Policies on sexual expression in forensic psychiatric settings in different European countries

Background: Sexual expression by forensic psychiatric patients is poorly researched. Methods: Forensic experts representing 14 European countries were interviewed to explore the diverse ways in which sexual expression within forensic settings is handled. Results: No country had a national policy, although many had local policies or shared practices. Progressive approaches to patient sexuality were evident in nine of the countries sampled. The UK appeared the most prohibiting and excluding, its protocols apparently based on risk aversion and lack of emphasis or consideration of patients’ sexual needs. Conclusions: Uniform national policy supporting patients’ sexual expression would provide significant improvements

Prevalence and predictors of verbal aggression in a secure mental health service:use of the HCR-20

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR-20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3-month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR-20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item-outcome analysis revealed that impulsivity, negative attitudes, and non-compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients

Violent aggression predicted by multiple pre-adult environmental hits

Early exposure to negative environmental impact shapes individual behavior and potentially contributes to any mental disease. We reported previously that accumulated environmental risk markedly decreases age at schizophrenia onset. Follow-up of matched extreme group individuals (≤1 vs. ≥3 risks) unexpectedly revealed that high-risk subjects had >5 times greater probability of forensic hospitalization. In line with longstanding sociological theories, we hypothesized that risk accumulation before adulthood induces violent aggression and criminal conduct, independent of mental illness. We determined in 6 independent cohorts (4 schizophrenia and 2 general population samples) pre-adult risk exposure, comprising urbanicity, migration, physical and sexual abuse as primary, and cannabis or alcohol as secondary hits. All single hits by themselves were marginally associated with higher violent aggression. Most strikingly, however, their accumulation strongly predicted violent aggression (odds ratio 10.5). An epigenome-wide association scan to detect differential methylation of blood-derived DNA of selected extreme group individuals yielded overall negative results. Conversely, determination in peripheral blood mononuclear cells of histone-deacetylase1 mRNA as ‘umbrella mediator’ of epigenetic processes revealed an increase in the high-risk group, suggesting lasting epigenetic alterations. Together, we provide sound evidence of a disease-independent unfortunate relationship between well-defined pre-adult environmental hits and violent aggression, calling for more efficient prevention

Patient characteristics and outcome measurement in a low secure forensic hospital

Background: Health services are increasingly required to measure outcomes after treatment, which can be reported to the funding body and may be scrutinised by the public. Extensive high quality measurements are time consuming. Routinely collected clinical data might, if anonymised, provide good enough evidence of useful change consequent on service received. Research question: Do the Health of the Nation Scale (HoNOS) and the 20 item Historical, Clinical, Risk (HCR-20) structured professional judgement tool scores provide evidence of clinical and risk change among low security hospital patients at 6 and 12 months after admission? Methods: One hundred and eight men were either resident on the unit on1st January 2011 or new admissions to the census date of 31st May 2013. Their routinely collected data were added to an outcome register following each patient’s Care Programme Approach clinical review meeting and analysed using repeated measures t-tests with Bonferroni corrections. Results: Most of the men, mean age 34.3 years, were single (93%), White British (71%) and with a primary diagnosis of schizophrenia (62%). There were significant reductions in the 11-item HoNOS (excluding the community living condition scale) scores between baseline and 6 months, and between 6 months and 12 months, but no change on its additional 7-item secure subscale. Individual effect sizes indicated that 39% of the men had better social function, although 18% had deteriorated at six months. There was little overall change in the HCR-20; individual effect sizes indicated that 11 men (15%) were rated as being at lower risk level and 10 (14%) at higher after six months in the study. Conclusions/implications for clinical practice: Standard clinical measures are promising as indicators of change in low security hospital patients. Risk ratings may be conservative, but, at this stage of a secure hospital admission, higher scores may be as likely to indicate progress in identifying and quantifying risks as apparent increase in risk

Violent aggression predicted by multiple pre-adult environmental hits

Early exposure to negative environmental impact shapes individual behavior and potentially contributes to any mental disease. We reported previously that accumulated environmental risk markedly decreases age at schizophrenia onset. Follow-up of matched extreme group individuals (≤1 vs. ≥3 risks) unexpectedly revealed that high-risk subjects had >5 times greater probability of forensic hospitalization. In line with longstanding sociological theories, we hypothesized that risk accumulation before adulthood induces violent aggression and criminal conduct, independent of mental illness. We determined in 6 independent cohorts (4 schizophrenia and 2 general population samples) pre-adult risk exposure, comprising urbanicity, migration, physical and sexual abuse as primary, and cannabis or alcohol as secondary hits. All single hits by themselves were marginally associated with higher violent aggression. Most strikingly, however, their accumulation strongly predicted violent aggression (odds ratio 10.5). An epigenome-wide association scan to detect differential methylation of blood-derived DNA of selected extreme group individuals yielded overall negative results. Conversely, determination in peripheral blood mononuclear cells of histone-deacetylase1 mRNA as 'umbrella mediator' of epigenetic processes revealed an increase in the high-risk group, suggesting lasting epigenetic alterations. Together, we provide sound evidence of a disease-independent unfortunate relationship between well-defined pre-adult environmental hits and violent aggression, calling for more efficient prevention

