A retrospective study on risk assessment and management of forensic psychiatric inpatients in Hong Kong

The Department of Forensic Psychiatry of Castle Peak Hospital is the only facility in Hong Kong that provides territory-wide forensic psychiatric services for patients with criminal involvement. This retrospective study aimed to explore whether the rehabilitation programs provided by the department could significantly reduce the risks of forensic psychiatric inpatients as measured by the Short-Term Assessment of Risk and Treatability (START). START ratings of inpatients who were hospitalized in the department for more than 3 months and were discharged to the community during the period from 11 April 2015 to 31 March 2019 were analyzed. A total of 79 patients were assessed, of whom 61 (77.2%) were males. Fifty-four (68.4%) patients suffered from schizophrenia. START scores upon admission (strength score = 5.67; vulnerability score = 17.43) and upon discharge (strength score = 6.87, vulnerability score = 11.18) indicated significant reduction of risks among inpatients (p < 0.05).     

Using dynamic risk and protective factors to predict inpatient aggression: Reliability and validity of START assessments

The Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & C. Middleton, 2004) is a relatively new structured professional judgment guide for the assessment and management of short-term risks associated with mental, substance use, and personality disorders. The scheme may be distinguished from other violence risk assessment instruments because of its inclusion of 20 dynamic factors that are rated in terms of both vulnerability and strength. This study examined the reliability and validity of START assessments in predicting inpatient aggression. Research assistants completed START assessments for 120 male forensic psychiatric patients through review of hospital files. They also completed Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997) and Hare Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) assessments. Outcome data were coded from hospital files for a 12-month follow-up period using the Overt Aggression Scale (OAS; S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986). START assessments evidenced excellent interrater reliability and demonstrated both predictive and incremental validity over the HCR-20 Historical subscale scores and PCL:SV total scores. Overall, results support the reliability and validity of START assessments and use of the structured professional judgment approach more broadly, as well as the value of using dynamic risk and protective factors to assess violence risk. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

The Short-Term Assessment of Risk and Treatability (START): a prospective validation study in a forensic psychiatric sample

A new assessment scheme--the Short-Term Assessment of Risk and Treatability (START)--presents a workable method for assessing risks to self and others encountered in mentally and personality disordered clients. This study aimed to demonstrate (a) prevalence and severity of risk behaviors measured by the START, (b) psychometric properties of START, (c) similarities and differences in START scores across different mental health professionals, and (d) concurrent validity of START with diverse negative outcomes. Treatment team members completed the 20-item, dynamically focused START for 137 forensic psychiatric inpatients. Prevalence and severity of START risk domains were measured for 51 patients detained in the hospital for 1 year. Results revealed high rates of generally low-level adverse events. With some exceptions, START scores were meaningfully associated with outcomes measured by a modified Overt Aggression Scale.     

The Effect of Masculinity on Community Reintegration Following TBI in Military Veterans

The present study examined the effect of level of traditional masculine gender role norms as well as the moderating effect of cognitive flexibility on community reintegration outcomes in a sample of 60 male military veterans who had sustained a traumatic brain injury during deployment. Data were collected through self-report measures and cognitive tests. Results suggested that greater endorsement of traditional masculine gender role beliefs, attitudes, and behaviors was significantly inversely related to the community integration domains of relationships and living skills and not significantly related to work and leisure. The effect of masculinity on healthy living skills was moderated by cognitive flexibility; the protective effect of low masculinity on living skills was only present if the veteran also had high cognitive flexibility skills. Results are discussed in the context of gender role strain, potential limiting aspects of stereotypy on recovery and reintegration, and the importance of cognitive flexibility in the recovery/reintegration process.     

Characteristics of START Assessments Completed in Mental Health Jail Diversion Programs

Many different instruments have been developed to assist in the assessment of risk for violence and other criminal behavior. However, there is limited evidence regarding how these instruments work in the 'real world'. Even less is known about how these instruments might work for assessing risk in jail diversion populations, whether in research or practice. To address these knowledge gaps, the present study examined the characteristics of risk assessments completed by program staff (n?=?10) on 96 mental health jail diversion clients (72 men and 24 women) using the Short-Term Assessment of Risk and Treatability (START). The findings provide preliminary support for the reliability and validity of START assessments completed in jail diversion programs, the first evidence of the transportability of START outside psychiatric settings, and further evidence regarding the reliability and validity of START assessments completed in the field. They additionally support the consideration of an eighth, general offending risk domain in START assessments. Copyright ? 2012 John Wiley & Sons, Ltd.     

