Intentions to use mental health and suicide prevention resources among individuals with symptoms of the suicide crisis syndrome and/or suicidal ideation.

INTRODUCTION: The suicide crisis syndrome (SCS) has demonstrated efficacy in predicting suicide attempts, showing potential utility in detecting at-risk individuals who may not be willing to disclose suicidal ideation (SI). The present international study examined differences in intentions to utilize mental health and suicide prevention resources among community-based adults with varying suicide risk (i.e., presence/absence of SCS and/or SI). METHODS: A sample of 16,934 community-based adults from 13 countries completed measures about the SCS and SI. Mental health and suicide prevention resources were provided to all participants, who indicated their intentions to use these resources. RESULTS: Individuals with SCS (55.7%) were just as likely as those with SI alone (54.0%), and more likely than those with no suicide-related symptoms (45.7%), to report willingness to utilize mental health resources. Those with SI (both with and without SCS) were more likely to seek suicide prevention resources (52.6% and 50.5%, respectively) than those without SI (41.7% and 41.8%); however, when examining endorsements for personal use, those with SCS (21.6%) were more likely to use resources than individuals not at risk (15.1%). CONCLUSIONS: These findings provide insight into individuals' willingness to use resources across configurations of explicitly disclosed (SI) and indirect (SCS) suicide risk.

Relationship Between Severity and Length of Exposure to COVID-19 Parameters and Resulting Government Responses and the Suicide Crisis Syndrome (SCS).

OBJECTIVE: The COVID-19 pandemic has had a globally devastating psychosocial impact. A detailed understanding of the mental health implications of this worldwide crisis is critical for successful mitigation of and preparation for future pandemics. Using a large international sample, we investigated in the present study the relationship between multiple COVID-19 parameters (both disease characteristics and government responses) and the incidence of the suicide crisis syndrome (SCS), an acute negative affect state associated with near-term suicidal behavior. METHODS: Data were collected from 5528 adults across 10 different countries in an anonymous web-based survey between June 2020 and January 2021. RESULTS: Individuals scoring above the SCS cut-off lived in countries with higher peak daily cases and deaths during the first wave of the pandemic. Additionally, the longer participants had been exposed to markers of pandemic severity (eg, lockdowns), the more likely they were to screen positive for the SCS. Findings reflected both country-to-country comparisons and individual variation within the pooled sample. CONCLUSION: Both the pandemic itself and the government interventions utilized to contain the spread appear to be associated with suicide risk. Public policy should include efforts to mitigate the mental health impact of current and future global disasters.

Subjective and objective assessments of executive functions are independently predictive of aggressive tendencies in patients with substance use disorder.

BACKGROUND AND AIMS: Impairments in executive functions have been found to influence violent behavior. Executive functions are crucial in the treatment of patients with substance use disorders because substance use generally impairs cognitive processes and is therefore detrimental for executive functions thereby reducing control of behavior and thus of consumption impulses. We studied correlations between subjective, i.e. self-report, and objective, i.e. behavior-based, assessment of executive functions and the predictive validity of these measures for aggression in patients with substance use disorder. METHODS: The study included 64 patients with a diagnosed substance use disorder who were convicted according to the German Criminal Code for crimes they committed in the context of their disorder and were therefore in treatment in forensic psychiatric departments in Germany. Multiple self-report and behavior-based instruments were used to assess executive functions, appetitive and facilitative aggression as well as clinical and sociodemographic variables. RESULTS: Participants showed impaired executive functions, and measures of executive functions predicted aggressive tendencies and violent offenses. Despite ecological validity of the findings, the subjective and objective assessments of executive functions did not correlate with each other, which corroborates studies in other clinical settings. CONCLUSIONS: We discuss that this finding may be due to the conceptual differences between subjective and objective measures. Therefore, self-report and behavior-based measures should not be used as proxies of each other but as complementary measures that are useful for comprehensive diagnostics of cognitive impairments and assessment of risks for violent behavior.

