Electronic monitoring ('tracking') of individuals has been used in the UK criminal justice system for over three decades, and its use is increasing. Electronic monitoring has more recently been implemented in forensic psychiatric services, which has generated considerable debate about the appropriateness of its use in clinical settings, and about legal and ethical concerns. The purpose of this article is to formally address the ethical issues that arise from using electronic monitoring in forensic psychiatry. These issues are considered using the Four Principles approach to medical ethics, namely autonomy, beneficence, non-maleficence, and justice. We conclude that by adopting a patient-centred approach, where informed consent is sought, and the patient's best interests remain central to the decision-making process, electronic monitoring is both ethical and justifiable. More robust studies are required to develop standardised clinical guidelines for the use of EM in forensic psychiatry, and to apply the theory of patient-centred, consent-driven care to practice.

Burnout and well being in forensic psychiatrists have been insufficiently examined, with most research focusing on vicarious trauma, compassion fatigue, or posttraumatic stress disorder among forensic mental health professionals. Previous research in Canada from 2023 highlighted a high prevalence of burnout among forensic psychiatrists, particularly among early-career psychiatrists, those whose values were misaligned with their institution, and those who had a low perceived control over their workload. Building upon this, the current study provides an assessment of the U.S. workforce in forensic psychiatry, identifying aspects of practice that contribute to, or mitigate, burnout and enhance professional fulfillment. Survey results of American Academy of Psychiatry and the Law (AAPL) members (response rate 11%) indicated that those experiencing burnout were younger, female, perceived to have had less control over their workload, spent more time on the electronic medical record (EMR), and felt their values were misaligned with leadership and colleagues. Factors predicting professional fulfillment were overall job satisfaction, value alignment with colleagues, and mentoring others. The findings of this survey will help to identify interventions at institutional and systems levels to address contributors to burnout, promote professional fulfillment and well being, and enhance recruitment and retention in the field of forensic psychiatry.

Medical schools and residency programs vary widely in the depth and breadth of training offered within their social justice curricula, creating an uneven knowledge base for incoming forensic psychiatry fellows. To address this disparity, a core faculty group in a forensic psychiatry fellowship designed a novel social justice curriculum to ensure that all fellows possess the knowledge needed for competent forensic evaluation and treatment. The course begins with an introduction to the ethics of practicing within an unjust system and utilizes a three-tiered model that explores the social determinants of outcomes within the legal system, bias in forensic evaluation, and special population considerations. The curriculum is designed to provide a space for fellows to discuss the influence of identity on legal and forensic mental health outcomes, enhance their knowledge of social justice, recognize and reduce their biases, and understand the lived experiences of those whom they evaluate and treat. This course provides a potential solution for training inequities and offers a national model to ensure that all fellows, regardless of previous educational experiences, receive training that is vital to competent practice in forensic psychiatry.

Childhood lead toxicity remains a nationwide problem, despite significant progress in reducing exposure sources in the United States since the 1970s. Neurodevelopmental sequelae of lead exposures often persist into adulthood, with limited reversibility. These include long-lasting deficits in intelligence, impulse control, and emotional and behavioral regulation, which can increase one's propensity for aggression and criminality. Yet, despite the strong association between lead poisoning and criminality, there is little agreement thus far among U.S. jurisdictions about how to apply such knowledge to criminal legal proceedings. Here, we explore forensic considerations of childhood lead toxicity for evaluation, sentencing, and staff support in the criminal justice system. We cite both clinical science and case law in navigating this complex intersection of forensic psychiatry, public health, and the environment. We aim to provide preliminary guidance on how forensic psychiatrists can approach and refer to lead toxicity in their medicolegal work. This article may hopefully inspire further forensic research on the topic and the eventual creation of standardized, lead-related guidelines for criminal legal proceedings.

Mental disorder in the courtroom: Challenges for legal practice in low-resource criminal justice system: A qualitative analysis from Indonesia.