Further Evidence for Reliability and Validity of the Triarchic Psychopathy Measure in a Forensic Sample and a Community Sample

Psychopathy is often described as a constellation of personality characteristics encompassing features such as impulsivity and antisociality, and a lack of empathy and guilt. Although the use of self-reports to assess psychopathy is still debated, there are distinct advantages to such measures and recent research suggests that they may not be as problematic as previously thought. This study further examined the reliability and validity of the Triarchic Psychopathy Measure (TriPM) in a community sample (N = 496) and forensic psychiatric patient sample (N = 217). Results indicated excellent internal consistencies. Additionally, the TriPM total and subscale scores related as expected to different subscales of the Psychopathic Personality Inventory –Revised (PPI-R) and to the Reactive and Proactive Aggression Questionnaire, reflecting good construct validity. Most importantly, ROC curve analyses showed that the TriPM evidenced better discrimination between the community sample and forensic psychiatric patients than the PPI-R. The current study extends the existent evidence demonstrating that the TriPM can be used as an efficient self-report instrument.     

The predictive validity and practical utility of structured schemes used to assess risk for aggression in psychiatric inpatient settings

There has been increased interest in structured schemes for the assessment of risk for aggression within inpatient psychiatric settings. The most commonly utilized schemes are those previously developed to assess risk for prisoners being considered for release on parole and for forensic psychiatric patients being considered for discharge from the hospital to the community. Few structured schemes have been developed with the explicit aim of assessing risk for aggression in the inpatient setting. Recent research utilising a variety of risk assessment schemes has revealed reasonable predictive validity. This narrative review summarizes and appraises this expanding literature within the context of risk assessment decision making tasks typically undertaken by psychiatric unit staff. It is concluded that a number of structured risk assessments schemes do have acceptable predictive validity. Unfortunately, many of the schemes tested are compromised by a lack of practical utility, and only a few are capable of contributing to the entire range of risk assessment decision making tasks required. Options for the application of structured risk assessment schemes are raised.     

L’intelligence artificielle peut-elle aider à estimer le risque de récidive dans les comportements violents ?

In forensic psychiatry, magistrates raise the question of the existence of a risk of recidivism and dangerousness to psychiatric experts. Follow-up studies in forensic psychiatry showed that the psychiatric elements predictive of recidivism were mainly related to serious mental illnesses, toxic consumption, addictions, high levels of impulsivity, low insight, associated personality disorders, in particular antisocial personality disorders. There are also protective factors, in particular the observance of treatments. Given the complexity of psychiatric and criminological risk factors and protection, can artificial intelligence (AI) help psychiatrists and magistrates to improve the predictivity of recidivism?MethodsSystematic review of the literature on AI applications in the prediction of recidivism in forensic psychiatry, conducted according to PRISMA criteria, using the: “Artificial Intelligence”, “Recidivism”, “Personality Disorder”, “Impulsive” Behavior”, “Alcohol abuse”, “Drug Abuse”, “Schizophrenia”, “Bipolar disorder” on the PubMed, Science Direct, Clinical Trial and Google Scholar databases.ResultsThe vast majority of studies come from legal or computer reviews and very few from medical databases. The studies evaluating the AI in Forensic Psychiatry most often used Machine Learning based on sociodemographic, sociological and criminological data, notably the age of the first offense and the number of previous convictions. To date, there are very few studies evaluating psychiatric parameters, focusing on psychopathic personality disorders.Discussion/conclusionThe applications of the AI in Forensic Psychiatry are still very premature. However, some psychiatric criteria should be more prominent in this field, especially those from Webster's HCR-20 and Hare PCL-R scales. The challenge will also be to find relevant behavioral, psychological and psychiatric keywords to include in AI.     

Entlassene Problemf?lle in der ambulanten Nachsorge von langzeitinhaftierten und langzeituntergebrachten Patienten

The reintegration of patients into society after long-term inmate or long-term forensic hospital treatment is as difficult as it is important. At present only a few specialized forensic outpatient departments can be found in Germany. In the following article essential pillars for successful outpatient care by taking all participants in the reintegration process into account will be presented.     