Predicting violence in female forensic inpatients with substance use disorders - the utility of a gender-responsive assessment.

Introduction: Given that risk assessment tools are commonly based on male samples, the applicability to justice-involved women remains to be clarified. This study aimed at assessing (1) the predictive validity of the HCR-20 V3, the prevailing, yet primarily male-based violence risk assessment instrument, and (2) the incremental validity of the FAM, a gender-responsive supplement, for both inpatient violence and violent recidivism in justice-involved women. Methods: The sample included 452 female forensic inpatients with substance use disorder discharged from German forensic psychiatric care between 2001 and 2018. Results: ROC analyses revealed good predictive accuracy for the HCR-20 V3 while the FAM failed to provide incremental validity. Further, binary logistic regression determined several predictors of violence including personality disorder, covert/manipulative behavior, suicidal behavior/self-harm, and problematic intimate relationship. Discussion: These findings support the applicability of the HCR-20 V3 in justice-involved women with substance use disorder, while highlighting the clinical relevance of the FAM in supporting a gender-informed risk management.

The role of interpersonal stressors and connectedness in acute suicide risk and the suicide crisis syndrome during the COVID-19 pandemic.

BACKGROUND: The global COVID-19 pandemic rapidly and drastically impacted everyday life and relationships. Fear of contracting and spreading the virus brought governments and individuals to adopt strict social distancing measures. These changes have had a significant negative impact on mental health, including a suggested increase in suicidal behaviors. The present study examined the role of interpersonal stress and connectedness in suicidal ideation, deliberate self-harm, suicide attempts, and the suicide crisis syndrome during the COVID-19 pandemic. METHODS: An international sample of 7837 adult participants was recruited across ten participating countries to complete an anonymous online battery of self-report questionnaires. Questionnaires assessed suicide-related outcomes, stressful life events (SLE), and connectedness. Multilevel regression analyses were used to examine the associations between SLE and connectedness on suicide-related outcomes within the past month. RESULTS: Interpersonal SLEs and low connectedness were associated with an increased likelihood of suicide-related outcomes and increased severity of suicide crisis syndrome. Specifically, higher rates of SLEs and lower levels of connectedness were associated with more suicide-related outcomes. LIMITATIONS: The use of a cross-sectional design and snowball sampling method may restrict the ability to establish causal relationships and limit the representativeness of the findings. CONCLUSIONS: Our findings suggest elevated suicide-related outcomes during the COVID-19 pandemic among individuals experiencing multiple interpersonal stressful life events and low connectedness with others. The circumstances of social life during the COVID-19 pandemic highlight the urgency of implementing preventive programs aimed at mitigating potential suicide risks that may arise in the aftermath of public stress situations.

The curse of experiencing and committing violence as a criminal recidivism predictor: A comparison between female forensic psychiatric patients with severe mental disorders and substance use disorder.

BACKGROUND: Violence occurs frequently in the life of forensic psychiatric patients, both as active aggression and in the form of victimization. Undoubtedly, these incidents shape personality, behavior, and affect the ability to interact adequately socially. Thus, such experiences may influence criminal recidivism and serve as forensic psychiatric/psychological predictors upon hospital discharge. METHODS: Hence, this study aimed at characterizing two distinct female forensic psychiatric patient populations (nonsubstance use mental disorders [n = 110] versus substance use disorder [n = 415]) regarding their active and passive violent experiences as well as contextualizing these with their individual crime recidivism rates. The analysis followed a record-based, retrospective approach. RESULTS: While both groups experienced aggression throughout childhood and youth equally often, substance use disorder patients were significantly more often exposed to violence during adulthood. On the other hand, severely mentally ill patients tended to react more often with violence during their hospital confinement. However, regarding their violent recidivism rate, no intergroup effects were observed. Finally, within the addicted group, a violent index crime as well as physical aggression during hospital confinement increased the odds for violent reoffending by approximately 2.4-fold (95% confidence interval 1.3-4.5) and 2.5-fold (95% confidence interval 1.1-5.9), respectively. CONCLUSION: In summary, these findings underline the importance of active aggression rather than victimization as an influencing factor on resocialization especially in a substance use disorder patient population.

