Women in acute forensic psychiatric care: comparison of clinical, sociodemographic, and detention-related characteristics in pretrial detention, sentence execution, and court-ordered treatment.

Compared to men inmates, women display decreased prevalence of severe mental disorder but increased occurrence of substance use disorders (SUD) and higher rates of previous contacts with mental health services. The group of women in detention is highly heterogeneous according to the status of incarceration (pre-trial detention (PTD), sentence execution (SE) and court ordered treatments (COT)). Studies focusing on the comparison of sociodemographic patterns, detention-related and clinical variables between these groups are still lacking. We explored these parameters in 136 women admitted for acute psychiatric care in the sole Geneva forensic unit during a nine year period (2014-2023). Sociodemographic and detention-related data included age, nationality, marital status, presence of children, education attainment, most frequently speaking language, social support, employment before conviction and type of offenses. Clinical variables included the main ICD-10 diagnosis, presence of concomitant SUD, type of personality disorders, presence of suicidal thoughts and attempts at admission, as well as number and mean duration of stays. PTD and SE women had at least 9 years of formal education in 38.9% and 30.3% of cases. Most women in PTD (77.7%), SE (56.6%) and COT (56.2%) groups were Swiss or European citizens. The level of French knowledge was excellent in most of the cases. 43.8% of COT women had at least one child and this percentage is even higher for PTD and SE cases. The employment rate before conviction was also quite high, mainly for PTD and SE (61.1% and 60.6%) and, in a lesser degree, for COT (43.8%) women. Significant social support was present in the vast majority of women without any significant group difference. The distribution of type of offenses did not differ between the three types of detention with a predominance of physical violence, and drug trafficking. The number of stays during the period of reference was significantly higher in COT compared to both SE and PTD women. History of previous inpatient care was also significantly more frequent in COT that SE and PTD women. Adjustment and affective disorders were more often found in SE and PTD cases, these diagnoses were absent in the COT group. In contrast, a main diagnosis of psychotic disorders was found in 62.5% of COT cases compared to only 21.2% in SE and 24.1% in PTD cases. The number of stays, history of inpatient care and diagnosis of psychosis were independent predictors of COT status. In conclusion, the present data reveal the good social integration and emotional support of women needing acute psychiatric care in prison independently of the type of detention. Clinically, women in PTD and SE display more often emotional distress whereas those in COT suffer from acute psychotic symptoms with previous history of psychiatric care and multiple inpatient stays.

Determinants of clinical outcome and length of stay in acute care forensic psychiatry units.

Criminological and sociodemographic variables, such as previous criminal convictions, increased risk of violence, early onset of mental disorder, antisocial personality, psychosis and low social support, have all been related to longer length of stay (LoS) and poorer outcome in long stay forensic services. The factors impacting on LoS and clinical response in acute care specialized units are poorly documented. To address this issue, we examined the psychiatric records of all cases admitted between January 1st and December 31th 2020 in the sole acute ward for detained persons located in the central prison of the Geneva County, Switzerland. Information on judicial status included pre-trial versus sentence execution, previous incarcerations, and age of the first incarceration. Sociodemographic data included age, gender, marital status, and education attainment. Previous inpatient stays prior to incarceration were recorded. All of the ICD-10 clinical diagnoses were made by two independent, board-certified psychiatrists blind to the scope of the study. The standardized assessment was based on the HoNOS (Health of Nation Outcome Scales) at admission and discharge, HONOS-secure at admission, HCR-20 (Historical Clinical Risk 20) version 2, PCL-R (Psychopathy Checklist Revised), and SAPROF (Structured Assessment of Protective Factors). Stepwise forward multiple linear regression models predicting the LoS and delta HONOS respectively were built with the above mentioned parameters. The selected variables were then used in univariate and multivariable regression models. Higher HCR-scores (mainly on clinical items), and longer LoS were related to higher delta HONOS scores. In contrast, cases in pre-trial detention showed a worst clinical outcome. In multivariable models, all three variables remained independent predictors of the clinical outcome and explained 30.7% of its variance. Only education and diagnosis of borderline personality were related to the LoS and explained 12.6% of its variance in multivariable models. Our results suggest that the use of acute wards specialized in forensic psychiatry are mainly useful for patients with prior inpatient care experience, and higher violence risk during sentence execution. In contrast, they seem to be less performant for persons in pre-trial detention that could benefit from less restrictive clinical settings.