Does Reintegration Stress Contribute to Suicidal Ideation Among Returning Veterans Seeking PTSD Treatment?

Although posttraumatic stress disorder (PTSD) and other psychiatric symptoms are well‐established risk factors for suicidal ideation among returning veterans, less attention has been paid to whether the stress of reintegrating into civilian society contributes to suicidal ideation. Utilizing a sample of 232 returning veterans (95% male, mean age = 33.63 years) seeking PTSD treatment, this study tested whether reintegration difficulties contribute to suicidal ideation over and above the influence of PTSD symptoms, depression symptoms, and potential substance misuse. Logistic regressions indicated that reintegration stress had a unique effect on suicidal ideation over and above PTSD and depression symptoms. Reintegration stress interacted with substance misuse to predict suicidal ideation, such that the effect of reintegration stress on suicidal ideation was much larger for those with potential substance misuse. Exploratory analyses also examined which types of reintegration difficulties were associated with suicidal ideation, and found that difficulty maintaining military friendships, difficulty getting along with relatives, difficulty feeling like you belong in civilian society, and difficulty finding meaning/purpose in life were all significantly associated with suicidal ideation, beyond the effects of psychiatric symptoms and potential substance misuse. Findings highlight the importance of addressing reintegration stress for the prevention of suicide among returning veterans. Implications for treatment are discussed.     

Umgang mit gefährlichen Straftätern in England und Wales

Forensic psychiatric institutions exist in all western European countries. Their organisation depends on a number of factors including the legal framework and societal attitudes towards mentally disordered offenders. This article describes and critically comments on the forensic psychiatric system in England and Wales, its legal framework and approaches to dealing with dangerous offenders. England and Wales have a long forensic psychiatric tradition with the first high security hospital, Broadmoor hospital, having been established in 1863. Evidence-based treatment approaches in forensic hospitals as well as in prisons, training of forensic psychiatrists and research in the field of forensic psychiatry have gained international recognition. However, there are some worrying aspects in the system of forensic psychiatric care and the criminal justice system more generally, in particular the high and still increasing number of prisoners in comparison with other European countries, the low age of criminal responsibility, long sentences, increasing length of stay in forensic care and the increasingly risk averse culture. A number of differences to the German system can be found; one such difference relates to the role of criminal responsibility which is irrelevant for decisions regarding commitment in England and Wales. Only the mental state and need for treatment at the time of trial (or later assessment in prison) determine whether an offender is admitted to psychiatric care or receives a prison sentence. A number of new initiatives have been launched in recent years resulting in an increasing number of individuals being detained in forensic psychiatric and criminal justice institutions, in particular the initiative for the detention and treatment of individuals with so-called dangerous and severe personality disorders, the sexual offenders register and the new sentence of indeterminate imprisonment for public protection. These initiatives have been the subject of a number of complaints to the European Court of Human Rights. Nevertheless, the trend towards a more and more risk averse culture continues.     

Self-reported personality traits and disorders (DSM-IV) and risk of criminal recidivism: a prospective study

Assessment and management of criminal offenders require valid methods to recognize personality psychopathology and other risk and protective factors for recidivism. We prospectively explored the association between dimensional and categorical measures of personality disorder (PD) measured with the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q, Ottosson et al., 1995) and registered reconvictions in adult offenders. One hundred and sixty-eight offenders consecutively referred for pre-sentencing forensic psychiatric evaluation in Sweden during 1995-1996 completed DIP-Q self-reports. The subjects received different types of sanctions and were followed for an average of 36 months after release from prison, discharge from a forensic psychiatric hospital, or onset of nondetaining sentences. Age-adjusted odds ratios revealed a 4.8 times higher risk for any recidivism and a 3.7 times higher risk for violent recidivism among subjects whose self-reports suggested a categorical diagnosis of antisocial PD as compared to offenders without antisocial PD. The remaining nine categorical DSM-IV PD diagnoses were not significantly related to recidivism. In dimensional analyses, each additional antisocial and schizoid PD symptom endorsed by participants at baseline increased the risk for violent reoffending. Our results suggest a relationship between self-reported behavioral instability and interpersonal dysfunction captured primarily by DSM-IV antisocial and schizoid PD constructs, and criminal re-offending also in a multi-problem sample of identified offenders.     

