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1.
Artículo en Inglés | MEDLINE | ID: mdl-39054039

RESUMEN

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

2.
J Forensic Sci ; 2024 Jul 22.
Artículo en Inglés | MEDLINE | ID: mdl-39039689

RESUMEN

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by marked differences in communication patterns, reciprocal social interactions, and restricted, stereotyped, and repetitive interests and activities. Various behavioral problems in ASD, more so when accompanied by coexisting psychopathology, can sometimes lead to legal problems. In this study, the cases in which an opinion was requested in terms of criminal responsibility with the diagnosis of ASD in the 5-year period between 2018 and 2022 in the expertise department of psychiatric observation, where psychiatric cases were hospitalized and observed in the Council of Forensic Medicine (CFM), which is the official expert institution in Türkiye, were retrospectively evaluated. The mean age of the group whose criminal responsibility was reduced or removed was 22.9 years (±7.52) and the mean IQ score was 76.63 ± 18.94. The most common crime in this group was intentional injury (5/11), and it is noteworthy that the victims of these crimes were usually relatives of people with ASD (5/6). The criminal acts of people with ASD are usually single-movement, spontaneous, unplanned, impulsive acts. In addition, although there is no problem in cognitive perception in people with high functioning ASD (HF-ASD), various forensic situations may arise due to defects in emotional awareness. When we look at the practices of the CFM in Türkiye, it is seen that in cases where the diagnosis of ASD is clear and can be associated with the crime, criminal responsibility is usually completely eliminated. In HF-ASD types, although it is important to be associated with the crime, it is seen that criminal responsibility is generally reduced.

3.
Front Psychiatry ; 15: 1437363, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-39015885

RESUMEN

Frontotemporal dementia (FTD) affects the frontal and temporal lobes of the brain, leading to personality changes, language impairments, and behavioral disturbances, including impulsivity and disinhibition. Assessing responsibility and recidivism risk in forensic evaluations is challenging due to the evolving nature of FTD. Despite limited literature, we present a case of a 45-year-old man with no prior legal or medical history, who committed criminal acts due to behavioral changes linked to the behavioral variant of frontotemporal dementia (bvFTD). Initial assessment found him irresponsible, with a non-evaluable risk of recidivism. Subsequent evaluation showed a low recidivism risk based on clinical evolution. We discuss these findings considering existing literature and Swiss jurisprudence.

4.
Psychiatry Res ; 339: 116079, 2024 Jul 09.
Artículo en Inglés | MEDLINE | ID: mdl-39024890

RESUMEN

Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.

5.
Front Psychiatry ; 15: 1330993, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38947186

RESUMEN

Introduction: Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback. Method: In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events. Results: Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members. Discussion: None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

7.
Arch Psychiatr Nurs ; 51: 120-126, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-39034067

RESUMEN

AIM: Concerns about the applicability of recovery orientation to forensic care have surfaced due to the traditionally restrictive practices associated with forensic institutions. We interviewed 19 experts-by-experience and 18 professionals working with them across five Finnish forensic hospitals and one out-patient clinic to describe how they define recovery in forensic. METHODS: We utilized semi-structured, one-on-one interviews and then analyzed the collected data using structural narrative analysis. Our points of interest were the plots of the recovery stories and the ways in which various factors affected recovery. We also investigated whether staff and experts-by-experience had different perceptions of recovery in forensic psychiatry, and whether recovery-oriented practices were present in these accounts. RESULTS: A wider mutual narrative with a chronological plot was identified, and recovery-oriented practices and goals were found with a special emphasis on offending. Insight into mental illness, motivation for self-care, trust in therapeutic relationships, and gaining possibilities to proceed in care were found to promote recovery, whereas insufficient understanding of the illness, a closed environment, lack of trust, and substance abuse hindered the recovery process. Both the professionals and experts felt that the most prominent goal of recovery is integration into society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The views of the interviewed experts-by-experience and professionals regarding recovery were rather univocal. Forensic psychiatric services in Finland were found to demonstrate recovery-oriented features, which can be promoted further by involving experts-by-experience in different assignments. The results also highlight that the families of patients should become more active partners in care. IMPACT AND IMPLICATIONS STATEMENT: Recovery in forensic psychiatric hospitals can be perceived as a process towards a new role in society. To reach this goal the forensic patients need support from staff, peers, and family. We found numerous factors which enable and hinder the recovery process, and which should be considered during forensic care.


