Development of mental health quality indicators (MHQIs) for inpatient psychiatry based on the interRAI mental health assessment.

BACKGROUND: Outcome quality indicators are rarely used to evaluate mental health services because most jurisdictions lack clinical data systems to construct indicators in a meaningful way across mental health providers. As a result, important information about the effectiveness of health services remains unknown. This study examined the feasibility of developing mental health quality indicators (MHQIs) using the Resident Assessment Instrument - Mental Health (RAI-MH), a clinical assessment system mandated for use in Ontario, Canada as well as many other jurisdictions internationally. METHODS: Retrospective analyses were performed on two datasets containing RAI-MH assessments for 1,056 patients from 7 facilities and 34,788 patients from 70 facilities in Ontario, Canada. The RAI-MH was completed by clinical staff of each facility at admission and follow-up, typically at discharge. The RAI-MH includes a breadth of information on symptoms, functioning, socio-demographics, and service utilization. Potential MHQIs were derived by examining the empirical patterns of improvement and incidence in depressive symptoms and cognitive performance across facilities in both sets of data. A prevalence indicator was also constructed to compare restraint use. Logistic regression was used to evaluate risk adjustment of MHQIs using patient case-mix index scores derived from the RAI-MH System for Classification of Inpatient Psychiatry. RESULTS: Subscales from the RAI-MH, the Depression Severity Index (DSI) and Cognitive Performance Scale (CPS), were found to have good reliability and strong convergent validity. Unadjusted rates of five MHQIs based on the DSI, CPS, and restraints showed substantial variation among facilities in both sets of data. For instance, there was a 29.3% difference between the first and third quartile facility rates of improvement in cognitive performance. The case-mix index score was significantly related to MHQIs for cognitive performance and restraints but had a relatively small impact on adjusted rates/prevalence. CONCLUSIONS: The RAI-MH is a feasible assessment system for deriving MHQIs. Given the breadth of clinical content on the RAI-MH there is an opportunity to expand the number of MHQIs beyond indicators of depression, cognitive performance, and restraints. Further research is needed to improve risk adjustment of the MHQIs for their use in mental health services report card and benchmarking activities.

Quality of resident violence risk assessments in psychiatric emergency settings.

OBJECTIVE: To identify how psychiatric residents perceive their ability to conduct violence risk assessments and the risk factors they considered relevant in an emergency department setting. METHOD: We surveyed 55 of 159 psychiatric residents at the University of Toronto as to their experience and education in assessing suicide and violence risk. The residents, and a comparison group of 11 of 16 staff psychiatrists in the Law and Mental Health program at the Centre for Addiction and Mental Health, then participated in a mock interview with one of the authors. The subjects were directed to ask for all risk factors that would be relevant in determining the violence risk of a hypothetical patient with homicidal ideation. The risk factors they requested were compared with the risk factors found in the Historical, Clinical and Risk Management-20 (HCR-20) structured clinical judgment tool. RESULTS: Psychiatric residents, on average, inquired about 6 fewer HCR-20 risk factors than staff psychiatrists (8.5, compared with 14.7). The number of HCR-20 items identified by residents correlated with several items; more risk factors were elicited by residents in a higher year of training, those who had received more formal and informal education, the number of patients for whom they had discharged a duty to warn, and the number of suicidal and violent patients they had previously assessed. Confidence at assessing violence risk was not correlated with performance. CONCLUSIONS: Psychiatric residents identify significantly fewer risk factors for violence than staff psychiatrists. Resident performance was correlated with increasing experience and education. It was not related to self-confidence in performing this task.

The Forensic Supplement to the interRAI Mental Health Assessment Instrument: Evaluation and Validation of the Problem Behavior Scale.

