A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders).

BACKGROUND: Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. METHODS: In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. RESULTS: A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours. CONCLUSION: Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.

The psychiatric management of prisoners on hunger strike: developing a management algorithm using the Delphi technique.

PURPOSE: The assessment and management of prisoners on hunger strikes in a custodial setting is complex. There is limited clinical guidance available for psychiatrists to draw upon in such cases. The purpose of this paper is to develop a management algorithm through expert elicitation to inform the psychiatric care of prisoners on a hunger strike. DESIGN/METHODOLOGY/APPROACH: A Delphi method was used to elicit views from Irish forensic psychiatrists, a legal expert and an expert in ethics using a structured questionnaire. Themes were extracted from the results of the questionnaire to propose a management algorithm. A consensus was reached on management considerations. FINDINGS: Five consultant forensic psychiatrists, a legal expert and an expert on psychiatric ethics ( n=7) consented to participation, with a subsequent response rate of 71.4 per cent. Consensus was achieved on a proposed management algorithm. Assessment for mental disorder, capacity to refuse food and motivation for food refusal are seen as key psychiatric tasks. The need to work closely with the prison general practitioner and the value of multidisciplinary working and legal advice are described. Relevant aspects of law included mental health, criminal law (insanity) and capacity legislation. ORIGINALITY/VALUE: This study outlines a management algorithm for the psychiatric assessment and management of prisoners on a hunger strike, a subject about which there is limited guidance to date. Although written from an Irish perspective, this study outlines key considerations for psychiatrists in keeping with international guidance and therefore may be generalisable to other jurisdictions.

Longitudinal assessment of psychopathological domains over late-stage schizophrenia in relation to duration of initially untreated psychosis: 3-year prospective study in a long-term inpatient population.

There remains uncertainty regarding any progressive nature of psychopathology and cognitive dysfunction in late-stage schizophrenia, and whether duration of initially untreated psychosis (DUP) might be associated with such 'progression'. This study examines longitudinally, over 3 years, the psychopathology and neuropsychology in 82 inpatients with DSM-IV schizophrenia, many of whom were admitted in the pre-neuroleptic era. Increase in executive dysfunction exceeded that in general cognitive impairment. Positive but not negative symptom severity decreased modestly; the primary predictor of negative symptom severity was DUP. On index assessment, psychopathology evidenced a three-factor structure; at follow-up, psychomotor poverty evidenced greater prominence and cohesion, and was on both occasions predicted primarily by DUP, while reality distortion was altered and disorganisation disassembled into alternative elements. It would appear that as years of chronic, refractory illness accrue, psychomotor poverty becomes more sharply delineated and dominant within the overall structure of psychopathology, and its prominence is predicted enduringly by DUP.

Psychiatric morbidity in male remanded and sentenced committals to Irish prisons.

OBJECTIVES: To describe the prevalence of psychiatric morbidity and the treatment needs of new committals to Irish prisons. METHODS: A population survey of 615 prisoners representing 7.9% of male committals to Irish prisons in the year of survey, 313 remands (9.6% of total remand committals) and 302 sentenced committals (6.4% of total sentenced committals). The main outcome measures were ICD-10 diagnoses of mental disorder based on interviews using SADS-L and prison medical records. RESULTS: Current prevalence rates of any psychotic illness were 3.8% (remand) and 0.3% (sentenced), six month prevalence rate 5.1% (remand) and 2.6% (sentenced) and lifetime rate 9.3% (remand) and 6.6% (sentenced). Schizophrenia and drug/organic psychoses were the most common psychoses. Major depressive disorder had a current prevalence of 4.5% (remand) and 4.6% (sentenced), a six month prevalence of 4.8% (remand) and 6.0% (sentenced), and a lifetime prevalence of 8.6% (remand) and 15.9% (sentenced). Sixty-point-six per cent of the sample had a current substance misuse problem. CONCLUSIONS: There is significant psychiatric morbidity in committal prisoners.

Psychiatric morbidity in the male sentenced Irish prisons population.

BACKGROUND: This is the first epidemiologically representative cross-sectional study of psychiatric morbidity using research diagnostic instruments in sentenced prisoners in Ireland. OBJECTIVE: To estimate the prevalence of psychiatric morbidity and psychiatric service requirements. METHOD: We interviewed 340 men serving a fixed sentence (14.6% of total) and 98 men serving a life sentence (82% of total). Prisoners were drawn from 15 different prisons using a random stratified sampling method. Mental illness and substance misuse was measured using the SADS-L, SODQ and a structured interview to generate ICD-10-DCR diagnoses. RESULTS: We found a high prevalence of mental illness. Our six month prevalence for psychosis (2.7%) was similar to an international meta-analysis. We found a significantly higher prevalence of psychosis in life sentenced prisoners (6.1%) compared to fixed sentenced prisoners (1.8%). Drugs and alcohol problems were very prevalent. CONCLUSIONS: Using the six month prevalence figures found for psychosis, we estimate that there are approximately 79 sentenced male prisoners with a severe mental illness who would require treatment in hospital additional to current provision. We discuss the relationship between drug availability and the prevalence of severe mental illnesses in prisons.