Risk factors for violence among female forensic inpatients with schizophrenia.

Introduction: Schizophrenia is associated with a heightened risk of violent behavior. However, conclusions on the nature of this relationship remain inconclusive. Equally, the empirical evidence on female patients with schizophrenia spectrum disorders (SSD) is strongly underrepresented. Methods: For this purpose, the first aim of the present retrospective follow-up study was to determine the risk factors of violence in a sample of 99 female SSD patients discharged from forensic psychiatric treatment between 2001 and 2017, using three different measures of violence at varying time points (i.e., violent index offense, inpatient violence, and violent recidivism). Potential risk factors were retrieved from the relevant literature on SSD as well as two violence risk assessment instruments (i.e., HCR-20 V3, FAM). Further, we aimed to assess the predictive validity of the HCR-20 V3 in terms of violent recidivism and evaluate the incremental validity of the FAM as a supplementary gender-responsive assessment. Results: The given results indicate strong heterogeneity between the assessed violence groups in terms of risk factors. Particularly, violence during the index offense was related to psychotic symptoms while inpatient violence was associated with affective and behavioral instability as well as violent ideation/intent, psychotic symptoms, and non-responsiveness to treatment. Lastly, violent recidivism was related to non-compliance, cognitive instability, lack of insight, childhood antisocial behavior, and poverty. Further, the application of the HCR-20 V3 resulted in moderate predictive accuracy (AUC = 0.695), while the supplementary assessment of the FAM did not add any incremental validity. Discussion: This article provides important insights into the risk factors of violence among female SSD patients while highlighting the importance of differentiating between various forms of violence. Equally, it substitutes the existing evidence on violence risk assessment in female offenders with SSD.

[Sexuality in Forensic Psychiatry. Results of a Qualitative Study on Professionals' Perspectives and Recommendations for Clinical Practice]. / Sexualität im Maßregelvollzug. Ergebnisse einer qualitativen Befragung von Mitarbeitenden und Handlungsempfehlungen für die klinische Praxis.

OBJECTIVE: Investigation of employees' perspectives on sexuality and sexual health of inpatients in two gender-separated forensic psychiatries in Bavaria. METHODS: 19 semi-structured interviews were analyzed with qualitative content analysis. The results were discussed with employees and a recommendation for action was developed. RESULTS: Employees describe insufficient and non-systematic consideration of sexuality in forensic institutions. Regulations on permitted and non-permitted behavior either do not exist, are unknown or remain on an implicit level for many employees and patients. CONCLUSION: The consideration of sexuality and the sexual needs of patients should be comprehensible and transparent. An attached recommendation for dealing with sexuality can help institutions to give more consideration to sexuality in forensic institutions.

Alcohol use disorder as a risk factor for violent offending and reoffending in delinquent women with substance use disorders.

Female gender is generally less associated with aggressive behavior and violent offending than male gender. Therefore, most studies on violence and (re-)offending include only men. However, it is crucial to better understand pathways to female offending in order to enable efficient psychological interventions and risk assessment in women. Well-established risk factors for aggressive behavior include alcohol use disorder (AUD) and other substance use disorders (SUDs). We retrospectively analyzed the association of AUD and other SUDs with violent offending and reoffending in a sample of female offenders (N = 334) in a forensic treatment facility. In total, 72% of the patients with an AUD had committed a violent crime leading to admission, whereas only 19% of those with other SUDs had. Over 70% of the participants with AUD had a family history of AUD, and over 83% had experienced physical violence in adulthood. Rates of AUD and other SUDs did not differ regarding aggressive behavior during inpatient treatment, while the risk of reoffending with a violent crime after discharge was nine times higher in patients with an AUD than in those with other SUDs. Our results indicate that AUD is a significant risk factor for violent offending and reoffending in women. A familial background of AUD and a history of physical abuse increase the probability for both AUD and offending, suggesting a possible interaction between (epi-)genetic and environmental factors. The comparable rates of aggression during inpatient treatment in patients with AUD and other SUDs indicate that abstinence is a protective factor for violence.