Background: Numerous validation studies support the use of the interRAI Mental Health (MH) assessment system for inpatient mental health assessment, triage, treatment planning, and outcome measurement. However, there have been suggestions that the interRAI MH does not include sufficient content relevant to forensic mental health. We address this potential deficiency through the development of a Forensic Supplement (FS) to the interRAI MH system. Using three forensic risk assessment instruments (PCL-R; HCR-20; VRAG) that had a record of independent cross validation in the forensic literature, we identified forensic content domains that were missing in the interRAI MH. We then independently developed items to provide forensic coverage. The resulting FS is a single-page, 19-item supplementary document that can be scored along with the interRAI MH, adding approximately 10-15 min to administration time. We constructed the Problem Behavior Scale (PBS) using 11 items from the interRAI MH and FS. The Developmental Sample, 168 forensic mental health inpatients from two large mental health specialty hospitals, was assessed with both an earlier version of the interRAI MH and FS. This sample also provided us access to scores on the PCL-R, the HCR-20 and the VRAG. To validate our initial findings, we sought additional samples where scoring of the interRAI MH and the FS had been done. The first, the Forensic Sample (N = 587), consisted of forensic inpatients in other mental health units/hospitals. The second, the Correctional Sample (N = 618) was a random, representative sample of inmates in prisons, and the third, the Youth Sample (N = 90) comprised a group of youth in police custody. Results: The PBS ranged from 0 to 11, was positively skewed with most scores below 3, and had good internal consistency (Cronbach's Alpha = 0.80). In a test of concurrent validity, correlations between PBS scores and forensic risk scores were moderate to high (i.e., r with PCL-R Factor two of 0.317; with HCR-20 Clinical of 0.46; and with HCR-20 Risk of 0.39). In a test of convergent validity, we used Binary Logistic Regression to demonstrate that the PBS was related to three negative patient experiences (recent verbal abuse, use of a seclusion room, and failure to attain an unaccompanied leave). For each of these three samples, we conducted the same convergent validity statistical analyses as we had for the Developmental Sample and the earlier findings were replicated. Finally, we examined the relationship between PBS scores and care planning triggers, part of the interRAI systems Clinical Assessment Protocols (CAPs). In all three validity samples, the PBS was significantly related to the following CAPs being triggered: Harm to Others, Interpersonal Conflict, Traumatic Life Events, and Control Interventions. These additional validations generalize our findings across age groups (adult, youth) and across health care and correctional settings. Conclusions: The FS improves the interRAI MH's ability to identify risk for negative patient experiences and assess clinical needs in hospitalized/incarcerated forensic patients. These results generalize across age groups and across health care and correctional settings.

Cerebral white matter deficiencies in pedophilic men.

The present investigation sought to identify which brain regions distinguish pedophilic from nonpedophilic men, using unbiased, automated analyses of the whole brain. T1-weighted magnetic resonance images (MRIs) were acquired from men who demonstrated illegal or clinically significant sexual behaviors or interests (n = 65) and from men who had histories of nonsexual offenses but no sexual offenses (n = 62). Sexual interest in children was assessed by participants' admissions of pedophilic interest, histories of committing sexual offenses against children, and psychophysiological responses in the laboratory to erotic stimuli depicting children or adults. Automated parcellation of the MRIs revealed significant negative associations between pedophilia and white matter volumes of the temporal and parietal lobes bilaterally. Voxel-based morphometry corroborated the associations and indicated that the regions of lower white matter volumes followed, and were limited to, two major fiber bundles: the superior fronto-occipital fasciculus and the right arcuate fasciculus. No significant differences were found in grey matter or in cerebrospinal fluid (CSF). Because the superior fronto-occipital and arcuate fasciculi connect the cortical regions that respond to sexual cues, these results suggest (1) that those cortical regions operate as a network for recognizing sexually relevant stimuli and (2) that pedophilia results from a partial disconnection within that network.

Further investigation of findings reported for the Minnesota sex offender screening tool-revised.

Among a number of widely used risk assessment instruments with adult sexual offenders, the Minnesota Sex Offender Screening Tool-Revised (MnSOST-R) has been subject to relatively few evaluation studies. Only two independent research groups have published replication studies in the peer-reviewed literature with data not provided by the MnSOST-R's developers, and the results regarding the accuracy of predicting sexual recidivism have been mixed. In this article, important differences between the Barbaree et al. and Langton et al. studies are presented. Analyses reported for the various subsets comprising these two samples indicate that coding discrepancies in the Barbaree et al. study account for the different findings, with a moderate level of predictive accuracy using the Receiver Operating Characteristic curve ultimately found for the MnSOST-R in both data sets.

The use of a brief mental health screener to enhance the ability of police officers to identify persons with serious mental disorders.

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Psychopathy, treatment behavior, and recidivism: an extended follow-up of Seto and Barbaree.

Seto and Barbaree reported the unexpected finding that adult male sex offenders who scored higher on psychopathy and exhibited better behavior in treatment were almost four times more likely to commit a new serious offence than other offenders once released. The present study reexamined this sample after a longer follow-up time using more complete recidivism data from a national police database. Although psychopathy continued to be a significant predictor of general and serious recidivism, treatment behavior was no longer related to either general or serious recidivism, and there was no statistically significant interaction between psychopathy and treatment behavior. Additional analyses ruled out the possibility that the differences between studies could be accounted for by the different average length of follow-up. A direct comparison of the two sources of recidivism data showed that differences in recidivism between subgroups were reduced by using the more complete recidivism data.

The development of sexual aggression through the life span: the effect of age on sexual arousal and recidivism among sex offenders.