Asunto(s)
Psiquiatría Forense , Hospitales Psiquiátricos , Trastornos Mentales , Humanos , Finlandia , Trastornos Mentales/psicología , Trastornos Mentales/rehabilitación , Trastornos Mentales/terapia , Femenino , Masculino , Entrevistas como Asunto , Narración , Adulto , Investigación Cualitativa , Persona de Mediana Edad , Actitud del Personal de Salud
8.
Psychiatr Serv ; 75(7): 710-712, 2024 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-38835251

RESUMEN

Mental disorders and suicide are important causes of increased morbidity and mortality rates during pregnancy. Since the U.S. Supreme Court's 2022 Dobbs decision, many state legislatures have passed stringent abortion bans and restrictions. These laws define exceptions under which abortion may be legally obtained. Suicidality and other psychiatric symptoms have been excluded from such definitions. In this column, the authors examine how legislatures, courts, and professional regulatory bodies in several abortion-restricting states have defined their medical emergency exceptions. The authors argue that psychiatrists should be concerned about the management of psychiatric emergencies during pregnancy as well as emerging legal intrusions into physician-patient decision making.


Asunto(s)
Aborto Legal , Humanos , Estados Unidos , Femenino , Embarazo , Aborto Legal/legislación & jurisprudencia , Aborto Inducido/legislación & jurisprudencia , Decisiones de la Corte Suprema , Trastornos Mentales/terapia
10.
Crim Behav Ment Health ; 34(4): 347-359, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38824652

RESUMEN

BACKGROUND: Psychosocial rehabilitation in forensic psychiatric services requires sound measurement of patient and staff perceptions of psychosocial function. The recommended World Health Organisation Disability Assessment Schedule 2.0 (WHODAS), designed for this, has not been examined with offender patients. AIMS: To examine patient and staff WHODAS ratings of secure hospital inpatients with psychosis, any differences between them and explore associations with other clinical factors. METHODS: Seventy-three patients self-rated on the WHODAS after 3 months as inpatients. An occupational therapist interviewed the patient's primary nurse and care team at about the same time (staff ratings). Scores were calculated according to the WHODAS manual. WHODAS scores and interview-rated symptom severity, cognitive measures, daily antipsychotic dose and duration of care were compared. RESULTS: Patient ratings indicated less disability than staff ratings for total score and for the domains of understanding and communicating, getting along and life activities. Self-care and participation ratings were similar. Patients were more likely to rate themselves as disabled in getting around (mobility). Only one-fifth of patient- and staff- ratings (16, 22%) were similar, while for nearly a third of the patients (23, 32%) self-ratings were higher than staff ratings. More severe positive symptoms were associated with higher self-rated WHODAS disability after accounting for treatment duration, negative symptoms, cognitive score and antipsychotic dose. No variable accounted for the staff/patient differences in ratings. CONCLUSION: Our mean WHODAS score findings echoed those in other patient samples-of patient underestimation of disability, linked to severity of symptoms. In this study using the WHODAS for the first time in a forensic mental health secure inpatient service, however, we found that, by comparing individuals, half of the patients reported equivalent or greater disability than did staff. Future research should focus on elucidating from patients what contributes to their self-ratings. Understanding their thought processes in rating may enhance rehabilitation planning.


Asunto(s)
Evaluación de la Discapacidad , Psiquiatría Forense , Pacientes Internos , Trastornos Psicóticos , Organización Mundial de la Salud , Humanos , Masculino , Femenino , Adulto , Pacientes Internos/psicología , Persona de Mediana Edad , Personas con Discapacidad/psicología , Criminales/psicología
11.
Front Psychiatry ; 15: 1394535, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38832326