The Predictive Accuracy of the LSI-R in Female Forensic Inpatients-Assessing the Utility of Gender-Responsive Risk Factors.

Female reoffending has long been a neglected research interest. Accordingly, risk assessment instruments were developed based on the criminological knowledge of male recidivism. While feminist researchers have repeatedly criticized the failure to incorporate gender-responsive risk (GR) factors, opinions on the gender neutrality of existing instruments remain inconsistent. In order to substitute the existing literature, while extending the scope to mentally disordered offenders, the aim of the given study was the prediction of general recidivism in a sample of 525 female forensic inpatients who had been discharged from forensic psychiatric care in Germany between 2001 and 2018. Primarily, ROC analysis was conducted to assess the predictive accuracy of the LSI-R. Subsequently, separate binary logistic regression analyses were performed to determine the predictive utility of GR factors on recidivism. Lastly, multiple binary logistic regression was used to assess the incremental validity of the GR factors. The results showed that the GR factors (i.e., intimate relationship dysfunction, mental health issues, parental stress, adult physical abuse, and poverty) significantly contributed to the prediction of recidivism, while a mixed personality disorder, a dissocial personality, an unsupportive partner, and poverty added incremental validity to the predictive accuracy of the LSI-R. However, given that the added variables could only improve classification accuracy by 2.2%, the inclusion of gender-specific factors should be cautiously evaluated.

[Treatment Outcome of Migrants and Non-Migrants in Forensic Psychiatry. A Retrospective Case Control Study Using Bavarian Data From 2010 to 2019]. / Behandlungsoutcome von Maßregelpatient:innen mit Migrationshintergrund. Analyse bayerischer Daten zur Qualitätserfassung von 2010 bis 2019.

Objective Analysis of the relationship between patients' migration status and the outcomes of forensic psychiatry in terms of time from entry to discharge and discharge mode.Methods Based on outcome data of the Bavarian forensic psychiatry, a retrospective case-control analysis between migrants and non-migrants was conducted. Participants were matched on age, sex, main diagnosis and main offence.Results Regarding treatment according to Section 63 of the German Criminal Code (Placement in psychiatric hospital), migrant and non-migrants didn't differ significanlty in the observed variables. Regarding treatment according to Section 64 of the German Criminal Code (Placement in addiction treatment facility), migrants' treatment was terminated prematurely more often and after less time than non-migrant's treatment.Conclusion Treatment according to Section 64 of the German Criminal Code is less successful for migrants.

Gender Differences in the Psychopharmacological Treatment of Forensic In-Patients With Schizophrenia.

Background: In forensic psychiatry, psychopharmacological treatment plays a crucial role for patients with schizophrenia in improving their medical as well as legal prognosis. However, an increase in the number of females entering forensic treatment has yet to yield empirical research on the outcome of psychopharmacological treatment of female patients with schizophrenia in terms of efficacy and tolerability. Aims: The aim of the present study is to elucidate pharmacological treatment strategies of women with schizophrenia in forensic psychiatry in comparison with men. Methods: This study compares psychopharmacological treatment strategies, psychopathological features, as well as neurological and metabolic side effects of treatment between 29 female and 29 male in-patients with schizophrenia in three forensic facilities in Bavaria, Germany. Results: Results show significant differences between genders. Poorer psychopathological and neurological features were found in the female sample, while men registered worse metabolic parameters. In terms of psychopharmacological treatment strategies, female in-patients were more often prescribed second-generation depot antipsychotics. Surprisingly, the potency of the dosages did not differ between genders. The results suggest that female forensic patients with schizophrenia have more severe and refractory diseases than their male counterparts. Conclusion: Recommendations for gender-specific treatment strategies are derived.