There is a strong belief in the field that sexual aggression persists unabated into old age. If libido is one of the important determinants of sexual aggression, as has been theorized, and if libido decreases with aging, then it follows that sexual aggression should show similar aging effects. The present study examines the effects of age on sexual arousal and sexual recidivism in sex offenders. In the first study, 1431 sex offenders' erectile responses were measured using volumetric phallometry during presentations of visual and auditory depictions of prepubescent, pubescent, and adult males and females. The maximum degree of arousal was plotted over the age of the offender at the time of the test. Age was a powerful determinant of sexual arousal and a line-of-best-fit indicated that arousal decreased as a reciprocal of the age-at-test. In the second study, 468 sex offenders released into the community were followed for an average period of over five years. The effects of age-at-release were examined using Kaplan-Meier survival curves plotted for subjects in different age-at-release cohorts. Results indicated that offenders released at an older age were less likely to recommit sexual offenses and that sexual recidivism decreased as a linear function of age-at-release. Age-related decreases were confirmed while controlling for other risk factors using Cox regression analysis. The implications of reductions in sexual aggression with age are discussed in relation to our understanding of the etiology of sexual aggression and our use of actuarial risk assessments.

Symptoms and treatment of mental illness among prisoners: a study of Michigan state prisons.

This study reports on a representative sample of prisoners in Michigan correctional facilities to determine the prevalence of psychiatric illness and the delivery of mental health (MH) services. Mental health assessments were conducted with 618 incarcerated subjects using the interRAI Correctional Facilities (interRAI CF). Subjects were randomly sampled based on four strata: males in the general population, males in administrative segregation, males in special units, and females. The interRAI CF assessments were merged with secondary data provided by the Michigan Department of Corrections (MDOC) containing information on MH diagnoses or services that the subjects were receiving within the facilities, demographics, and sentencing. Study results show that 20.1% of men and 24.8% of women in Michigan prisons have a substantial level of MH symptoms and that 16.5% and 28.9%, respectively, are receiving MH services. However, when compared with Michigan Department of Corrections MH care records, 65.0% of prisoners who are experiencing symptoms of mental illness are not currently receiving any psychiatric services. The mis-match between symptoms and service delivery suggests the need for improved procedures for identifying and measuring psychiatric symptoms within Michigan correctional facilities to ensure that appropriate individuals receive needed care. It is recommended that a standardized assessment process be implemented and conducted at regular intervals for targeting and improving psychiatric care in the prison system.

Pathways to forensic mental health care in Toronto: a comparison of European, African-Caribbean, and other ethnoracial groups in Toronto.

OBJECTIVE: To describe pathways taken to care by a sample of patients in a secure forensic unit who have been found not criminally responsible or unfit to stand trial, and to investigate the pathways taken by patients within 3 ethnoracial subgroups of origin: European, African or Caribbean, and Other. METHOD: Fifty patients from secure forensic units were interviewed using the Encounter Form developed for pathways mapping undertaken in the World Health Organization field trials. Differences in the types of caregivers seen, the total number of caregivers seen, and the time taken to reach forensic psychiatric services were compared across the 3 ethnoracial groupings. RESULTS: Most people committed their index offence after they had already had contact with general mental health services. Few significant differences were observed in the pathways to secure forensic units across the European, African-Caribbean, and Other ethnoracial groups. CONCLUSIONS: These findings suggest that improvements in general mental health services may be a key to decreasing the use of forensic psychiatric services. Further research is required to explore factors that may predict and prevent offending. Larger studies are needed to examine ethnoracial differences in pathways to care.

Commentary: Hebephilia--a would-be paraphilia caught in the twilight zone between prepubescence and adulthood.

This commentary addresses the controversy surrounding the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision (DSM-5) diagnosis of pedohebephilia. We examine adult male sexual attraction to young pubescent females and whether such attraction is deviant and constitutes a mental disorder, and, independent of that question, whether there is any defensible basis for asserting that hebephilia is a legitimate paraphilia. We conclude our analysis by looking at three profiles: adults with sexualized interest in pre- and postpubescent children, adults with sexualized interest in adult and pubescent adolescent women, and adults with exclusive sexualized interest in young pubescent women. We suggest that in the third instance of exclusivity, the Criterion B requirement of impairment may become critical to legitimizing a diagnosis of hebephilia.

Different actuarial risk measures produce different risk rankings for sexual offenders.

