The influence of admission characteristics on outcome: evidence from a medium secure forensic cohort.

OBJECTIVE: Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related. METHOD: Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan-Meier analysis and Cox regression. RESULTS: Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%-4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients. CONCLUSION: This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted. SIGNIFICANT OUTCOMES: This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted. LIMITATIONS: Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together.

Patients with a history of arson admitted to medium security: characteristics on admission and follow-up postdischarge.

Patients who set fires are a perennial cause of concern with psychiatric services although perhaps rather neglected in the clinical research literature. The current study considered the characteristics on admission of 129 patients, 93 men and 36 women, with a known history of arson who had been admitted to a medium secure psychiatric hospital. The distinguishing characteristics of the sample were high numbers of patients with extensive criminal histories, most probably due to high levels of prison transfer and a higher occurrence of mental illness than psychopathic disorder. Aside from return to prison, most patients were discharged either to another psychiatric hospital or directly to the community. There was a high rate of re-conviction after discharge, mainly for minor offences, with about one in 10 of discharged patients committing arson. It was established, however, that not all incidents of arson led to a prosecution. It is concluded that there are weaknesses in the areas of both risk assessment and evidence-based treatment for arsonists.

Long-term suicide risk in forensic psychiatric patients.

The objectives of this study was to describe the rate of suicide and other causes of death in first admissions to a (medium) secure forensic psychiatric facility. All 595 patients were followed up for a maximum of 20 years. Death certificates were obtained and Standardized Mortality Ratios (SMRs) were calculated. At the June 2003 census, 57 patients (9.6%) had died of whom 18 (3.0%) had committed suicide; if deaths categorized as open verdicts are included the number rises to 26 (4.4%). The SMR for death by suicide was higher for a Mental Health Act classification of Mental Illness (SMR = 3,553) compared to Psychopathic Disorder (SMR = 1,892). The risks of mortality in this population are high from any cause, particularly from suicide.

Life-threatening hyponatraemia and intramuscular olanzapine: the world's longest therapeutic trial.

This case report provides a different perspective on the management of a patient with a psychotic illness. The detained patient, a man aged 50, had specific delusional beliefs about toxins affecting his kidneys, such that he needed to drink water to 'detoxify' himself. This resulted in him developing life-threatening hyponatraemia. It became clear that he was very resistant to taking oral medication and was reluctant to engage with any psychological treatment. A novel approach was considered, involving the 'off licence' use of short acting intramuscular olanzapine for the successful treatment of the psychotic illness. The case demonstrates the safe use of intramuscular olanzapine for 155 days, which is the longest reported case for the use of intramuscular olanzapine for the treatment of a psychotic illness. The individual was later discharged on oral olanzapine.

The EssenCES measure of social climate: a preliminary validation and normative data in UK high secure hospital settings.

BACKGROUND: The social climate of forensic units is important but little investigated, in part because of the unavailability of a clinically practical and statistically sound measure. AIMS: To provide preliminary psychometric and normative data for the English version of the Essen Climate Evaluation Schema (EssenCES) in UK high-security hospital settings. METHOD: A total of 324 staff and patients from three high-security hospital services completed the EssenCES, and a subgroup completed a range of other questionnaires related to therapeutic milieu and working environment (GMI, WAAM, WES-10). RESULTS: The original three-factor structure and satisfactory internal consistency were retained. The pattern of correlations between the EssenCES scales and other climate-related variables support the construct validity of the EssenCES measure, with the exception of the Patient Cohesion subscale. CONCLUSIONS: Although preliminary, these data suggest that the English version of EssenCES may be a valid tool for assessing the social climate of high secure hospital settings in the UK, but a larger research study is required, covering a wider range of psychiatric disorders, types of service and levels of security.

Long-term outcomes after discharge from medium secure care: a cause for concern.

BACKGROUND: There are few long-term follow-up studies of patients discharged from medium secure units in the UK, even though these units were introduced over 20 years ago. AIMS: To describe mortality, rates of reconviction at different time periods; violent behaviour (not leading to conviction), readmission and employment, after discharge from a medium secure unit. METHOD: Of 595 first admissions over a 20-year period, 550 discharged cases were followed-up. Multiple data sources were used. RESULTS: Fifty-seven (10%) patients had died, of whom 18 (32%) died by suicide, and the risk of death was six times greater than in the general population. Almost half (49%) of those discharged were reconvicted and almost two-fifths (38%) of patients were readmitted to secure care. CONCLUSIONS: Community psychiatric services need to be aware that those discharged from medium secure care are a highly vulnerable group requiring careful follow-up if excess mortality, high levels of psychiatric morbidity and further offending are to be prevented.

Meeting patients' needs in secure forensic psychiatric units.

The authors have developed a security needs assessment profile designed to match the service provided in secure, forensic psychiatric units more accurately with the needs of individual patients. They are carrying out an 18-month survey of all secure units in England and are seeking participants to help refine the profile, gain more understanding of what is provided throughout the country, and assess the views of other clinicians and managers.

Therapeutic community treatment of personality disorder: service use and mortality over 3 years' follow-up.

BACKGROUND: A number of studies have demonstrated reductions in the utilisation of psychiatric services, especially acute in-patient admissions, following therapeutic community treatment of personality disorder. These studies have, however, been of limited duration (1 year) and follow-up has not always been complete. AIMS: To identify hospital admissions before and after therapeutic community treatment of personality disorder. METHOD: A naturalistic clinical cohort of patients admitted between January 1993 and December 1995 was followed up for 3 years. All subjects were traced to their current consultant psychiatrist, general practitioner or death. RESULTS: All patients were traced at 3-year follow-up. The significant reduction in in-patient admissions seen in the first year was maintained over 3 years. Those with the poorest outcomes, suicide, accidental death or prolonged admission were all in the quartile with the shortest admissions (under 42 days) to the therapeutic community. CONCLUSIONS: Previously reported reductions in psychiatric admissions following therapeutic community treatment of personality disorder are maintained over 3 years.