Are Women Really Different? Comparison of Men and Women in a Sample of Forensic Psychiatric Inpatients.

Background: Women in detention remain a widely understudied group. Although the number of studies in women in prison has grown in the past decade, research on female forensic psychiatric inpatients has not increased, and women are in the minority in forensic psychiatry not only as patients but also as examinees. Consequently, most treatment manuals and risk assessments were developed in male samples and apply to male offenders. However, the same treatment and risk assessment rationale can be applied in male and female mentally ill offenders only if evidence shows that no relevant sex differences exist. Aims: The aim of the present study was to examine a sample of male and female forensic psychiatric inpatients with substance use disorders and to compare the socio-demographic, legal, and clinical characteristics between the sexes. Methods: The sample included 115 male and 61 female patients. All patients were in mandatory inpatient forensic psychiatry treatment according to section 64 of the German penal code. Results: We found no significant differences between men and women in terms of educational status and vocational training. However, women were more often single and less likely to be employed full time, and they reported adverse childhood experiences more often than men. Regarding clinical variables, women appeared to be less likely to have a substance use disorder due to alcohol use and had more previous psychiatric treatments than men. Male patients were significantly younger on first conviction and detention, had more criminal records and served longer total penalties than female patients. Furthermore, men committed more violent crimes and women, more narcotics-related crimes. Conclusions: The study identified sex-specific differences in forensic psychiatric patients that should be considered in the context of forensic therapy.

Efficacy of outpatient treatment of sex offenders.

The efficacy of sex offender treatment (SOT) is a matter of ongoing discussion and research in forensic psychotherapy. This study evaluates the efficacy of outpatient SOT after discharge from prison. Recidivism rates of participants treated in outpatient departments for sex offenders in Bavaria between 2008 and 2016 (treatment group, TG; n = 353) were compared with those of a matched group of released offenders without treatment (control group, CG; n = 353). The mean follow-up period was 4.5 years. The primary outcome of interest was whether the rates of reoffending differed significantly between the two groups. We compared general and specific rates of reoffending, time to reoffending, and type of reoffending. The groups differed significantly regarding the rates and time of violent reoffending and reoffending overall, but not regarding sexual reoffending respectively the type of sexual reoffending. The results indicate that outpatient SOT is effective in reducing the general but not the specific risk of reoffending.

Gender-Specific Differences in Depressive Behavior Among Forensic Psychiatric Patients.

BACKGROUND: Women are almost twice as likely to develop depression than men, but men commit suicide more often. One explanation for this paradox is that current depression inventories do not fully capture typical male symptoms of depression. Several studies showed that most depression symptoms in men are masked by externalizing behaviors, such as aggressiveness, addiction, and risky behavior. Here, we explored the differences in depression symptoms between men and women in a forensic psychiatric sample. METHODS: We screened 182 forensic psychiatric patients and selected a matched sample (21 women and 21 men). External symptoms of depression were assessed with the Gender-Sensitive Depression Screening (GSDS) and internal symptoms with the Beck Depression Inventory Revision. RESULTS: Although externalizing behaviors were similar in both groups, we found a significant relationship between external and internal depression symptoms only in men. In addition, male forensic patients with a history of suicide had higher scores in the GSDS, whereas female patients with a history of suicide had higher scores in the Beck Depression Inventory Revision. DISCUSSION: The finding that the GSDS detected depression symptoms in men indicates that this instrument might be useful for developing assessments to prevent suicide in forensic practice.

Childhood Trauma, the Combination of MAO-A and COMT Genetic Polymorphisms and the Joy of Being Aggressive in Forensic Psychiatric Patients.