Psychiatric morbidity among women prisoners newly committed and amongst remanded and sentenced women in the Irish prison system.

OBJECTIVES: To estimate the prevalence of psychiatric morbidity, substance misuse problems and related health and social problems among women prisoners newly committed and a cross-section remanded and sentenced in the Irish prison population. In 2002 women represented 10.7% (1043) of all persons committed to the Irish Prison system, and 3.3% (104) of the daily average number of persons in custody. We surveyed psychiatric morbidity in these two groups to assess the need for psychiatric services for women prisoners, and to compare Irish morbidity with an international average. METHOD: We interviewed 94 newly committed women prisoners within 72 hours of committal, representing approximately 9% of female committals per year. We also interviewed a cross sectional sample of 92 women, representing approximately 90% of all women in custody. Mental illness and substance misuse was measured using the SADS-L, SODQ and a structured interview. RESULTS: Five (5.4%) of the committal and 5 (5.4%) of the cross-sectional sample had a psychotic illness within the previous six months. 8 (8.5%) of the committals and 15 (16.3%) of the women in the cross-sectional sample had a major depressive disorder in the last six months. 8 (8.6%) committals and 14 (15.2%) in the cross-sectional sample had an anxiety disorder within the last six months. 61 (65.6%) of the women interviewed at committal and 61 (65.2%) of the cross-sectional sample had a substance misuse problem in the last six months. CONCLUSIONS: There is a high prevalence of mental illness and substance misuse problems amongst women newly committed to prison and in a cross section of those remanded or sentenced in prison in Ireland. We found evidence of a cycle of deprivation and institutionalisation. These findings highlight the need for the integration of community and forensic psychiatric services, and for ongoing collaboration with drug services.

Irish Travellers and forensic mental health.

OBJECTIVES: To determine whether Irish Travellers are over-represented amongst transfers from prison to psychiatric hospital. If so, to determine whether this represents an excess over the proportion of Irish Travellers committed to prison. METHOD: Irish Travellers admitted to the National Forensic Psychiatry service were identified from a case register over three years 1997-1999. New prison committals were sampled and interviewed as part of the routine committal screening to identify ethnicity. RESULTS: Irish Travellers accounted for 3.4% of forensic psychiatric admissions compared to 0.38% of the adult population. Travellers transferred from prison to psychiatric hospital had more learning disability and less severe mental illness than other groups, while black and other ethnic minorities had a higher proportion of severe mental illness. Travellers accounted for 6% (95% CI 3-11) of 154 male committals and 4% (95% CI 2-12) of 70 female committals. The estimated annualised prison committal rate was 2.8% (95% CI 2.4-3.3) of all adult male Travellers in Ireland and 1% for female Travellers (95% CI 0.8-1.3). Male Travellers had a relative risk of imprisonment compared to the settled community of 17.4 (95% CI 2.3-131.4), the relative risk for female Travellers was 12.9 (95% CI 1.7-96.7). Imprisoned Travellers had greater rates of drugs and alcohol problems than other prisoners (Relative risk 1.46, 95% C11.11-1.90). CONCLUSION: There is gross over-representation of Travellers in forensic psychiatric admissions. This reflects the excess of Travellers amongst prison committals.

Long-stay forensic psychiatric inpatients in the Republic of Ireland: aggregated needs assessment.

OBJECTIVES: To profile the current cohort of forensic psychiatric inpatients in the Republic of Ireland, comparing psychiatric healthcare and placement needs of long-stay patients with those more recently admitted. METHOD: All forensic psychiatric inpatients in the Central Mental Hospital, Dundrum on a census date were included in the study. Patients and key worker were interviewed using a standardised schedule and validated research instruments. Static and dynamic risk factors for violence including demographic, diagnostic and legal characteristics were supplemented by detailed chart review. Standardised anonymised case vignettes were presented to panels of forensic and community psychiatric multidisciplinary teams who assessed current and future treatment and placement requirements for the cohort. RESULTS: There were 88 forensic psychiatric inpatients on the census date. Forty-three had lengths of stay over two years (17 over 20 years). Both patient groups were predominantly males with severe mental illness and histories of violent offending. The majority of the long-stay group were receiving regular parole and this group had lower levels of positive symptoms and comorbid substance misuse disorders. Significant gaps in existing rehabilitation inputs were identified. Almost half the long-stay patients were inappropriately placed. Thirty per cent of long-stay patients could be safely transferred to lower levels of security within six months and 63% within three years. CONCLUSIONS: Holding patients in conditions of excessive security impedes rehabilitation and has considerable human rights implications. Almost half of long-stay forensic psychiatric patients in Ireland are inappropriately placed. Barriers to discharge include legislative inadequacies, lack of local low-secure facilities and under-resourcing of community psychiatric services. Such barriers lead to inappropriate utilisation of limited resources and limit access to secure facilities for higher-risk mentally disordered offenders. These findings are of particular relevance in the context of proposed new insanity legislation.