The electronic Dynamic Appraisal of Situational Aggression combined with the Aggression Prevention Protocol (eDASA+APP) is a clinical decision support system designed to prevent aggression, reduce coercive practices and promote proactive nursing interventions. It has previously been tested in forensic psychiatry in Australia. Adaptation and feasibility testing are required before implementation in new clinical and linguistic contexts. The aim of this study was to examine the feasibility of the Finnish version of the eDASA+APP using a mixed methods approach. The study took place in four Finnish mental health inpatient units. Nurses completed an online learning module and used the eDASA+APP for 2 weeks. Quantitative and qualitative data were collected on nursing documentation and feasibility. As a result, the eDASA+APP was perceived as easy to use and helpful in establishing a shared process and terminology for aggression prevention. Documentation of risk assessments and preventive interventions increased. The e-learning module was considered adequate. One unit caring for older adults found the risk assessment component less practical. The Finnish eDASA+APP appears feasible and beneficial, supporting a larger implementation in units with adult patients. However, the feasibility testing in older adult services is recommended. The Mixed Methods Reporting in Rehabilitation & Health Sciences checklist was followed in reporting this study.

Staff attitudes towards coercion in psychiatry: The role of violence, emotional burden, and insecurity - Evidence from a nationwide study using multiple regression and moderation analyses.

Clozapine augmentation with antipsychotics (CAA) is commonly used to treat complex cases in forensic psychiatric settings. This study aims to investigate the prevalence and determinants of CAA among individuals with schizophrenia spectrum disorders within the Ontario forensic system. A retrospective analysis was conducted on 262 patients in forensic psychiatric settings who were prescribed clozapine during the 2014/15 reporting year. The mean age of the patients was 41 years (SD = 11.8), and 227 of them (86.6%) were male. For comparative analysis, the patients were categorized into two groups: clozapine monotherapy and CAA. Logistic regression analysis was then applied to evaluate factors associated with CAA. Nearly half (48.5%) of forensic psychiatric patients on clozapine received antipsychotic augmentation. CAA was more prevalent among patients with violent offenses (adjusted odds ratio [aOR] 4.32, 95% confidence interval [CI]: 1.02-18.27, p = 0.047), and absconsion incidents (aOR 2.55 95% CI: 1.16-5.58, p = 0.019). Patients with a good treatment response (aOR of 0.25, 95% CI: 0.11-0.54, p <0.001) and a history of self-harm were less likely to be prescribed CAA (aOR of 0.32, 95% CI: 0.12-0.85, p = 0.022). Patients with severe symptoms and significant risk profiles were more likely to receive CAA. Capacity development and further research are needed to support an effective and safe clozapine therapy strategy.

Sleep-related violence in parasomnias: Forensic and clinical insights for criminal responsibility assessments.

This cross-sectional study examined the associations between childhood trauma, psychopathology, functional impairment, and recidivism in female juvenile offenders. The sample included 73 girls aged 12–18 who were referred to a forensic psychiatry board for criminal responsibility evaluations between February and November 2023. Data were collected using the Sociodemographic Form, the Childhood Trauma Questionnaire (CTQ), the Strengths and Difficulties Questionnaire (SDQ), and the Weiss Functional Impairment Rating Scale–Self Report (WFIRS–S). Results indicated that 97.3% of participants had experienced childhood trauma, with emotional abuse (45.2%), emotional neglect (43.8%), and physical neglect (39.7%) being the most prevalent forms. Psychiatric disorders were reported in 57.5%, 43.8% engaged in self-injurious behavior, and 12.3% reported substance use. Recidivism was significantly associated with substance use (χ2 = 9.38, p < .001), disrupted family structure (χ2 = 7.57, p = .01), and low educational attainment (χ2 = 5.67, p = .02). CTQ scores were positively correlated with conduct problems (r = .44), hyperactivity/inattention (r = .52), emotional symptoms (r = .57), and functional impairment (r = .59) (all ps < .01). These results underscore the high prevalence of childhood trauma among justice-involved girls and its significant associations with emotional and behavioral problems, functional impairment, and recidivism. This study provides gender-specific evidence from a court-referred female cohort in Turkey, offering practice-relevant insights for trauma-informed and gender-responsive interventions.