RESUMEN

Transgressive incidents directed at staff by forensic patients occur frequently, leading to detrimental psychological and physical harm, underscoring urgency of preventive measures. These incidents, emerging within therapeutic relationships, involve complex interactions between patient and staff behavior. This study aims to identify clusters of transgressive incidents based on incident characteristics such as impact, severity, (presumed) cause, type of aggression, and consequences, using latent class analysis (LCA). Additionally, variations in incident clusters based on staff, patient, and context characteristics were investigated. A total of 1,184 transgressive incidents, reported by staff and targeted at staff by patients between 2018-2022, were extracted from a digital incident reporting system at Fivoor, a Dutch forensic psychiatric healthcare organisation. Latent Class Analysis revealed six incident classes: 1) verbal aggression with low impact; 2) verbal aggression with medium impact; 3) physical aggression with medium impact; 4) verbal menacing/aggression with medium impact; 5) physical aggression with high impact; and 6) verbal and physical menacing/aggression with high impact. Significant differences in age and gender of both staff and patients, staff function, and patient diagnoses were observed among these classes. Incidents with higher impact were more prevalent in high security clinics, while lower-impact incidents were more common in clinics for patients with intellectual disabilities. Despite limitations like missing information, tailored prevention approaches are needed due to varying types of transgressive incidents across patients, staff, and units.

12.
J Am Acad Psychiatry Law ; 52(2): 161-164, 2024 Jun 04.
Artículo en Inglés | MEDLINE | ID: mdl-38834360

RESUMEN

Empirical research is foundational to the discipline of forensic psychiatry. Candilis and Parker provide a cogent systematic review of the empirical literature on restoration of competence to stand trial using National Institutes of Health quality metrics. Components of the study methodology are highlighted, as they represent current best practices for conducting a systematic review. A discussion of strategies to increase empirical research uptake in forensic psychiatry is pursued alongside concrete examples of how the American Academy of Psychiatry and the Law Research Committee can help facilitate this goal.


Asunto(s)
Psiquiatría Forense , Humanos , Competencia Mental/legislación & jurisprudencia , Investigación Empírica , Estados Unidos
13.
J Forensic Sci ; 2024 Jun 14.
Artículo en Inglés | MEDLINE | ID: mdl-38876483

RESUMEN

Pathological dissociation is relatively common in the United States and may be associated with violent or criminal behavior. Dissociative Disorders, especially Dissociative Identity Disorder, are considered controversial diagnoses by some in the psychiatric and legal professions. Individuals who offend during dissociative states may not be criminally responsible if they meet the legal standard for insanity, however, insanity pleas based on dissociative symptoms are rare. This review examined Federal appellate case law for potential legal barriers to the insanity defense for dissociative conditions and any restrictions imposed on related expert evidence. Few rulings directly addressed these questions but there do not appear to be any unique barriers for dissociation-related insanity pleas. Some cases provided valuable insights regarding the admission of expert evidence, effective expert testimony, and the role of defense counsel.

14.
Child Adolesc Psychiatr Clin N Am ; 33(3): 397-409, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38823812

RESUMEN

Child and adolescent psychiatrists (CAPs) play a crucial role beyond the provision of clinical care. CAPs are uniquely placed to understand and help patients navigate the fine line among psychiatric care, health and well-being, and the laws and policies supporting or impairing these processes. Focusing on vulnerable populations, such as legal system impacted youth and families, CAPs can contribute to the ongoing development of a more just and equitable world for the children of today and of tomorrow.


Asunto(s)
Psiquiatría del Adolescente , Psiquiatría Infantil , Rol del Médico , Humanos , Adolescente , Psiquiatría del Adolescente/legislación & jurisprudencia , Psiquiatría Infantil/legislación & jurisprudencia , Niño , Psiquiatras
15.
Front Psychiatry ; 15: 1404263, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38919633