Operationalizing the Assessment and Management of Violence Risk in the Short-term

Assessing risk of violence in the short term is crucial for managing and preventing violence, especially in institutions such as psychiatric units and prisons. Despite a lack of consensus on the definition of "short term", a number of recent tools and guidelines have been developed to aid short-term clinical decision-making. Whereas the supporting evidence for the new tools is impressive, limitations remain in terms of the focus on prediction, limited consideration of strengths, and poor integration with formulation and risk management. The Short-Term Assessment of Risk and Treatability (START) is a brief clinical guide for the dynamic assessment of risks, strengths and treatability. It focuses on short-term risks and the characteristics of the individual that, if changed, might lead to an increase or decrease in risk. The START has the potential to operationalize the structured professional judgment (SPJ) approach in order to inform the evaluation of multiple risk domains relevant to everyday psychiatric clinical practice. However, explicit guidance on integrating risk assessment, formulation and management is limited in the START and this paper describes the SPJ approach, reviews recent developments in approaches to risk, and considers how the START can be used to inform SPJ approaches and link risk assessment, formulation, and management. Copyright ? 2012 John Wiley & Sons, Ltd.     

Drawing to reconstruct: Pilot study on acknowledging prisoners' internal and external resources in a penitentiary institution

Since the first offender rehabilitation treatments, all theoretical approaches have been focusing on reducing risk factors that may influence recidivism, without satisfactory results. Recent resilience research has instead shown the important mediating or moderating role of protective factors and provided the theoretical principles for the Good Lives Model Comprehensive. This holistic model suggests the importance of integrating the reduction of risk factors with the reinforcement of protective factors in offenders' treatment programs. This combined action is considered the main condition through which offenders are motivated to change their life and develop a sense of agency on their current life conditions. This article presents a pilot study, aimed at analyzing the feasibility of a psychosocial intervention, based on graphic workshops. The purpose of the intervention is helping prisoners strive toward adaptation in jail, and facilitating the redesign of their life beyond bars. Drawing activities allowed prisoners to enhance their own internal and external resources, and recognize risk and protective factors that could influence their successful reintegration into society. The main limit of this study is directly linked to the setting of the penitentiary institution where the study was conducted, which is characterized by a high prisoners' turn over.     

Comparison of outcome in men and women after treatment in psychiatric security hospitals in Germany

Previous research has shown that forensic psychiatric treatment reduces reoffending, rehospitalization and premature mortality. Treatment outcome varies with diagnosis, but little is known about the influence of sex, psychosocial adjustment and aftercare. To assess these variables, we interviewed male and female patients discharged from three psychiatric security hospitals in Germany in the years 2010–2017. Participants were interviewed at discharge (n = 609) and 1 year later (n = 366) about reoffending, readmissions, substance use and psychosocial adjustment. Among patients with substance use disorder (SUD), 14% reoffended, 20% were re-hospitalized and 60% maintained abstinence. Among patients with severe mental disorder, 5% reoffended and 13% were re-hospitalized. Significant sex differences were found in offenders with SUD. The results suggest that sociodemographic and disorder-related risk factors are associated with treatment success and that female patients with SUD might need a specific treatment approach. Sex-specific aspects, diagnosis and psychosocial adjustment should be considered in forensic psychiatric treatment and risk assessment.     

Extending the Validity of the Personality Assessment Inventory's (PAI) Level of Care Index (LOCI) in Multiple Psychiatric Settings

The purpose of this study was to extend the validity and clinical application of the Level of Care Index (LOCI) from the Personality Assessment Inventory (PAI) in 2 independent psychiatric samples. In Study 1 (N = 201), the LOCI effectively differentiated level of care (inpatients from outpatients), and was also meaningfully associated with risk factors for psychiatric admission (e.g., suicidal ideation, self-harming behavior, previous psychiatric admission, etc.), even after controlling for other demographic variables (range of Cohen's ds = 0.57–1.00). Likewise, the LOCI also incremented other risk indicators (suicide and violence history) and relevant PAI indexes (i.e., Mean Clinical Elevation, and Suicide and Violence Potential) in predicting level of care, and explained an additional 6% to 12% of variance in the target variable. Diagnostic efficiency analyses indicated LOCI scores in the range of 15 to 18 optimize positive and negative predictive power, and classification rate. In Study 2 (N = 96), the LOCI was found to be significantly higher in those with a recent psychiatric admission within the past 6 months (d = 0.64), as compared to those without an admission. Similarly, those who were admitted for suicide risk had significantly higher mean LOCI scores as compared to those who did not (d = 0.70). The clinical implications of these findings and potential application of the LOCI are discussed.     

