Forensic learning disabilities: the evidence base. Executive summary.
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Comorbidity↗
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Risk assessment in offenders with intellectual disability: the evidence base.
A review of the current literature on risk assessment and management in offenders with intellectual disability (ID) revealed little direct evidence for the specific population. Theoretical models and non-ID populations have been abstracted and adapted, but not validated, for those with ID. The varying conceptual frameworks of risk, and its assessment and management, must be considered in context. Difficulties remain with the consideration of offences versus offence-like behaviour, offender versus those with similar needs, and indeed, what is regarded as 'intellectual disability'. Mainstream forensic assessment has moved towards a more dynamic appreciation of risk and risk management, as opposed to risk elimination. This development is more in line with the normalization principles of 'risk-taking' in ID. Consideration is given to future research and development priorities.
Comorbidity↗
Defining actuarial and clinical prediction: comment on Johnston S.J. Risk assessment in offenders with intellectual disability: the evidence base. Journal of Intellectual Disability Research, 46 (Suppl.1), 47-56.
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Actuarial Analysis↗
The development and evaluation of a brief risk screening instrument for the psychiatric inpatient setting.
This paper reports on the development and evaluation of a risk screening instrument (RSI) intended for use by nursing staff on general acute psychiatric admission wards. The RSI comprised six questions concerning patient status on admission (e.g. sex, legal status, employment) and 11 items of judgement concerning the presentation of the patient (e.g. threatening behaviour, suicidality, family and social support). The interrater reliability of the RSI was calculated to be 85% overall. The predictive value of the RSI was not confirmed when tested against harmful incidents subsequent to admission. However, the mean RSI score of that group of patients involved in harmful incidents tended to be higher than that group of patients not involved in such incidents, and all such incidents were found to occur within eight days of admission. Analysis of other data collected in the course of the study revealed discrete patient groups and provided systematic insights into their characteristics, which are potentially valuable when considering the nursing skills required on acute psychiatric inpatient units. It is concluded that the RSI tested has the potential to contribute to the assessment and management of risk within the acute psychiatric inpatient setting, by augmenting and guiding clinical judgement.
Adolescent↗
A review of clinical risk and related assessments in forensic psychiatric units.
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Antisocial Personality Disorder↗
Influence and coercion: relational and rights-based ethical approaches to forced psychiatric treatment.
The dominant rights-based approach to the ethics of coercion in psychiatric treatment guides clinicians in deciding whether treatment should be compelled or the patient's autonomy respected, but provides no guidance across the remaining broad continuum of influence that clinicians exert with patients. The assumptions of the rights-based approach lead to three dichotomous decisions: (1) 'Is the treatment voluntary?'; (2) 'Is the patient competent?' and (3) 'Are the consequence of no treatment dangerous?'. The assumptions of a relational approach lead to ethical guidance across the full range in the intensity and types of influence which may be ethically justified or required in psychiatric treatment. These assumptions are: (1) influence is inherent in the clinical relationship; (2) the relevant factors are continuous and (3) all decisions are subjective. While the rights-approach emphasizes defining competence and developing techniques to predict future patient dangerousness, the relational approach emphasizes patient-clinician responsibilities in ethical relationships and understanding all factors which legitimately bear on the use of influence. An initial list of such factors is offered.
Coercion↗
Constructing mental illness as dangerous: a pilot study.
OBJECTIVE: There is a dearth of studies examining how dangerousness is constructed in media depictions of mentally ill individuals who are frequently portrayed as acting violently. The aim of the present study was to identify the contribution of diverse technical, semiotic and discursive resources utilised in portraying a character with a mental illness in a prime-time drama as dangerous. METHOD: Discourse analytic techniques, involving systematic, repeated, critical viewings, were applied to a single program drawn from a sample of prime-time television drama episodes touching on mental illness. RESULTS: Nine devices (appearance, music and sound effects, lighting, language, intercutting, jump-cutting, point of view shots, horror conventions and intertextuality) were identified as contributing to the signified dangerousness of person receiving care in the community for a mental illness. CONCLUSIONS: These techniques combine in signifying mental illness and a person suffering from it as dangerous. The findings suggest that mental health professionals working to reduce the stigma of mental illness need to have a reasonably sophisticated understanding of the practices and priorities of television production if they are to collaborate effectively with producers to create dramas that convey more human and sympathetic understandings of mental illness or to combat the negative effects of such portrayals.
