The Nurse-Police Assistance Crisis Team (N-PACT): A new role for nursing.

AIM: This study aimed to gain insights into forensic nurses' perspectives and approaches to behavioural crisis situations, comparing them to disciplines traditionally involved in first-line behavioural crisis response. DESIGN: This study used a descriptive, qualitative exploratory design and was informed by Systems Theory. METHODS: The study was carried in the United States, between 2022 and 2023. Data were gathered through four focus groups: police officers (n = 12), co-response (mental health) clinicians (n = 13), sexual assault nurse examiners (n = 6) and correctional nurses (n = 4). Thematic analysis was performed. REPORTING METHOD: The Standards for Reporting Qualitative Research (SRQR) guidelines were used. RESULTS: Findings revealed temporal themes in crisis response: (1) Searching for Historical Information; (2) Safety and Acting at the Present Scene; and (3) Future Strategies and Interventions. Common priorities (e.g. safety and de-escalation) were identified across groups. Notably, nurses demonstrated a comprehensive approach, addressing physical and mental health assessments, substance involvement, and physical injury evaluation. CONCLUSION: This study proposes the creation of a novel nursing role within first-line multidisciplinary teams (MDTs) for crisis response-the Nurse-Police Assistance Crisis Team (N-PACT). Nurses bring expertise and comprehensive assessment skills to enhance crisis responses, particularly in cases involving mental health emergencies, medical crises, and drug-related incidents. IMPLICATIONS: Forensic nurses, with their diverse competencies and comprehensive training, are highly valuable assets within MDTs. Their expertise extends to proficiently conducting mental and physical assessments, ensuring safety and adeptly navigating situations that intersect with the legal system. IMPACT: The N-PACT concept can improve outcomes and streamline the allocation of resources, particularly considering the number of police calls involving behavioural crises. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Introduction to special issue on social media for forensic mental evaluations.

This special issue of Behavioral Sciences & the Law presents six articles that focus on various issues related to social media in forensic mental health evaluations. These eclectic articles provide updated information about social media's use and navigating difficult ethical concerns. Ranging from violence risk assessment to disability evaluations, the up-to-date information in this special issue allows the forensic evaluator to be more prepared when they inevitably encounter information from social media. As social media continues to grow, both in terms of overall use and the number of available platforms, forensic clinicians will need to remain cognizant of the ways these data can be appropriately utilized as collateral data.

The Internet is a scary place: How does evidence source and examinee race or ethnicity influence determinations of threat?

Violent rhetoric online is becoming increasingly relevant to the practice of forensic mental health assessment as examinee's virtual lives may transform into real-world acts of violence. With the rise of a diverse subculture of violent online communities, the aim of the present study was to inform how concerns with online sources of collateral data and racial/ethnic biases may influence determinations of violence potential. Using an experimental design, jury-eligible participants (N = 278) and forensic mental health experts (N = 78) were presented with mock Twitter (now referred to as X) posts that varied by data source (i.e., how information was accessed) and the examinee's race/ethnicity. Results showed no differences in participants' ratings of data credibility, how much weight they would place on the posts in a threat assessment, or how likely the examinee was to act violently against his intended target. Implications regarding the interpretation of social media evidence, relevant limitations, and future research are discussed.

Readmission after discharge from a medium secure service between 1999 and 2017: A retrospective cohort study.

BACKGROUND: Previous research into outcomes after treatment in medium secure psychiatric hospitals has mostly relied on pre-millennium data. AIMS: To examine patient and inpatient service-related factors associated with readmission within 2 years following discharge to the community or open conditions from conditions of medium security. METHODS: A retrospective cohort study of 137 patients discharged either to the community or to open conditions from one 64-bed South Wales Regional Medium Secure Hospital Unit between July 1999 and November 2017 was completed using data from healthcare records to document demographics, diagnosis and nature of index offences together with researcher-completed ratings of inpatient progress using the Dangerousness Understanding Recovery and Urgency Manual (DUNDRUM) Programme Completion and DUNDRUM Recovery scales. Binary logistic regression analyses were used to identify independent associations between inpatient progress according to these measures and readmission. RESULTS: Forty-three patients (31%) were readmitted within 2 years of discharge and 23 (17%) in breach of legal conditions on discharge. Most readmitted patients (n = 29, 67%) returned directly to medium secure care. There were significant binary level associations between readmission and severity of the index offences (lower), number of adverse childhood experiences (higher), history of drug misuse (more likely) and number of previous psychiatric admissions (higher). Binary logistic regression confirmed that these relationships were not independent. No inpatient service-related variables, according to DUNDRUM scale scores, showed an independent association with readmission within 2 years post-discharge. CONCLUSIONS: The proportion of medium security hospital patients who were readmitted within 2 years of discharge aligns with estimates found in earlier national research using the same follow-up period. Since levels of inpatient progress bore little if any relationship to longer term outcomes, our findings highlight the need for investigating factors in the discharge environment that are linked to readmission. It is possible that readmission may indicate effective monitoring and responsive care to the changing needs of patients, but a better understanding of this is essential.