Aggression and violent offenses are common amongst forensic psychiatric patients. Notably, research distinguishes two motivationally distinct dimension of aggression-instrumental and reactive aggression. Instrumental aggression comprises of appetitive, goal-directed aggressive acts, whereas reactive aggression consists of affective, defensive violence with both their biological basis remaining largely unknown. Childhood trauma and functional genetic polymorphisms in catecholamines converting enzymes, such as mono-amino-oxidase A (MAO-A) and catechol-o-methyltransferase (COMT) have been suggested to augment an aggressive behavioral response in adulthood. However, it warrants clarification if these factors influence one or both types of aggression. Furthermore, it remains elusive, if having a combination of unfavorable enzyme genotypes and childhood maltreatment further increases violent behavior. Hence, we set out to address these questions in the current study. First, analysis revealed an overall marginally increased frequency of the unfavorable MAO-A genotype in the test population. Second, each gene polymorphisms together with a traumatic childhood significantly increased the AFAS (Appetitive and Facilitative Aggression Scale) scores for both reactive and appetitive aggression. Third, having a combination of both disadvantageous genotypes and a negative childhood served as a minor positive predictor for increased reactive aggression, but had a strong influence on the joy of being aggressive.

Migrants With Schizophrenia in Forensic Psychiatric Hospitals Benefit From High-Intensity Second Language Programs.

Background: As a result of migration, an increasing number of patients in forensic psychiatric hospitals show poor skills in the national language, which can affect their treatment. Improving the second language (L2) of inpatients with schizophrenia may help to enable effective psychotherapy and thus reduce the risk of criminal recidivism and facilitate reintegration into society, for example because of a language-related higher degree of social functioning. For this purpose, a Hessian forensic psychiatric hospital established a ward specialized in L2 acquisition. The ward accommodates up to 21 patients with schizophrenia, who attend an L2 program consisting of 800-900 lessons within 1 year. Aims: The study aimed to evaluate whether patients on the specialized ward (experimental group) achieve at least Common European Framework of Reference (CEFR) level A2 in the L2 program. Additionally, it examined whether language acquisition is better among participants in the experimental group than among those on regular wards (control group). Methods: Achievements in the L2 were assessed by an L2 test 3 times: at the beginning of the program, after 6 months, and after 1 year. The impact of intelligence on achievements in L2 was evaluated using Raven's Standard Progressive Matrices. Results: The experimental group showed significantly better improvement than the control group. Literacy was a significant predictor of improvement in the L2. The majority of the experimental group reached at least CEFR level A2 after 1 year. Conclusions: High-intensity L2 programs are an effective way to improve the L2 of inpatients with schizophrenia in forensic psychiatric hospitals.

Immigrant Patients Adapt to the Culture of Admission and Experience Less Safety in Forensic Psychiatric Care.

Patients with an immigrant background are overrepresented in forensic psychiatric hospitals. As a result, daily work is impeded by language barriers and cultural differences. Furthermore, general therapy processes have not yet been adapted to this special patient population, and little reliable knowledge is available. All immigrants go through an acculturation process, which is related to their mental well-being. Four acculturation strategies exist: integration, separation, assimilation, and marginalization. The strategy chosen depends on the extent of someone's orientation toward their country of origin and the country of admission. The current study aimed to expand knowledge of forensic patients with a migration background in Germany by evaluating their self-reported acculturation processes and associated individual and social factors, e.g., the ward climate. Therefore, we studied forensic patients with a migration background from 11 forensic hospitals in Bavaria, Germany. Besides completing the Frankfurter Acculturation Scale (FRACC) and Essen Climate Evaluation Schema (EssenCES), the participants provided information on their clinical and biographical history. We recruited 235 patients with a migration background and found that the participants oriented themselves more toward the culture of admission and less toward the country of origin than the reference sample did. Moreover, the patients experienced significantly less safety on the ward than the forensic reference sample did. A possible explanation for the patients' orientation is the lack of possibilities to adhere to their cultural traditions. Patients may feel less safe because of their limited knowledge of German and cultural misunderstandings.