Dangerous Behavior↗
Inquiries into homicides and serious violence perpetrated by psychiatric patients in New Zealand: need for consistency of method and result analysis.
BACKGROUND: The violent action of mentally ill people is a source of considerable public and professional concern. At times such incidents are subject to inquiry. In England and Wales, homicides by people suffering from mental illness are subject to mandatory external inquiry. Further, the Royal College of Psychiatrists coordinates a confidential research study into homicide and suicide by people in contact with mental health services. Inquiries have raised concern regarding widespread problems in mental health service delivery. Within New Zealand, similar concerns have been raised, but inquiries have been irregular and not of consistent methodology. The paper aims to review 10 years of inquiries into violent incidents to describe their methods, structure and findings. METHOD: All inquiries into violent actions perpetrated by patients in contact with mental health services between 1988 and 1998 and held by the Ministry of Health were reviewed. The nature of the inquiry, the incident, findings and recommendations were summarized. For each inquiry, an assessment was made as to whether the incident was predictable or preventable. RESULTS: There were 11 incidents leading to 13 inquiries, six of homicide, two of rape, one of the release of a dangerous patient and two in which a patient was shot by police. Two internal inquiries were followed by external inquiries. All inquiries found deficiencies of varying severity, the degree of deficiency being greater with external inquiries. Consistent criticisms related to skill, resource, coordination and communication failures. Two of the 11 inquiries found the incident to be 'predictable', and eight to have been 'preventable'. CONCLUSIONS: The problems in New Zealand are similar to those noted in England and Wales. Small numbers of inquiries make firm conclusions difficult, but the authors feel that a mandatory process of independent review of serious incidents is wise.
Cross-Sectional Studies↗
Deinstitutionalization for long-term mental illness: a 6-year evaluation.
OBJECTIVE: Forty-seven patients with long-term mental illness were transferred to the community following the closure of a psychiatric hospital in Sydney. This 6-year evaluation is an extension of a detailed clinical, ethnographic and economic study of the initial 2-years of community transition. METHOD: Quantitative evaluation was conducted using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Assessments were completed prior to discharge and at two- and 6-year intervals following community transfer. Repeated measures analysis was utilized to determine changes in outcome variables over time. The residents' perception of 6-years of community living was explored in qualitative semistructured interviews. Details of accommodation, level of care, readmissions, incidents and medication were also documented. RESULTS: During the 6 years following community relocation a total of seven residents returned to hospital for long-term care, three residents died from medical causes and one resident required detention in a corrective services facility. The 36 residents who remained in the community at the 6-year follow-up no longer required intensive 24-h supervision. Living semi-independently, 23 residents resided in two to three person accommodation with either daily or weekly case manager visits. Clinically, community residents remained stable over the 6 years without significant changes in psychiatric symptoms, depression, living skills or social behaviour problems. Clinical stability was achieved with significant reduction in medication levels over the 6 years. Community-based residents continued to experience improved quality of life and reported their marked preference for living in the community. CONCLUSION: The residents maintained community tenure with significant improvement in quality of life and a reduction in medication, supported by a mental health system with adequate community resources. Issues regarding continuing rehabilitation and social integration need to be addressed. Further deinstitutionalization will require 24-h supervision for most initially and for some on a continuing basis. An ageing population will require specific age related medical and psychiatric services.
Activities of Daily Living↗
Incident monitoring in psychiatry.
Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the 'adverse outcome' and 'near-miss' categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.