Forensic psychiatric nursing staff are exposed to workplace violence, which harms well-being and may undermine safe care. To identify preventive factors for workplace violence on forensic psychiatric wards as reported in incident reports by nursing staff and nurse managers. Qualitative inductive content analysis of workplace violence incident reports over 5 years at one Finnish forensic psychiatric hospital, focusing on prevention-oriented free-text fields. Categories were descriptively quantified as the number (%) of reports containing each category. Incident reports portrayed workplace violence prevention as a layered entity covering clinical stabilisation, staffing and work organisation, anticipatory routines, therapeutic interaction and de-escalation, environmental and technological safety measures, restrictions and external-risk control, and information flow, debriefing and organisational learning. Clinical, organisational and environmental factors were intertwined in prevention. Incident report narratives and measures may provide a qualitative source for examining prevention-related practices and follow-up actions in forensic psychiatric care. Single-hospital data, possible underreporting and a nursing-only focus limit transferability. Following recommendations emerging from incident reports, such as ensuring adequate staffing, providing training and maintaining safe work environments, may support workplace violence prevention. Forensic psychiatric inpatient services may benefit from strengthening layered prevention strategies and from using incident report narratives to inform local policy and practice. Workplace violence is a persistent occupational hazard in forensic psychiatric nursing, yet little is known about how prevention is described in workplace violence incident reports. This study analyses prevention-oriented incident report entries from a Finnish forensic psychiatric hospital to examine how nursing staff and nurse managers describe workplace violence prevention. Prevention was described as a layered entity involving clinical stabilisation, staffing and competence, anticipatory practices, therapeutic interaction, environmental and safety measures, restrictions and external-risk control, and post-incident information flow, debriefing and follow-up actions. These findings may inform use of incident reports and prevention planning in similar secure forensic inpatient settings.

BackgroundArtificial intelligence (AI)–themed delusions are increasingly observed in psychotic-spectrum disorders, reflecting the incorporation of contemporary sociotechnical elements into delusional systems. However, it remains unclear whether the structural role of AI within these belief systems is associated with increased violence risk or more restrictive forensic outcomes. Given the importance of dynamic clinical factors (eg, insight and treatment adherence) in forensic risk assessment, clarifying the role of AI centrality has clinical and legal relevance.ObjectiveThis study examined whether AI centrality within psychotic delusional systems is associated with (1) violence toward others and (2) judicial findings of significant public safety risk in forensic psychiatric decisions.MethodsThis retrospective observational study used jurisprudential data from the Société québécoise d’information juridique database, including all publicly available Quebec tribunal and court decisions up to December 31, 2025. Eligible cases (N=29) involved psychotic-spectrum disorders with explicit AI-related delusional content and judicial consideration of dangerousness or disposition. The unit of analysis was the judicial decision. AI centrality was coded as central (n=15, 51.7%) or noncentral (n=14, 48.3%) using a structured, text-based framework. The primary outcome was documented violence toward others; secondary outcomes included direct AI-linked violence attribution and judicial findings of significant public safety risk. Covariates included impaired insight, treatment nonadherence, substance use disorder, and prior violence history. Data were extracted through full-text review using a standardized coding grid. Bivariate associations were analyzed using Fisher exact tests (α=.05), and odds ratios (ORs) with 95% CIs were calculated. Exploratory logistic regression models were performed to assess adjusted associations.ResultsViolence toward others was documented in 20/29 (69%) cases. AI centrality was not significantly associated with violence (12/15, 80.0%, vs 8/14, 57.1%; OR 2.91, 95% CI 0.63-13.45; P=.26) but was strongly associated with direct AI-linked violence attribution (9/15, 60.0%, vs 2/14, 14.3%; OR 9.00, 95% CI 1.48-54.6; P=.01). Judicial findings of significant public safety risk were more frequent in AI-central cases (13/15, 86.7%, vs 9/14, 64.3%; OR 3.60, 95% CI 0.63-20.5; P=.24), although not statistically significant. AI-central cases demonstrated higher prevalence of impaired insight (13/15, 86.7%, vs 8/14, 57.1%; OR 4.89, 95% CI 0.79-30.1) and treatment nonadherence (9/15, 60.0%, vs 4/14, 28.6%; OR 3.75, 95% CI 0.74-18.9).ConclusionsAI centrality within delusional systems appears to be not independently associated with increased violence toward others but is strongly associated with AI-based attribution of behavior and markers of epistemic vulnerability, including impaired insight and treatment nonadherence. The findings suggest that AI-themed delusions function as structural organizers of meaning and agency rather than novel criminogenic risk factors. Clinically and legally, this underscores the importance of prioritizing dynamic risk variables over thematic novelty, informing more proportionate forensic decision-making and risk assessment in an era of rapidly evolving digital environments.