Randomised controlled trial of the short-term effects of osmotic-release oral system methylphenidate on symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder: CIAO-II study.

BACKGROUND: Research has shown that 20-30% of prisoners meet the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but effects in prisoners are uncertain because of comorbid mental health and substance use disorders. AIMS: To estimate the efficacy of an osmotic-release oral system methylphenidate (OROS-methylphenidate) in reducing ADHD symptoms in young adult prisoners with ADHD. METHOD: We conducted an 8-week parallel-arm, double-blind, randomised placebo-controlled trial of OROS-methylphenidate versus placebo in male prisoners (aged 16-25 years) meeting the DSM-5 criteria for ADHD. Primary outcome was ADHD symptoms at 8 weeks, using the investigator-rated Connors Adult ADHD Rating Scale (CAARS-O). Thirteen secondary outcomes were measured, including emotional dysregulation, mind wandering, violent attitudes, mental health symptoms, and prison officer and educational staff ratings of behaviour and aggression. RESULTS: In the OROS-methylphenidate arm, mean CAARS-O score at 8 weeks was estimated to be reduced by 0.57 points relative to the placebo arm (95% CI -2.41 to 3.56), and non-significant. The responder rate, defined as a 20% reduction in CAARS-O score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. No statistically significant trial arm differences were detected for any of the secondary outcomes. Mean final titrated dose was 53.8 mg in the OROS-methylphenidate arm. CONCLUSIONS: ADHD symptoms did not respond to OROS-methylphenidate in young adult prisoners. The findings do not support routine treatment with OROS-methylphenidate in this population. Further research is needed to evaluate effects of higher average dosing and adherence to treatment, multi-modal treatments and preventative interventions in the community.

Methylphenidate for prison inmates with ADHD: yes or no?

In a double-blind randomised controlled trial by Asherson et al., involving prisoners with attention-deficit hyperactivity disorder (ADHD), the rates of response to osmotic-release oral system methylphenidate (OROS-methylphenidate) and placebo were very similar (~50%). I critically discuss this trial against other international literature, highlighting the key issues in the field in terms of clinical practice and research.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project.

BACKGROUND: The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence. METHOD: Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process. RESULTS: The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant. CONCLUSIONS: This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

First Nations Peoples in the forensic mental health system in New South Wales: Characteristics and rates of criminal charges post-release.

BACKGROUND: It is well established that First Nations Peoples in Australia are overrepresented within the criminal justice system. However, First Nations Peoples appear to be comparatively underrepresented in the forensic mental health system, and little is known about their outcomes once released from secure care. OBJECTIVE: To compare the characteristics and rates of repeat criminal justice contact for a criminal charge of First Nations and non-First Nations forensic patients in New South Wales. METHODS: Data on the sample were extracted from the New South Wales Mental Health Review Tribunal paper and electronic files matched to the Bureau of Crime Statistics and Research Reoffending Database. Characteristics of First Nations and non-First Nations patients were compared using univariate logistic regression analysis. Univariate and multivariate Cox proportional hazard regression was used to determine predictors of post-release criminal charges. RESULTS: Key differences in the sociodemographic, clinical and forensic characteristics of First Nations compared with non-First Nations forensic patients were identified. The time to first criminal justice contact following release was significantly shorter for First Nations forensic patients (p < 0.01). CONCLUSION: The findings of this study confirm that First Nations forensic patients have distinct and complex needs that are apparent at entry to the forensic mental health system and that their poorer criminal justice contact rates following release from secure care indicate that these needs are not being adequately met either during treatment or once in the community. Responses to these study findings must consider the complex and continuing impact of colonisation on First Nations Peoples, as well as the need for solutions to be culturally safe.

