Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital.

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Quality improvement in forensic mental health: the East London forensic violence reduction collaborative.

Ward-based violence is the most significant cause of reported safety incidents at East London NHS Foundation Trust (ELFT). It impacts on patient and staff safety, well-being, clinical care and the broader hospital community in various direct and indirect ways. The contributing factors are varied and complex. Several factors differentiate the forensic setting, which has been identified as a particularly stressful work environment. Staff must constantly balance addressing therapeutic needs with robust risk management in a complex patient cohort. ELFT identified reducing inpatient physical violence on mental health wards as a major quality improvement (QI) priority. The aim was to use a QI methodology to reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and March 2018. Collaborative learning was central to this project. It sought to foster a culture of openness within the organisation around violence and to support service users and staff to work together to understand and address it. A QI methodology was applied in medium and low secure inpatient settings. A change bundle was tested for effectiveness, which included: safety huddles, safety crosses and weekly community safety discussions. Operational definitions for non-physical violence, physical violence and sexual harassment were developed and used. Reductions of 8% and 16.6% in rates of physical and non-physical violent incidents, respectively, were achieved and sustained. Compared with baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards. Three wards achieved at least a 30% reduction in incidents of physical violence per week. Five wards achieved at least a 30% reduction in incidents of non-physical violence per week. This collaborative brought significant improvements and a cultural shift towards openness around inpatient violence.

Rising inpatient numbers in forensic security hospitals of German federal state of Baden-Württemberg: Background and explanatory approaches.

In this article, we describe critical epidemiological trends in forensic psychiatric care in the German federal state of Baden-Württemberg. For some years, there has been a marked increase in the number of patients with psychoses and with a migration background in the high-security hospitals of Baden-Württemberg. We present a number of studies exploring hypotheses as to why this is the case. Taking into account a set of person-related and non-person (forensic system)-related variables, we suggest that rising treatment figures may be understood in terms of system variables rather than individual patient characteristics. Findings regarding predictors of treatment length and legal outcome, as well as characteristics of migrant patients and patients assigned to forensic aftercare, are discussed.

[The contribution of forensic neuroscience to psychopathy]. / La psychopathie ­ L'éclairage des neurosciences médicolégales.

Psychopathy is a construct characterized by symptoms of emotional detachment, a lack of empathy, guilt and remorse, irresponsibility and a propensity for impulsive behavior. This article critically evaluates the contribution of structural and functional neuroimaging to the understanding of this personality disorder in North American forensic populations with psychopathic traits. Neuroimaging results are highly variable. They report numerous structural and functional abnormalities that are not limited to the amygdala and the ventromedial prefrontal cortex but include the striatum, hippocampus, and uncinate fasciculus. These brain abnormalities underlie an attenuated emotion processing functioning (but not an absence) and aversion to negative and threats signals, reinforcement learning, representation of rewards and modulation of attention that have an impact in decision-making, caring for others, and moral judgment. It is important to note that the neuroanatomical, neurofunctional, and behavioral differences between individuals with high psychopathic traits and those with low traits are highly heterogeneous and of degree rather than of nature.

Jail diversion: the Miami model.

The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP), located in Miami-Dade County, FL, was established in 2000 to divert individuals with serious mental illnesses (SMI; eg, schizophrenia, bipolar disorder, and major depression) or co-occurring SMI and substance use disorders away from the criminal justice system and into comprehensive community-based treatment and support services. The program operates two primary components: prebooking jail diversion consisting of Crisis Intervention Team (CIT) training for law enforcement officers and postbooking jail diversion serving individuals booked into the county jail and awaiting adjudication. In addition, the CMHP offers a variety of overlay services intended to: streamline screening and identification of program participants; develop evidence-based community reentry plans to ensure appropriate linkages to community-based treatment and support services; improve outcomes among individuals with histories of noncompliance with treatment; and expedite access to federal and state entitlement benefits. The CMHP provides an effective, cost-efficient solution to a community problem and works by eliminating gaps in services, and by forging productive and innovative relationships among all stakeholders who have an interest in the welfare and safety of one of our community's most vulnerable populations.

Community forensic psychiatric services in England and Wales.

Forensic psychiatry is an established medical specialty in England and Wales. Although its origins lie in the 19th century, the development of secure hospitals accelerated in the late 20th century. Services for mentally disordered offenders in the community have developed most recently and it is these services, which are the focus of this article. We have looked broadly at community services and have included criminal justice liaison and diversion services in our remit. We have also considered partnerships between health and justice agencies as well as mental health and criminal legislation. We consider the limited research evidence in relation to community forensic services and the discussion this has provoked.

Examining the Past and Advocating for the Future of Forensic Psychiatry Training.