Schizophrene Patienten der forensischen Psychiatrie im Vergleich zu schizophrenen Patienten der Allgemeinpsychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Some researchers assume that these forensic patients form a group of patients with very complex mental disorders, a number of risk factors and insufficient pretreatment in general psychiatry. This study aimed to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples included 72 male patients from forensic wards and 72 male patients from general psychiatric institutions diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as outpatient psychiatrists and patients’ legal custodians and by analyzing patient medical records.

Results

In contrast to the general psychiatric patients, prior to admission forensic patients were less integrated into psychiatric care and showed a lower rate of treatment compliance. They also showed a higher rate of previous compulsory treatment because of aggressive behavior towards other persons as well as higher rates of treatment difficulties and violent behavior during previous inpatient treatment. Furthermore, forensic patients had a higher number of previous criminal convictions and had been convicted more often for violent offences. With regard to other relevant risk factors (e.g. comorbid substance abuse disorder, age, education, conduct disorder, antisocial personality disorder, previous exposure to violent and abusive behavior) the two patient groups were, however, comparable.

Conclusions

Regarding schizophrenic patients with comorbid substance abuse disorders, previous violent delinquency and violent behavior during previous inpatient treatment, an intensive outpatient aftercare should be arranged before they are discharged from general psychiatric institutions.     

Improving forensic tribunal decisions: the role of the clinician

Three empirical investigations of forensic decision-making were conducted: a study of 104 hearings by a forensic tribunal; an evaluation of which aspects of forensic patients' clinical presentation were empirical predictors of violence; and a survey of forensic clinicians to determine which factors they said they used to assess risk of violent recidivism and which they actually used. Results showed a significant correlation between actuarial risk and clinical advice to the tribunal, and a nonsignificant trend for patients higher in actuarial risk to receive more restrictive dispositions. Psychotic diagnoses and symptoms were not indicators of increased risk of violent recidivism. Clinicians endorsed some empirically valid indicators of risk, but also relied on some invalid indicators. There was also inconsistency between factors clinicians said they used and factors actually related to their hypothetical decision-making. An automated system is presented as an illustration of how the consistency and validity of forensic decisions could be enhanced.     

Short-Term Assessment of Risk and Treatability (START): The case for a new structured professional judgment scheme

The Short-Term Assessment of Risk and Treatability (START) is a new structured professional judgment scheme intended to inform multiple risk domains relevant to everyday psychiatric clinical practice (e.g. risk to others, suicide, self-harm, self-neglect, substance abuse, unauthorized leave, and victimization). The article describes the processes involved in establishing an interdisciplinary approach to risk assessment and management. The authors present a review of the rationale for START, including the value of dynamic variables, the importance of strengths, and the extent to which clinicians must be attentive to multiple risk domains, reflecting theoretical and scientific evidence of the overlap among risks. Using the development, validation, and implementation of START as an example, the authors describe the processes by which other researchers, clinicians, and administrators could adapt existing assessment schemes or create new ones to bridge some remaining gaps in the risk assessment and management continuum.     

The development of an instrument to measure occupational stress in teachers: The Teacher Stress Inventory

The content validity, factorial validity, and internal consistency reliability of a scale developed to assess occupational stress in teachers were investigated. The content validity of the scale was determined from expert opinion and appraisal data collected from 92 teachers, stress researchers and practitioners. Data collected from two samples of special education teachers (n = 370; n = 371) and one sample of regular education teachers (n = 433) were then subjected to factor analyses followed by varimax and oblique rotations. Six factors resulted for each of two measures: stress strength and stress frequency. Additional analyses indicated that each subscale has moderate-to-high internal consistency reliabilities for both strength and frequency dimensions, moderate-to-high correlations between the strength and frequency measures of each subscale, and a large degree of agreement for the content validity of each subscale, for each of six subscales: Personal/Professional Stressors; Professional Distress; Discipline and Motivation; Emotional Manifestations; Biobehavioural Manifestations; and Physiological-Fatigue Manifestations.