk of psychosis on committal to a young offender prison: an unrecognised opportunity for early intervention.

BACKGROUND: The ultra high risk state for psychosis has not been studied in young offender populations. Prison populations have higher rates of psychiatric morbidity and substance use disorders. Due to the age profile of young offenders one would expect to find a high prevalence of individuals with pre-psychotic or ultra-high risk mental states for psychosis (UHR). Accordingly young offender institutions offer an opportunity for early interventions which could result in improved long term mental health, social and legal outcomes. In the course of establishing a mental health in-reach service into Ireland's only young offender prison, we sought to estimate unmet mental health needs. METHODS: Every third new committal to a young offenders prison was interviewed using the Comprehensive Assessment of At-Risk Mental States (CAARMS) to identify the Ultra High Risk (UHR) state and a structured interview for assessing drug and alcohol misuse according to DSM-IV-TR criteria, the Developmental Understanding of Drug Misuse and Dependence - Short Form (DUNDRUM-S). RESULTS: Over a twelve month period 171 young male offenders aged 16 to 20 were assessed. Of these 39 (23%, 95% confidence interval 18% to 30%) met UHR criteria. UHR states peaked at 18 years, were associated with lower SOFAS scores for social and occupational function and were also associated with multiple substance misuse. The relationship with lower SOFAS scores persisted even when co-varying for multiple substance misuse. CONCLUSIONS: Although psychotic symptoms are common in community samples of children and adolescents, the prevalence of the UHR state in young offenders was higher than reported for community samples. The association with impaired function also suggests that this may be part of a developing disorder. Much more attention should be paid to the relationship of UHR states to substance misuse and to the health needs of young offenders.

Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20.

BACKGROUND: We examined whether new structured professional judgment instruments for assessing need for therapeutic security, treatment completion and recovery in forensic settings were related to moves from higher to lower levels of therapeutic security and added anything to assessment of risk. METHODS: This was a prospective naturalistic twelve month observational study of a cohort of patients in a forensic hospital placed according to their need for therapeutic security along a pathway of moves from high to progressively less secure units in preparation for discharge. Patients were assessed using the DUNDRUM-1 triage security scale, the DUNDRUM-3 programme completion scale and the DUNDRUM-4 recovery scale and assessments of risk of violence, self harm and suicide, symptom severity and global function. Patients were subsequently observed for positive moves to less secure units and negative moves to more secure units. RESULTS: There were 86 male patients at baseline with mean follow-up 0.9 years, 11 positive and 9 negative moves. For positive moves, logistic regression indicated that along with location at baseline, the DUNDRUM-1, HCR-20 dynamic and PANSS general symptom scores were associated with subsequent positive moves. The receiver operating characteristic was significant for the DUNDRUM-1 while ANOVA co-varying for both location at baseline and HCR-20 dynamic score was significant for DUNDRUM-1. For negative moves, logistic regression showed DUNDRUM-1 and HCR-20 dynamic scores were associated with subsequent negative moves, along with DUNDRUM-3 and PANSS negative symptoms in some models. The receiver operating characteristic was significant for the DUNDRUM-4 recovery and HCR-20 dynamic scores with DUNDRUM-1, DUNDRUM-3, PANSS general and GAF marginal. ANOVA co-varying for both location at baseline and HCR-20 dynamic scores showed only DUNDRUM-1 and PANSS negative symptoms associated with subsequent negative moves. CONCLUSIONS: Clinicians appear to decide moves based on combinations of current and imminent (dynamic) risk measured by HCR-20 dynamic score and historical seriousness of risk as measured by need for therapeutic security (DUNDRUM-1) in keeping with Scott's formulation of risk and seriousness. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales have utility as dynamic measures that can off-set perceived 'dangerousness'.