RESUMEN

Introduction: There is evidence that there is a small group of people with schizophrenia spectrum disorders who are more likely to commit homicide than those in the general population. However, there is limited knowledge about the psychopathology that leads to homicide in this group. The aim of this study was to examine two commonly used definitions of the Threat/Control-Override (TCO) concept, which aims to identify a certain risk of serious violence in patients with schizophrenia spectrum disorders. Methods: This is a sub analysis of a file-based, retrospective and exploratory cross-sectional study. All forensic homicide offenders with schizophrenia spectrum disorders who were detained at the Forensic Hospital Berlin as of 31 December 2014 were examined for the occurrence of TCO according to two commonly used definitions. Results: Of a total of 419 forensic patients with schizophrenia spectrum disorders, 78 committed homicide (18.6%). The forensic homicide offenders with schizophrenia spectrum disorders were characterised by being male, unemployed, single and having committed (attempted) manslaughter. Irrespective of the definition used, the entire TCO complex was present in less than a third of the sample. In both definitions, Threat symptoms were slightly less frequent than Control-Override symptoms. While Threat symptoms occurred less frequently in Stompe et al.'s definition, Control-Override symptoms were the most common. With regard to Kröber's definition of Threat and Control-Override, the situation is exactly the opposite. Discussion: Regarding the entire TCO complex, Kröber's definition seems a little more open and Stompe et al.'s more strict (38.5% vs. 35.9%). Since TCO only occurs in about one third of the subjects in both definitions, neither definition appears to be conclusive. A combination with proportions from both definitions could be a contribution to a future definition of TCO. The present study provides scarcely published primary data on psychopathology in homicide offenders with schizophrenia spectrum disorders, especially on the much discussed TCO concept in two definitions. In order to determine the most useful definition of TCO, to avoid false positives and to identify clear psychopathological risk symptoms, larger samples and comparative studies with offenders and non-offenders should be conducted in the future.

16.
Artículo en Inglés | MEDLINE | ID: mdl-38922757

RESUMEN

WHAT IS KNOWN ON THE SUBJECT?: Clinical guidelines and staff training recommend using de-escalation over restrictive practices, such as restraint and seclusion Evidence suggests that restrictive practices continue to be used frequently despite training This suggests a lack of impact of existing staff de-escalation training. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: The features of de-escalation training that are acceptable to staff and perceived to be impactful A co-designed and co-delivered training session on a trauma-informed approach to de-escalation on mental health wards was acceptable and perceived to be impactful Those attending training particularly valued how lived experience was incorporated into the training content and co-delivery The organizational and team context may need more consideration in adapting the training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: De-escalation training that adopts a trauma-informed approach and considers the context of ward environments is acceptable to staff Co-delivery models of training to tackle restrictive practice can be acceptable and impactful Further research will show how clinically effective this training is in improving outcomes for service users in ward contexts. ABSTRACT: BACKGROUND: Evidence suggests a discrepancy between recommended and routine practice in de-escalation in mental health settings, suggesting a lack of impact of existing training. AIM: To investigate the acceptability and perceived impact of a co-designed/delivered training intervention on a trauma-informed approach to de-escalation on mental health wards. METHODS: Trainees were invited to complete the Training Acceptability Rating Scale (TARS) post-training. Responses to the quantitative items were summarized using descriptive statistics, and open-text responses were coded using content analysis. RESULTS: Of 214 trainees, 211 completed the TARS. The trainees rated the training favourably (median overall TARS = 55/63), as acceptable (median 33/36) and impactful (median 23/27). There were five qualitative themes: modules of interest; multiple perspectives; modes of delivery; moulding to context; and modifying other elements. DISCUSSION: The EDITION training was found to be acceptable and impactful, with trainees particularly valuing the co-delivery model. Trainees suggested several ways in which the training could be improved, particularly around the need for further moulding of the intervention to the specific ward contexts/teams. IMPLICATIONS FOR PRACTICE: We recommend co-designing and co-delivering staff training to mental health professionals that tackles restrictive practices. RELEVANCE STATEMENT: This research is relevant to lived experience practitioners who want to be involved in training mental health professionals around restrictive practices, demonstrating the value and importance of their voice. It is relevant to current providers of de-escalation training, and to staff receiving training, outlining a novel, but acceptable and impactful, form of training on a key area of mental health practice. It is relevant to anyone with an interest in reducing restrictive practice via co-delivered training.