Prison inmates with court-ordered treatments: are they really different?

BACKGROUND: Both the frequency of court-ordered treatments (COT) for offenders and prevalence of mental disorders among regular prison inmates steadily increased in most western countries. Whether there are major sociodemographic and clinical differences between these two populations is still matter of debate. METHODS: We compared the sociodemographic and clinical characteristics in a representative sample of 139 regular prison inmates versus 61 offenders with COT admitted during a 5-year period in an acute psychiatric care unit located in the central prison of the Geneva county. Fisher exact, unpaired Student's t and Mann-Whitney U tests were used to compare demographic and clinical variables between COT patients and regular inmates. In addition, univariate and multivariable ordered logistic regression models were built to identify the sociodemographic and clinical determinants of COT. RESULTS: COT patients were significantly older, less frequently married, with better education attainment, predominantly French-speaking, of the Christian religious group and with regular religious practice. History of psychiatric outpatient care was significantly more frequent in this group. Unlike the significantly higher occurrence of adjustment disorders in regular prisoners, psychosis was the main diagnosis in COT patients. When all diagnostic categories were taken into account in multivariable models, the presence of personality and psychotic disorders were the stronger predictors of COT status. CONCLUSIONS: Our data reveal that offenders with COT represent a clinically distinct group with an overrepresentation of personality and psychotic disorders. Moreover, they show that, at least in the Swiss penitentiary system, COT patients are less exposed to acculturation issues compared to regular inmates.

Neurobiology of suicide: do biomarkers exist?

Clinical risk factors have a low predictive value on suicide. This may explain the increasing interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. This review aims to present the current neurobiological findings that have been shown to be implicated in suicide completers and to discuss how postmortem studies may be useful in characterizing these individuals. Data on the role of the main neurobiological systems in suicidality, such as the neurotransmitter families, hypothalamic-pituitary-adrenal axis, neurotrophic factors, and polyamines, are exposed at the different biochemical, genetic, and epigenetic levels. Some neuroanatomic and neuropathological aspects as well as their in vivo morphological and functional neuroimaging correlates are also described. Except for the serotoninergic system, particularly with respect to the polymorphism of the gene coding for the serotonin transporter (5-HTTLPR) and brain-derived neurotrophic factor, data did not converge to produce a univocal consensus. The possible limitations of currently published studies are discussed, as well as the scope for long-term prospective studies.

Patterns of admission in forensic units during the COVID-19 pandemic: a process analysis.

Introduction: The impact of COVID-19 pandemic on forensic service practice remains matter of debate. Increased rates of anxiety, depression, and exacerbation of psychotic symptoms were reported in the early phases of the pandemic among detained persons. However, longitudinal analyses in medium-security hospitals taking into account the whole pandemic period led to mitigated results. Methods: This report examines the evolution of the type (voluntary versus involuntary) and reason of admissions, length of stay, history of outpatient care, short-term seclusion hours for aggressive behaviors, and clinical diagnoses for detainees needing acute psychiatric care during the COVID-19 pandemic in the sole secure ward located in the central prison of Geneva, Switzerland. To determine the general trend of the processes over time we applied a combination of process analysis with run chart plotting, and fractional polynomial regression. Results: Run tests showed that the proportion of cases with personality disorders, substance use disorders (SUD), and previous outpatient care tended to increase during the COVID pandemic with subsequent decrease to reach the pre-COVID values. This was also the case for depressive symptoms as reason for admission. The proportion of involuntary admission showed a steady increase both during the COVID and post-COVID time periods. In contrast, short-term seclusion hours decreased during the COVID pandemic followed by a return to their pre-COVID values. Regression models revealed that the COVID pandemic was associated with a significant increase in the rates of inmates with personality disorders and SUD admitted for forensic care explaining 36 and 41% of their variance. Discussion: These data support the idea that, in terms of acute care needs, the COVID-19 pandemic was associated with increased needs for acute forensic care that concerned detainees with personality disorders characterized by increased levels of impulsiveness, decreased tolerance to frustrations, loss of control, increased extraversion and frequent SUD comorbidity.

Detained Persons Incarcerated for the First Time and Needing Acute Psychiatric Care: Sociodemographic and Clinical Characteristics.