Antidepressive Agents↗
Sex, kings and serial killers and other group-selected human traits.
(Note: This unorthodox paper contains the first argument for heart disease being a programmed age change and promoted by the dramatic, post age-40 increases in the hormones FSH and hCG seen in some individuals.) A recent issue of Science suggests that the evolutionary purpose of sex is unknown. PARADOX: Surviving to adulthood implies a valuable gene combination which is destroyed by sexual recombination. This should be detrimental to offspring. PROPOSED: Sex is group-selected in prey to allow coalescence of beneficial, and disposal of detrimental, mutations in single individuals enabling rapid adaptation to novel predation. Group selection is a universal force driven by local inter-species (not intra-species) competition. Aging, metabolism, litter size, and fixed body size are directly linked. Sexual recombination and chromosomes destroy gene linkage and exist because mutations are usually detrimental, rarely positive, and occur in linked groups. In unevolving environments, sex is selected against and asexuality emerges. Periodic evolution of novel predators, like man, can explain the 'punctuated equilibria' fossil record. Genes inhibited by methylation or chromatin condensation, expressed at older ages in predation-minimized environments, allow for group selection. Stress increases mutation rates and beneficial mutation likelihood. Females select bigger, brighter, louder, or stronger males that can survive predator attention. Size approximates age and thus predator encounters; male traits represent predation-survival potential. Human male traits include, balding, acne, beard-length, wrinkling, graying, nose/ear growth. Progeria accelerates development of most male traits. Domination of groups by single males allows rapid predation-defense evolution: adolescent males are expelled, brave the wild, and expel another group's male to mate. If expelled and dominant males are culled by predation, males reaching puberty first will reproduce. Hormonal acceleration of puberty accelerates aging/population turnover, induces smaller bodies, larger litters. With a fixed group biomass, more, smaller, stressed individuals with faster aging/turnover, increase beneficial mutation likelihood. 'Kin selection', where dominant families are supported by celibate relatives, allow the best group genes to survive famine. Dominant families gorge while others starve. Equal food sharing results in group extinction leading to group-evolved human traits of social hierarchy, greed, king/queen/God worship. Menstrual hormone cycling parallels aging. FSH and DHT promote ovarian, hair, acne, dental, and arterial follicle development causing ovulation, hair growth, pimples, dental caries, and atherosclerotic soft plaques. Soft plaques contain macrophages and LDL plug; upper plaque layers thin and rupture, releasing LDL plug, causing thrombosis. FSH withdrawal or LH/hCG increases trigger ovulation and thrombosis. Artery narrowing atherosclerotic hard plaques are stress-induced through cortisol-promoted necrotic calcification. LH/hCG-induced apoptosis promotes ovulation and aging-related somatic atrophy. Long-term estradiol stimulates, while progesterone suppresses, gonadotropin levels. Estradiol protects by inhibiting gonadotropin bioactivity and has extracellular antioxidant, but intranuclear free radical, effects. Female X-linked gene mosaicism conserves evolved aging systems. Maternal age factors for chromosomal trisomy suggest menopause prevents human parthenogenesis. Homosexuality and serial killing inhibit genetic contribution by individuals evolutionarily perceived as stressed. Smoking during pregnancy may induce homosexual offspring. Nitric oxide, a free radical, stimulates cGMP, but not cAMP. cGMP likely first evolved as an antioxidant defense to free radicals. Human aging syndromes might reflect human evolution progression. AS#4 affects tissues evolved from plant ancestors, AS#5a - from predators, AS#5b-immune system, and AS#6-sex tissues. (ABSTRACT TRUNCA
Aging↗
[Admissibility of physical immobilization of patients].
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Aggression↗
[Development of legislation for the care of the mentally ill as seen by the psychiatrist].