Why do nurses seek employment in forensic mental health and what are their first impressions of the clinical environment? A mixed methods study.

AIM: The aim of the study was to investigate why registered nurses seek forensic mental health employment and explore their initial impressions of this setting. DESIGN: Explanatory sequential mixed methods. METHODS: Registered nurses employed in a forensic mental health hospital completed an online survey about their reasons for seeking work in forensic mental health and their transition into the setting. To fully explore findings, semi-structured interviews were conducted with a sub-group of survey respondents. Descriptive statistics were used to analyse survey data, and thematic analysis was used to analyse the interviews. RESULTS: Sixty-nine respondents completed the survey, and 11 interviews were conducted. Prior interest in forensic mental health and encouragement from hospital staff were considered important influences in seeking forensic mental health employment. New knowledge, changes in clinical responsibility, exposure to patients' background offences and security processes overwhelmed some participants initially. However, participants reported that the initial challenges of their transition revealed opportunities to develop genuine connections with patients. CONCLUSION: This study provides a new understanding of the reasons why nurses seek employment in forensic mental health and the challenges and opportunities experienced when first working in this setting. Such professional and personal elements need to be considered by organizations to strengthen recruitment strategies and support future nurses' transition into forensic mental health settings. IMPACT: This study provides new knowledge about recruiting and supporting nurses' transition into forensic mental health employment. As such, it informs policymakers, clinical services and managers about strategies needed to attract and retain this workforce. PATIENT OR PUBLIC CONTRIBUTION: No public or patient involvement.

Examiners' perceptions of forensic mental health assessments conducted via videoconferencing.

The COVID-19 pandemic led to an acceleration in the adoption of videoconferencing (VC) for conducting forensic mental health evaluations (forensic mental health assessments [FMHA]). Two years into the COVID-19 pandemic, we administered a survey to 71 Minnesota-licensed forensic evaluators. Approximately two-thirds (65.7%) had started using VC for FMHA only after the pandemic, though a combined 84.5% reported performing FMHA via VC frequently at present. A striking 43.7% of respondents preferred VC for FMHA over in-person evaluation, and another 22.5% expressed no preference between modalities. Further, nearly 70% of respondents denied there were any populations for which they would never use VC to complete an FMHA. We conclude that the widespread adoption of VC for FMHA with the advent of the COVID-19 pandemic has induced a lasting change in the practice of FMHA. We postulate that with further advancements in technology and the development of testing instruments that can be administered online, the use of VC for FMHA will become standard practice.

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project.

BACKGROUND: There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries. AIMS: In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe. METHODS: Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed. RESULTS: Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others. CONCLUSIONS: Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Psychiatric rehabilitation in secure forensic settings in NSW: Measuring outcomes.

OBJECTIVE: To quantify outcomes for patients of forensic psychiatric rehabilitation in NSW. METHODS: Data on 245 conditionally released forensic patients was extracted from the Mental Health Review Tribunal (MHRT) files and matched to several state-wide datasets. Descriptive statistics were generated to establish the cohort characteristics, rates of reoffending and social and clinical outcomes. RESULTS: At conditional release, social circumstances for the majority of patients were improved. Clinically, the cohort was more stable, though many did not remain stable over time. Only one-fifth of the sample received a further criminal charge. CONCLUSION: Preliminary evidence suggests that forensic rehabilitation services in NSW are effective.

Eliciting an offence narrative: what types of questions do forensic mental health practitioners ask?

Maximising the accuracy and detail of information elicited through a clinical-forensic interview may increase the reliability and validity of an individual's assessment. Despite this, there is little empirical research on what questions forensic mental health practitioners employ, and whether these correspond with empirically established interviewing strategies. In this study, 22 forensic mental health practitioners participated in a mock interview of a young person referred for a sexual risk assessment. The results highlighted that participants asked very few 'open' questions, over-relied on 'specific' questions and an average of 13% of questions were leading. Finally, practitioners predominantly used 'yes/no' questions when exploring the young person's thoughts, feelings, and physiological responses. Overall, the study demonstrated that empirically supported interviewing techniques were not commonly employed and highlighted the need for further professional development and training around clinical forensic interviewing strategies that best elicit the information needed to inform risk assessment.

