Predictors of Mental Health Review Tribunal (MHRT) outcome in a forensic inpatient population: a prospective cohort study

Amelia Jewell,Tom Fahy,Alexis E Cullen,Kimberlie Dean

doi:10.1186/s12888-016-1188-8

Abstract

BackgroundPrevious studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; however, dynamic variables such as treatment compliance and substance misuse have scarcely been examined, particularly in UK samples. We aimed to determine whether dynamic factors related to behaviour, cooperation with treatment, and activities on the ward were prospectively associated with outcome at MHRT.MethodsAt baseline, demographic, clinical, behavioural, and treatment-related factors were ascertained via electronic medical records and census forms completed by the patient’s clinical team. Data on MHRTs (i.e., number attended, responsible clinician’s recommendation, and outcome) were collected at a 2-year follow-up. Logistic regression analyses were performed to determine factors associated with outcome among those who attended a MHRT within the follow-up period. Of the 135 forensic inpatients examined at baseline, 79 patients (59%) attended a MHRT during the 2-year follow-up period and therefore comprised the study sample. Of these 79 patients included in the current study, 28 (35%) were subsequently discharged.ResultsIn univariable analyses, unescorted community leave, responsible clinician’s recommendation of discharge, and restricted Mental Health Act section were associated with a greater likelihood of discharge at MHRT; whilst inpatient aggression, a recent episode of acute illness, higher total score on the Historical Clinical Risk – 20 (HCR-20), higher HCR-20 clinical and risk scores, and agitated behaviour were negatively associated with discharge (p < 0.05). In multivariable analyses, HCR-20 clinical scale scores and physical violence independently predicted outcome at tribunal after controlling for other dynamic variables.ConclusionBy identifying dynamic factors associated with discharge at tribunal, the results have important implications for forensic psychiatric patients and their clinical teams. Our findings suggest that by reducing levels of agitated behaviour, verbal aggression, and physical violence on the ward, achieving unescorted community leave, and targeting specific items on the HCR-20 risk assessment tool, patients may be able to improve their changes of discharge at a MHRT.

Highlights

Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; dynamic variables such as treatment compliance and substance misuse have scarcely been examined, in United Kingdom (UK) samples
Our finding that patients held on a restricted Mental Health Act 1983 (MHA) section were significantly more likely to be discharged is consistent with the statistics for England and Wales [16], this is important as the majority of forensic patients in the UK are held on restricted MHA sections [26]
Results with regards to the Historical Clinical Risk – 20 (HCR-20) violence risk assessment are consistent with previous forensic research; similar to Davoren and colleagues [21], we found that total scores on the HCR20, along with scores on the C and R subscales, were significant predictors of outcome at tribunal

Summary

Introduction

Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; dynamic variables such as treatment compliance and substance misuse have scarcely been examined, in UK samples. In the United Kingdom (UK), Mental Health Review Tribunals (MHRTs: renamed First-Tier Tribunals in 2008) are independent panels that review compulsory treatment orders for individuals with mental illness [1]. The tribunal panel — typically consisting of a medical member, a tribunal judge, and a lay member [5,6,7] — have the power to uphold the detention of a patient in psychiatric hospital or direct their discharge, either conditionally, in the case of restricted patients (i.e., those patients held on restriction orders directed by the Crown Court due to the risk that they pose to the public), or absolutely [5]. In the UK, any patient who has not attended a tribunal within the past 3 years is automatically referred by the Secretary of State [5]

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