The American Academy of Psychiatry and the Law (AAPL) has been devoted to the teaching of forensic psychiatry, and as AAPL celebrates its 50th Anniversary, it seems fitting to examine the history and the current status of forensic psychiatry teaching in general psychiatry residencies and forensic psychiatry fellowships. After a brief review of the history of AAPL and forensic psychiatry training, this article explores the current state of graduate medical education (GME) in the United States, the growing popularity of psychiatry as a specialty and forensic psychiatry as a subspecialty, the Accreditation Council for Graduate Medical Education's requirements for forensic training, and the methods currently used to teach forensic psychiatry to general psychiatry residents. This article also examines the current status of forensic psychiatry fellowship training in the United States. Finally, future challenges to forensic training in both residencies and fellowships will be discussed, as well as the need for AAPL and others in the profession to advocate for increased forensic teaching in a manner that leads to the production of both general and forensic psychiatrists who are competent to practice independently and who are sufficient in number to meet the growing demands for forensic expertise.

Forensic patients in state psychiatric hospitals: 1999-2016.

INTRODUCTION: In recent years mental health officials have reported a rise in the number of forensic patients present within their state psychiatric hospitals and the adverse impacts that these trends had on their hospitals. To date there have been no large-scale national studies conducted to determine if these trends are specific only to a few states or representative of a more global trend. The purpose of this study was to investigate these reported trends and their national prevalence. METHODS: The forensic directors of each state behavioral health agency (including the District of Columbia) were sent an Excel spreadsheet that had two components: a questionnaire and data tables with information collected between 1996 and 2014 from the State Profiling System maintained by the National Association of State Mental Health Program Directors Research Institute. They were asked to verify and update these data and respond to the questionnaire. RESULTS: Responses showed a 76% increase nationally in the number of forensic patients in state psychiatric hospitals between 1999 and 2014. The largest increase was for individuals who were court-committed after being found incompetent to stand trial and in need of inpatient restoration services. DISCUSSION: The data reviewed here indicate that increases in forensic referrals to state psychiatric hospitals, while not uniform across all states, are nonetheless substantial. CONCLUSION: More research is needed to determine whether this multi-state trend is merely a coincidence of differing local factors occurring in many states, or a product of larger systemic factors affecting mental health agencies and the courts.

Associations of multiple trauma types and MAOA with severe aggressive behavior and MAOA effects on training outcome.

Previous research showed that the disposition to react with disproportionate aggression in adults is influenced by an interaction between a variant in the X-chromosomal monoamine oxidase A gene (MAOA) and early traumatic events. Such studies have often focused on a single type of trauma, whereas we know that experiencing multiple trauma types is associated with more detrimental consequences. The differential susceptibility hypothesis suggests that individuals who are most susceptible to adversity, are also most likely to benefit from supportive experiences in childhood. Differences in susceptibility are thought to be partly genetically driven. In the present study we explored whether a genotype of MAOA linked to lower expression of the gene (MAOA-L) modified the effect of multiple types of trauma on aggression and/or altered responsiveness to treatment among adults with severe aggression. Forensic psychiatric outpatients (FPOs) (N=150) receiving treatment for aggression regulation problems were recruited. Traumatic events and aggression were measured using self-report. FPOs with multiple trauma types and those with the MAOA-L allele reported more severe levels of aggression. No interaction effects between MAOA genotype and trauma emerged. There were no differences in response to the intervention between FPOs with and without the MAOA-L variant, whereas FPOs with a single type of trauma showed the slowest reduction of aggression. FPOs with multiple types of trauma reported the highest levels of aggression over the course of treatment. Future research is needed to elucidate this association in further detail. The current study emphasized the importance of early recognition of early traumatic events.

Mentally disordered offenders and the law: Research update on the insanity defense, 2004-2019.

The insanity defense is among the most controversial legal constructs that has attracted the attention of scholars, practitioners and policy makers. Here, we conducted a systematic review of the literature spanning 2004 to 2019 that produced 58 studies of insanity defense research. Findings are organized according to: (1) assessments and assessment-related issues, (2) juror decision-making in defense trials, (3) characteristics of insanity acquittees, (4) release recommendations for insanity acquittees, (5) revocation of conditional release status of insanity acquittees, and (6) additional areas of insanity defense research. Implications of the research for the insanity defense and cognate legal issues are proffered.

Passive Monitoring of Mental Health Status in the Criminal Forensic Population.

Current approaches to monitoring patients' mental status rely heavily on self-reported symptomatology, clinician observation, and self-rated symptom scales. The limitations inherent in these methodologies have implications for the accuracy of diagnosis, treatment planning, and prognosis. Certain populations are particularly affected by these limitations because of their unique situations, including criminal forensic patients, who have a history of both criminal behavior and mental disorder, and experience increased stigma and restrictions in their access to mental health care. This population may benefit particularly from recent developments in technology and the growing use of mobile devices and sensors to collect behavioral information via passive monitoring. These technologies offer objective parameters that correlate with mental health status and create an opportunity to use Big Data and machine learning to refine diagnosis and predict behavior in a way that represents a marked shift from current practices. This article reviews the approaches to and limitations of psychiatric assessment and contrasts this with the promise of these new technologies. It then discusses the ethics concerns associated with these technologies and explores their potential relevance to criminal forensic psychiatry and the broader implications they carry for health and criminal justice policy.