Among detained persons, those incarcerated for the first time (FTI: first time incarceration) are known to present long-standing psychological vulnerability but also suffer significant deterioration of their mental health during the first year following imprisonment. Whether the patterns of psychiatric morbidity differ in FTI cases compared to cases with repeated and long term incarceration (RLTI) is still a matter of debate. We examined the sociodemographic and clinical differences between a subgroup of FTI vs. one of RLTI in a series of 139 randomly selected detained persons admitted to an acute psychiatric ward located in the central prison of Geneva, Switzerland. Fisher exact, unpaired Student t and Mann-Whitney U tests were used to explore sociodemographic (age, gender, marital status, religion, knowledge of French, education) and clinical (psychiatric outpatient care, suicidal behavior, psychiatric diagnosis) differences between the two groups. Subsequently, univariate and multiple logistic regression models were used to detect the variables associated with FTI. The proportion of women was significantly higher in the FTI compared to the RLTI group. FTI cases were also more frequently separated or divorced, with less frequent religious affiliation. 16.9% of FTI cases but only 1.3% of RLTI cases had a clinical diagnosis of depression. In multiple regression models, female sex and lower religious affiliation rate were associated with FTI status. Among diagnostic categories, depression was strongly related to FTI status both in univariate and multivariable models. Importantly, this was not the case for adjustment disorders, previous history of psychiatric care and suicidal behavior. Our observations support the assumption that FTI cases with lower affective support, less religious investment and without psychiatric care prior to imprisonment are particularly vulnerable to depressive illness.

Determinants of Revolving Door in an Acute Psychiatric Ward for Prison Inmates.

Among the different types of heavy use of mental health services, frequent inpatient admission in acute care units of individuals unable to return to their usual environment refers to as revolving-door (RD). RD in prisoners is related to increased violence (acted and supported) and suicidal recidivism. We explored the determinants of RD in 200 inmates from the Swiss-French speaking areas who were admitted to the sole acute psychiatric care unit for all of the Swiss-French counties, located in Geneva. The Cuzick's test for trend across ordered groups, Kruskal-Wallis test and oneway ANOVA were used to compare demographic and clinical variables between single (one admission, N = 100), frequent (3-7, N = 69) and RD (more than 8, N = 31) during a 12 months period. In addition, univariate and multivariable ordered logistic regression modes were built to examine the determinants of RD. The sample included 27 women (mean age: 31.2 years) and 173 men (34.5 years) who were admitted during the period 2014-2019. The vast majority were single (65%) with low level of education (<6 years, 78%). Suicidal behavior was the more frequent reason for admission (57%). Psychiatric history was positive in 77.5% of cases and in 54.5% of cases there was at least one episode of inpatient psychiatric care. The more frequent ICD-10 psychiatric diagnosis in the last admission were psychotic disorder (38%), personality disorder (29.5%) and adjustment disorder (19.5%). In contrast, depressive episodes (7%) and bipolar disorder (4.5%) were rare. Group comparison showed that the presence of court-ordered treatments, suicidal behavior, personality and psychotic disorders was associated with significantly increased frequency of RD use. In univariate models, the same factors were positively associated with RD, the highest odds ratio being found for court-ordered treatments (5.77) and personality disorders (2.14). In contrast, the diagnosis of adjustment disorders was related to decreased RD use (OR 0.25). Court-ordered treatments and personality disorders were the only factors to predict RD in multivariable regression models. These findings suggest that acute psychiatric care in these patients did not depend of environmental stressors but rather represents the expression of a long-lasting vulnerability related to their psychological profile and criminal status.

Development and validation of a short Italian UPPS-P Impulsive Behavior Scale.

Impulsivity is a multidimensional construct that plays a prominent role in the development, maintenance, and relapse of addictive disorders. The UPPS-P model of impulsivity, which distinguishes between five impulsivity components (positive urgency, negative urgency, lack of perseverance, lack of premeditation, sensation seeking), has been increasingly investigated during the last decade in relation to addictive and risky behaviors. Unfortunately, it currently lacks a validated scale that allows Italian researchers and clinicians to measure impulsivity based on the UPPS-P model. The current study fills this gap by testing the psychometric properties of a short 20-item Italian scale used to assess the five dimensions of the UPPS-P model in 188 volunteer participants from the community. Confirmatory factor analysis supported a model of five distinct, but interrelated, impulsivity components. The results indicated good internal consistency (Cronbach's α ranges from .73 to .84). Construct validity was evidenced by specific relations with measures of addictive behaviors and depressive symptoms. On the whole, this study demonstrated that the Italian short UPPS-P has good psychometric properties.