Percentile ranks were computed for N=262 sex offenders using each of 5 actuarial risk instruments commonly used with adult sex offenders (RRASOR, Static-99, VRAG, SORAG, and MnSOST-R). Mean differences between percentile ranks obtained by different actuarial measures were found to vary inversely with the correlation between the actuarial scores. Following studies of factor analyses of actuarial items, we argue that the discrepancies among actuarial instruments can be substantially accounted for by the way in which the factor Antisocial Behavior and various factors reflecting sexual deviance are represented among the items contained in each instrument. In the discussion, we provide guidance to clinicians in resolving discrepancies between instruments and we discuss implications for future developments in sex offender risk assessment.

The factor structure of static actuarial items: its relation to prediction.

Principal components analysis was conducted on items contained in actuarial instruments used with adult sex offenders, including: the Rapid Assessment of Sex Offender Risk for Recidivism (RASORR), the Static-99, the Violence Risk Appraisal Guide (VRAG), the Sex Offender Risk Appraisal Guide (SORAG), and the Minnesota Sex Offender Screening Tool-Revised (MnSOST-R). In a data set that included child molesters and rapists (N = 311), six interpretable components were identified: Antisocial Behavior, Child Sexual Abuse, Persistence, Detached Predatory Behavior, Young and Single, and Male Victim(s). The RRASOR was highly correlated with Persistence, and the VRAG and SORAG were highly correlated with Antisocial Behavior. Antisocial Behavior was a significant predictor of violent recidivism, while Persistence and Child Sexual Abuse were significant predictors of sexual recidivism.

Sex offenders' response to treatment and its association with recidivism as a function of psychopathy.

This study examined the relationship between recidivism and ratings of response to specialized cognitive behavioral treatment conducted in a prison setting among 418 sex offenders released to the community for an average follow-up period of over 5 years. As well as testing for a main effect for treatment ratings, the potential role of psychopathy assessed using the Psychopathy Checklist--Revised (PCL-R) as a moderator of response to treatment was investigated. Ratings of response to treatment failed to predict either serious (violent including sexual) or sexual recidivism. For the more inclusive outcome of serious recidivism, there was no significant interaction between psychopathy and treatment ratings; however, the ubiquitous effect of psychopathy on recidivism was found to be significant. For sexual recidivism, psychopathy was not significant as a main effect, but a significant interaction between psychopathy and treatment ratings was found. Among sex offenders with PCL-R scores of 25 or higher, those with ratings reflecting a more negative response to treatment recidivated sexually at a faster rate than others. This interaction effect was not significant when treatment noncompleters were removed from the data set. The results were discussed in terms of the methodology involved in the assessment of response to treatment among sex offenders.

The strength of sexual arousal as a function of the age of the sex offender: comparisons among pedophiles, hebephiles, and teleiophiles.

Previous research has shown that sexual arousability in human males declines from its peak in early adolescence until old age. This study compared the rates of decline in three groups of males: those most attracted sexually to prepubescent children (pedophiles), those most attracted to pubescent children (hebephiles), and those most attracted to physically mature persons (teleiophiles). The participants were 2,028 patients referred to Toronto's Centre for Addiction and Mental Health from 1995 to 2004 for evaluation of criminal or otherwise disturbing sexual behavior, but not for erectile or ejaculatory problems. All underwent phallometric assessment for erotic age-preference. This is a psychophysiological technique in which an individual's penile blood volume is monitored while he is presented with a standardized set of laboratory stimuli depicting male and female children, pubescents, and adults. The experimental measure of sexual arousability was the average of the participant's three greatest penile responses to any stimulus category, expressed in cubic cm of blood volume increase. The results showed that sexual arousability was an inverse function of age, and that there were no differences between the pedophiles, hebephiles, and teleiophiles in the rate at which arousability declined.

The screening scale for pedophilic interests predicts recidivism among adult sex offenders with child victims.

The Screening Scale for Pedophilic Interests (SSPI; Seto & Lalumière, 2001), a brief measure of sexual attraction to prepubescent children that is based on victim characteristics, was used in two samples of 113 and 145 adult male sex offenders with child victims. In both samples, the SSPI was significantly and positively correlated with an index of phallometrically-measured sexual arousal to stimuli depicting prepubescent children. It was also significantly and positively correlated in both samples with violent recidivism (meaning either nonsexually violent offenses or sexual offenses involving physical contact with a victim), and positively correlated with sexual recidivism, significantly so in the second, larger sample. Focusing on the larger sample, the SSPI added to the predictive accuracy of a measure of general antisociality (the Psychopathy Checklist-Revised), while the phallometric index of sexual arousal did not add predictive accuracy once the other two measures were entered. The SSPI also yielded the same interaction between anomalous sexual interests and psychopathy we had previously reported using phallometric data (Rice & Harris, 1997). These findings suggest that the SSPI has predictive utility among adult male sex offenders with child victims, and accounts for variance in sexual offending that is not explained by phallometric testing.