A Seat at the Table.

Organized medicine and psychiatry have a long tradition of governmental advocacy and public engagement. The American Academy of Psychiatry and the Law (AAPL), since its founding 50 years ago, has made some forays into these fields. However, its involvement has been less substantial than other similarly situated professional organizations. With its increasing membership and expertise, AAPL now possesses the capacity to dedicate some of its organizational attention, energy, and resources to educating policymakers and the public on current and future topics related to forensic mental health. In addition, an increasing number and type of professional activities related to this discipline are affected by governmental regulation and public opinion. Therefore, the need to become involved in shaping policy is more urgent, particularly in light of the fact that other forensic mental health organizations have been actively involved in governmental advocacy for decades. Finally, as a field and in the near future, we likely will deal with life-changing technological innovations related to the practice of forensic psychiatry. AAPL and its members are perhaps uniquely qualified and have a responsibility to help ensure that these innovations are developed, implemented, and utilized appropriately. This can only be accomplished by having a proverbial seat at the table in the process.

Changing characteristics of forensic psychiatric patients in Ontario: a population-based study from 1987 to 2012.

PURPOSE: To quantify the demand for forensic psychiatric services in Ontario over the past 25 years and investigate whether the sociodemographic, clinical and offense-based characteristics of forensic patients have changed over time. METHODS: We investigated all forensic admissions from 1987 to 2012 resulting in a disposition of Not Criminally Responsible on account of Mental Disorder (N = 2533). We present annual proportions of patients with specified sociodemographic, clinical and offense characteristics, and investigate whether the duration of forensic system tenure varies as a function of admission year, psychiatric diagnosis, or index offense. RESULTS: There has been a steady increase in forensic admissions over this time period, particularly individuals with comorbid substance use disorders and individuals of non-Caucasian ethno-racial background. The proportion of persons committing severe violence has remained low and has decreased over time. Having a comorbid personality, neurological, or substance use disorder significantly increased forensic system tenure, as did committing a violent offense. Individuals who came into the system in earlier years had slower rates of discharge compared to more recent admissions. CONCLUSIONS: Defining the trends characterizing the growth of the forensic population has important policy implications, as forensic services are costly and involve a significant loss of liberty. The current results indicate that young, substance abusing individuals of diverse ethno-racial backgrounds and who commit relatively low-level violence comprise an increasing proportion of Ontario's forensic population, and suggest that treatment must be optimized to best serve the needs of these individuals.

Diminished Responsibility: Law Reform in the United Kingdom and Personal Perspective on Forensic Psychiatric Practice in Hong Kong.

This commentary discusses law reform on diminished responsibility in the United Kingdom and provides a personal perspective on forensic psychiatric practice relating to diminished responsibility in Hong Kong.

Cause-specific mortality in Finnish forensic psychiatric patients.

PURPOSE: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980-2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths. MATERIALS AND METHODS: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population. RESULTS: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7. CONCLUSIONS: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.

The risks, needs and stages of recovery of a complete forensic patient cohort in an Australian state.

BACKGROUND: Routine outcome measures are increasingly being mandated across mental health services in Australia and overseas. This requirement includes forensic mental health services, but their utility in such specialist services and the inter-relationships between the measures remain unclear. This study sought to characterise the risks, needs and stages of recovery of an entire cohort of forensic patients in one jurisdiction in Australia. METHODS: Local expert groups, comprising of members of the forensic patient treating teams, were formed to gather information about the status and needs of all forensic patients in the State of New South Wales, Australia. The expert groups provided demographic information and completed three assessment tools concerning the risks, needs and stages of recovery of each forensic patient. RESULTS: The cohort of 327 forensic patients in NSW appears to be typical of forensic mental health service populations internationally when considering factors such as gender, diagnosis, and index offence. A number of important differences across the three structured tools for forensic patients in different levels of secure service provision are presented. The DUNDRUM Quartet demonstrated interesting findings, particularly in terms of the therapeutic security needs, the treatment completion, and the stages of recovery for the forensic patients in the community. The CANFOR highlighted the level of needs across the forensic patient population, whilst the HCR-20 data showed there was no significant difference in the mean clinical and risk management scores between male forensic patients across levels of security. CONCLUSIONS: To the authors' knowledge this is the first study of its kind in New South Wales, Australia. We have demonstrated the utility of using a suite of measures to evaluate the risks, needs, and stages of recovery for an entire cohort of forensic patients. The data set helps inform service planning and development, together with providing various avenues for future research.