17.
Front Psychiatry ; 15: 1400604, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38938459

RESUMEN

There is a growing body of international research investigating the impact of patient suicide on mental health professionals. The experience of losing a patient to suicide can have a significant and, in some cases, long-lasting (negative) impact on mental health professionals. However, the nature and extent of the impact on prison staff or forensic mental health professionals in particular is less clear. This narrative review summarises both quantitative and qualitative studies and key findings in this area, focusing on the above professions. A literature search was conducted using PsychInfo and Google Scholar, covering the period from 2000 onwards. The vast majority of findings relate to mental health professionals in general. We were unable to identify any published reports on the responses of forensic psychiatric staff. The majority of identified studies in the prison context are qualitative. Studies from German-speaking countries are particularly scarce in both the prison and mental health contexts. We conclude that there is a profound lack of knowledge about the impact of client/patient suicide on the subgroups of (German) prison and forensic psychiatric staff. Clearly, more research is needed on both the nature and extent of the impact, as well as on the specific organisational and supportive factors that help to mitigate the negative effects of suicide.

19.
J Am Acad Psychiatry Law ; 52(2): 149-152, 2024 Jun 04.
Artículo en Inglés | MEDLINE | ID: mdl-38834366

RESUMEN

There is a clear need for experts with the requisite knowledge and experience to offer medicolegal opinions pertaining to various neuropsychiatric conditions. There is also an important distinction between clinical and medicolegal roles, and the need for training and expertise applicable to forensic assessment. But there remain few available experts with credentials spanning neuropsychiatry and forensic assessment. This creates a dilemma whereby parties involved in litigation featuring neuropsychiatric illness or injury are frequently forced to choose between experts with either knowledge and skills applicable to neuropsychiatric conditions or experts with skills and experience applicable to forensic assessment. Either choice introduces risk. Whether flawed medicolegal opinions are a consequence of deficient medical knowledge or an inadequate forensic evaluation process, the result remains the same, with triers of fact potentially being exposed to problematic testimony. There is, however, a more fundamental problem that implicates patient care more broadly: spurious dichotomies created by the historical segregation of psychiatry and neurology. Optimizing clinical care for patients with neuropsychiatric conditions, improving medical education in support of such care, and enabling forensic neuropsychiatric assessment must then start with more proactive efforts to reintegrate psychiatry and neurology.


Asunto(s)
Testimonio de Experto , Neurólogos , Humanos , Neurólogos/legislación & jurisprudencia , Testimonio de Experto/legislación & jurisprudencia , Psiquiatría Forense , Neurología , Rol del Médico , Medicina Legal , Trastornos Mentales/diagnóstico
20.
Front Psychiatry ; 15: 1403618, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38903643

RESUMEN

Background: Attention-deficit/hyperactivity disorder (ADHD) is prevalent amongst offenders, increasing risks for aggressive and delinquent behaviors. Since ADHD and its symptoms can persist into adulthood, accurately diagnosing and maintaining diagnoses in offenders is crucial to ensure appropriate treatment and reduce recidivism. Methods: This study employed a retrospective longitudinal design to investigate ADHD amongst adult offenders with a confirmed diagnosis of ADHD during childhood or adolescence at a Swiss forensic outpatient clinic between 2008 and 2021. N = 181 patient files were reviewed, including forensic expert witness assessments and treatment reports. We charted the adulthood trajectory of patients with a confirmed childhood/adolescence ADHD diagnosis, examining the course of their diagnoses. Results: Of 181 patients, evidence indicated that 12 (7%) had an ADHD diagnosis in childhood/adolescence. In 1 (8%) of these 12 cases, the diagnosis was maintained throughout the observation period. For 4 patients (33%), a diagnosis was given in the first forensic psychiatric expert witness assessment in adulthood but subsequently dropped. In another 4 cases (33%), the diagnosis was dropped in adulthood but later re-assigned, whereas in 3 cases (25%), the diagnosis was discontinued throughout the observation period. In 50% of cases with a diagnostic change, the discontinuation of an adult ADHD diagnosis coincided with a newly diagnosed personality disorder (or vice versa). Conclusions: Our findings highlighted considerable inconsistencies in the assignment of adult ADHD diagnoses amongst offenders. Whilst ADHD remission in adulthood occurs, the diagnostic variability in our results warrants detailed scrutiny. One possibility is that ADHD has similar fluctuations to conditions like depression, as argued elsewhere. Equally, diagnoses may become "lost", meaning they are not given even when applicable and replaced by other diagnoses. Additionally, residual symptoms may remain but beyond the diagnostic threshold. This is significant because untreated ADHD can increase re-offending risks and adverse health outcomes.

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