Patient outcomes in an Australian low secure forensic psychiatric rehabilitation inpatient unit: a 10-year retrospective study.

The aim of this study is to investigate the background and discharge outcomes of the forensic patient population rehabilitated through a low secure forensic psychiatric rehabilitation inpatient unit. Currently within Australia and internationally there is a scarcity of research completed within this setting. A quantitative methodology was selected coupled with descriptive statistics to investigate a total of 23 patients and analyse their demographics, historical information, length of stay and post-discharge outcomes including readmission and breach of forensic orders. This study provides insights into this unique patient group and further clarifies their psychiatric treatment and biopsychosocial needs. A significant variance was found within patient length of stay throughout each stage of the forensic system. Low rates of readmissions and breaches of forensic orders were found. Additional research is needed in this low secure psychiatric rehabilitation setting to clarify the forensic pathways of care and needs amongst this cohort.

Care pathways in forensic mental health services in New Zealand.

On entering forensic mental health services (FMHS) patients progress along forensic care pathways (FCP) that aim to maximise well-being and reduce risk of reoffending. They progress through high-, medium-, and low-secure psychiatric units with changing care and security needs. There is minimal literature examining FCP or their efficacy. This retrospective study describes the characteristics of patients admitted to an acute FMHS and explores the clinical, sociodemographic, and legal factors that influence FCP progression. Most patients were referred from prison (65.1%) and presented with violent index offending (62.4%) and psychotic disorder (80.6%). Young Maori men with psychosis predominated the forensic population. Logistic regression revealed violent index offending and diagnosis were determinants of following FCP, while violent offending and longer duration of stay were predictive of FCP progression. This study found no reduction in re-hospitalisation rates or inpatient length of stay over a three year follow-up for patients that completed the FCP.

Care Pathways, Health Service Use Patterns and Opportunities for Justice Involvement Prevention Among Forensic Mental Health Clients.

OBJECTIVES: The objective of the present study is to describe the patterns of health service use and of prescription claims in the year preceding an offense leading to a verdict of not criminally responsible on account of a mental disorder (NCRMD). METHODS: Provincial health administrative databases were used to identify medical services, hospitalizations, and ambulatory prescription claims among 1,014 individuals found NCRMD in Québec. Contacts in the year preceding the offense were analyzed using descriptive analyses and latent class analysis. RESULTS: Overall, 71.4% of subjects were in contact with services for mental health reasons within a year of their NCRMD offense. Among those that received services and not hospitalized for psychiatric reasons at the time of the offense, 20.7% committed the NCRMD offense within a week of the most recent mental health contact. Among those that had at least one prescription claim for an antipsychotic, 45.8% were not taking any antipsychotic at the time of the offense. Latent class analysis provided a multidimensional representation of mental health service use and showed that 58.4% of subjects had no or very rare contact with services. CONCLUSIONS: Many forensic patients are likely to have experienced service disruption or discontinuity while in the community, for reasons that may relate to perceived need for care, to service organization, or to the acceptability, availability, and accessibility of services. Given the serious impact of the "forensic" label on the lives of service users, not to mention the increased pressure on resources, the considerable economic costs, and the impact on victims, there is reason to advocate for a greater involvement of mental and physical health service providers in early prevention of violence, which requires reorganizing resources to share the forensic knowledge upstream, before an offense is committed.

The Ontario Forensic Mental Health System: A Population-based Review.