Forensic mental health in Europe: some key figures

Purpose. While the number of forensic beds and the duration of psychiatric forensic psychiatric treatment have increased in several European Union (EU) states, this is not observed in others. Patient demographics, average lengths of stay and legal frameworks also differ substantially. The lack of basic epidemiological information on forensic patients and of shared indicators on forensic care within Europe is an obstacle to comparative research. The reasons for such variation are not well understood. Methods. Experts from seventeen EU states submitted data on forensic bed prevalence rates, gender distributions and average length of stay in forensic in-patient facilities. Average length of stay and bed prevalence rates were examined for associations with country-level variables including Gross Domestic Product (GDP), expenditure on healthcare, prison population, general psychiatric bed prevalence rates and democracy index scores. Results. The data demonstrated substantial differences between states. Average length of stay was approximately ten times greater in the Netherlands than Slovenia. In England and Wales, 18% of patients were female compared to 5% in Slovenia. There was a 17-fold difference in forensic bed rates per 100,000 between the Netherlands and Spain. Exploratory analyses suggested average length of stay was associated with GDP, expenditure on healthcare and democracy index scores. Conclusion. The data presented in this study represent the most recent overview of key epidemiological data in forensic services across seventeen EU states. However, systematically collected epidemiological data of good quality remain elusive in forensic psychiatry. States need to develop common definitions and recording practices and contribute to a publicly available database of such epidemiological indicators

The cross-sectional GRAS sample: A comprehensive phenotypical data collection of schizophrenic patients

<p>Abstract</p> <p>Background</p> <p>Schizophrenia is the collective term for an exclusively clinically diagnosed, heterogeneous group of mental disorders with still obscure biological roots. Based on the assumption that valuable information about relevant genetic and environmental disease mechanisms can be obtained by association studies on patient cohorts of ≥ 1000 patients, if performed on detailed clinical datasets and quantifiable biological readouts, we generated a new schizophrenia data base, the GRAS (Göttingen Research Association for Schizophrenia) data collection. GRAS is the necessary ground to study genetic causes of the schizophrenic phenotype in a 'phenotype-based genetic association study' (PGAS). This approach is different from and complementary to the genome-wide association studies (GWAS) on schizophrenia.</p> <p>Methods</p> <p>For this purpose, 1085 patients were recruited between 2005 and 2010 by an invariable team of traveling investigators in a cross-sectional field study that comprised 23 German psychiatric hospitals. Additionally, chart records and discharge letters of all patients were collected.</p> <p>Results</p> <p>The corresponding dataset extracted and presented in form of an overview here, comprises biographic information, disease history, medication including side effects, and results of comprehensive cross-sectional psychopathological, neuropsychological, and neurological examinations. With >3000 data points per schizophrenic subject, this data base of living patients, who are also accessible for follow-up studies, provides a wide-ranging and standardized phenotype characterization of as yet unprecedented detail.</p> <p>Conclusions</p> <p>The GRAS data base will serve as prerequisite for PGAS, a novel approach to better understanding 'the schizophrenias' through exploring the contribution of genetic variation to the schizophrenic phenotypes.</p

A systematic review of group work interventions in UK high secure hospitals

Background: Rehabilitating high secure hospital patients poses significant challenges. Group work is thought to play a key role in patient recovery; however, there have been no reviews conducted specifically assessing group work interventions for high secure hospital patients. Objectives: To review the focus of group work interventions that are being implemented and evaluated with high secure hospital patients in the UK, and to examine the effectiveness of these interventions and the methods used to assess intervention effectiveness. Method: A systematic literature search combined with reference screening was conducted examining group work interventions with high secure hospital patients in the UK. Results: In total, 28 manuscripts (outlining 29 group work intervention evaluations) were identified for review inclusion. Across these, ten focuses of group work intervention emerged: anger/aggression, offence-specific, enhancing insight and understanding of mental illness, thinking skills/problem solving, substance misuse, self-harm, relationships, self-esteem and well-being, relapse prevention, and moving on. Positive outcomes were generally reported across all ten areas. Conclusions: Studies assessing the impact of group work interventions could be improved by increasing sample sizes, reducing sole reliance on self-report measures, employing clear statistical and clinical significance testing, and increasing the use of follow-up assessments and control groups