Ten years after the introduction of the new legislation concerning mentally ill or impaired persons ("Betreuungsrecht") it is now possible to review the problems. These cover inter alia the appointment of a curator to the legal proceedings, the practice of the reservation of consent, the question of legal incapacity and the cost problem. The medical expert must be aware of the development of these issues, especially as the medical and the juridical point of view often do not correspond with the well-being of the patient. This article conveys views from the psychiatric perspective to the questions outlined above and offers suggestions for possible improvements.
Adult↗
[High utilizing as a team effort].
The following report describes Mr. Z., who was a former long-term hospitalized psychiatric patient and who turned from a permanent inpatient into a high utilizer of a hospital in a process of several years. In addition the report describes the commitment and often unconventional ways of cooperation by different staff and institutions, that made it possible for Mr. Z. to look forward to a future outside the hospital.
Activities of Daily Living↗
[Decisions about sectioning and medicating of schizophrenic patients in Germany and England--results of a comparative study].
Questionnaires with three case summaries have been presented to 143 psychiatrists in Germany and 27 in England. All three case summaries regard patients with schizophrenia who either show risk to themselves or others. The psychiatrists were asked whether they would recommend sectioning and furthermore whether they would recommend treatment against the patient's will. In the case regarding a risk to others there was widespread approval of sectioning and treatment (Germany 85 %, England 93 %) against the patient's will. Significant differences were seen in the cases of risk to the patients themselves with regards to treatment against the patient's will. This was the case with a scenario involving a young man with his first presentation of schizophrenia as well as in the case of a middle aged man presenting with chronic psychotic symptoms and self-neglect (approval in England: 96 % and 93 % respectively, in Germany: 63 % and 59 % respectively, p < 0.001 for both). When a logistic regression was performed the country of work was the most important predictive factor in deciding whether or not to treat a patient against his will.
Adult↗
[How does a general hospital psychiatric unit deal with violent patients? The border between community psychiatric services and forensic psychiatric hospitals].
ISSUE: In psychiatric and psychotherapeutic clinics that are responsible for supplying care for a region, how often are patients transferred to forensic psychiatric hospitals? Is there a tendency to "send off" aggressive or threatening patients as quickly as possible? METHOD: In the psychiatric and psychotherapeutic clinic responsible for the Berlin's Neukölln district, for one year (2000) all patients who committed a severe criminal offence immediately before or during their in-patient treatment were registered for observation in 2000. The steps of investigation and further legal consequences were recorded. RESULTS: During the period of observation, 0.1 percent of the patients were transferred from the clinic to a forensic psychiatric hospital. Weeks or months after their regular release, 0.4 percent of the patients were committed to a forensic department. The court ordered an ambulant psychiatric evaluation for 0.5 percent of the patients. CONCLUSION: Only a few patients were transferred to forensic psychiatric hospitals. A tendency to "send off" aggressive patients as soon as possible, thus abusing forensic psychiatry, was not found in this study.
Aggression↗
[Is there a reason to criminalize psychiatric patients to create treatment facilities for them?].
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Adult↗
[Compulsory admission of mentally ill patients in European union member States].
AIMS: A standardised and systematic analysis of commitment laws in the EU-Member States is still missing. This study aimed at gathering, describing and analysing information on the differences or similarities of legal frameworks for involuntary placement and treatment of mentally ill patients across the European Union Member States. METHOD: Information was gathered by means of a detailed questionnaire filled in by experts from all EU Member States. Legal criteria for compulsory admission, details of the assessment and decision process of compulsory admission and epidemiological data are outlined. RESULTS: Although common patterns among Member States can be identified upon comparison of crucial legislative or procedural details, these patterns are far from being consistent across all analysed items or approaches. With regard to compulsory admission quotas no significant influence of legal commitment criteria and the involvement of judicial authorities could be found but Member States with an obligatory inclusion of a legal representative during the commitment procedure showed significantly lower compulsory admission quotas. CONCLUSION: Results of this study show the strong necessity for further research in this field. Common international health reporting standards as annually updated involuntary placement rates detailed for regular and emergency cases seem to be essential.
Commitment of Persons with Psychiatric Disorders↗