OBJECTIVE: The purpose of this study was to increase the understanding of the Canadian forensic psychiatry system by providing a population-based overview of the Ontario forensic mental health system. METHODS: Data were collected on 1,240 accused adults who were subject to the jurisdiction of the Ontario Review Board (ORB) between 2014 and 2015. Archival data were retrieved from annual ORB hearing hospital reports for accused supervised by all nine adult forensic psychiatry facilities across Ontario. RESULTS: The sample included not criminally responsible (NCR; 91.6%) and unfit to stand trial (UST; 8.4%) accused. The majority of the sample was male (85.7%), single (70.1%), unemployed (63.6%), with a high school education (48.8%). Most were on a detention order (78.5%) and almost half were living in the community at the time of the report (48.8%). The majority had prior contact with psychiatric services (83.1%) and/or the criminal justice system (70.6%) before entering the forensic system. A history of elopement (31.5%) and inpatient aggression was high (60.6%). Most had a psychotic spectrum disorder (81.6%) and over half had a substance use disorder (57.2%) in the reporting year. A range of index offences was observed (69.9% violent, 20.3% general, 9.8% sexual), and the majority of the sample (61.0%) had an index offence that resulted in no injury or a minor injury to the victim. CONCLUSION: The Canadian forensic psychiatry system is comprised of a unique subset of justice-involved individuals. This study provides a detailed examination of accused who are subject to the jurisdiction of the ORB and provides key insight into risk factors associated with offending behaviour in this population. The results of this study will provide a framework for future studies examining the association between mental disorder and violence and the treatment trajectories for those in the forensic psychiatry system.

Fetal alcohol spectrum disorders (FASD) and youth firesetting: A call on criminal justice, emergency responder, and fire prevention specialists to become informed.

Central nervous system damage resulting from prenatal exposure to alcohol, often referred to as fetal alcohol spectrum disorders (FASD), commonly manifests as lacking cognitive functioning, problem solving, impulsivity, memory, executive functioning, and social skill deficits. For individuals with FASD, these brain-based deficits translate into impulsive behaviors and poorly thought-out decision-making, coupled with an inability to anticipate and recognize the sometimes very severe consequences of their behaviors. Not unexpectedly, individuals with FASD frequently find themselves disproportionately involved in the criminal justice system and mental health services. For some individuals with FASD, these behaviors can also include firesetting. First responders, like other health and legal professionals, are often unable to recognize the behavioral indicators of FASD, primarily due to a lack of training. As a result, firesetting behaviors are often attributed to deliberate, willful acts of delinquency, a desire to damage property, thrill seeking, or as attempts for personal gain, rather than being viewed as maladaptive attempts to solve problems by individuals who lack the tools to do this in more appropriate ways. These same skill deficits also present when individuals with FASD are interviewed about their involvement in such behaviors, sometimes resulting in confabulation, suggestibility, and false confessions. Further education and training in FASD are vital for first responders if they are to better support individuals with FASD and minimize their chances of becoming involved in firesetting behaviors. Furthermore, this training and education will help ensure that first responders can intervene in more appropriately when crisis situations do occur. This article will outline key behavioral symptoms of FASD as well as provide first responders with suggestions as to how to best support individuals when FASD is suspected. The brief quote that follows highlights some of the key challenges facing individuals with FASD and how poor decision-making and impulsiveness can result in severe consequences for the individual and those around them.

Rates and implications of fetal alcohol spectrum disorder among released offenders with mental disorder in Canada.

Fetal alcohol spectrum disorder (FASD) is prevalent among individuals involved in the justice system. However, many of the characteristics of justice-involved individuals with FASD remain unknown. We assessed patients in a forensic mental health hospital (n = 26) for FASD before their release. The two objectives were to establish the prevalence of FASD in this unique environment and to describe the mental health and neurocognitive characteristics of individuals with FASD compared to patients with complex needs and those without FASD. The prevalence of FASD was 46%. We found the FASD group to have more than six impaired brain domains, greater than the other groups, and a higher prevalence of ADHD. Given the high prevalence of FASD reported in this study, along with the complexities and adversities associated with FASD and criminal justice involvement, this is a population that requires screening, assessment, and intervention.

"It's still our child". A qualitative interview study with parent carers in forensic mental health.

The purpose of this study was to explore the experiences and perceptions of parents in forensic mental health services with regard to their cooperation with healthcare professionals and their role as parent carers. 15 participants were interviewed using qualitative, in-depth interviews and transcripts were analysed thematically. The identified themes were 'Medical dominance', 'Interactions with healthcare professionals', and 'Advocating for their daughter/son'. The themes were associated with the overall theme 'perceived impact on the parents' everyday lives'. The results suggest that parent carers perceive a malalignment between the institutional medicalised treatment focus and the need for an integrated holistic approach, which would include them as partners.