Introduction: Malingering, the intentional fabrication or exaggeration of symptoms for external gain, remains a significant challenge in forensic psychiatry. Psychiatric illnesses are particularly vulnerable to malingering due to their subjective symptom profiles and absence of objective biological markers. Early recognition is critical to protect genuine patients and maintain judicial integrity. Methods: We report three medico-legal cases referred by judicial authorities for psychiatric evaluation of fitness to stand trial. Each case was assessed through a multidisciplinary approach involving repeated clinical interviews, behavioral observation, review of medical records, collateral history, and standardized psychological assessments, including the Rorschach test and the Minnesota Multiphasic Personality Inventory (MMPI). Results: Indicators of malingering included initiation of treatment only after legal proceedings, inconsistencies between reported symptoms and observed behavior, and absence of expected side effects despite high-dose antipsychotics. Case I showed Ganser-like responses with intact Rorschach findings. Case II had elevated MMPI validity scales (F, Fp, FBS), consistent with over-reporting. Case III refused testing and displayed contradictions, such as claiming hallucinations without observable distraction. Together, these findings supported malingering driven by legal avoidance. Discussion: This series underscores the importance of multimodal evaluation in detecting malingering. Findings support The findings support the importance of multidisciplinary collaboration and the use of structured tools to improve diagnostic accuracy, prevent misuse of psychiatric diagnoses, and ensure justice in medico-legal contexts.

As I prepare to step down from my position as Psychopharmacology Columnist for the Journal of Psychiatric Practice after over 30 years in that role, it seemed appropriate to look back and discuss some major developments in psychopharmacology that have occurred over the course of the 50+ years of my career. To keep this narrative manageable in a column format, it is divided into 2 columns. Neither this column nor the next will cover everything-that would require a textbook. Instead, I will cover selected topics from a personal perspective. This column will principally focus on the first 25 years of my career and covers 5 main topics: therapeutic drug monitoring, which led to pharmacogenomics, studies in child and adolescent psychiatry, drug development research, neurobiology, and forensic psychiatry.

Gross and histopathological study of pituitary gland in cases of suicidal deaths: A case-control study.

Assessment of decision-making capacity and guardianship in hospitalized patients represents a critical interface between forensic psychiatry, clinical medicine, and law. In Turkiye, such evaluations are frequently requested by courts or notaries; however, empirical data describing their forensic characteristics remain limited. This study examined hospitalized patients referred for forensic psychiatric evaluation of decision-making capacity and guardianship and identified factors influencing medico-legal outcomes. This retrospective study included all inpatient consultations requested for forensic psychiatric evaluation between January 2018 and June 2025 at a university hospital. Sociodemographic characteristics, referring departments, psychiatric diagnoses, Mini-Mental State Examination (MMSE) scores, and forensic psychiatric opinions were extracted from electronic medical records. Eighty forensic psychiatric evaluations were analyzed, including 51 assessments for addressing decision-making capacity for power of attorney and 29 related to guardianship. The mean age was 70.7 ± 14.1 years, and 56.3% of patients were male. Most referrals originated from Internal Medicine and Intensive Care units. Among capacity evaluations, 74.5% of patients possessed decision-making capacity, while 19.6% lacked capacity. Patients assessed as possessing capacity had significantly higher MMSE scores than those assessed as lacking capacity (25.88 ± 2.37 vs. 19.33 ± 2.34; p < 0.001). Guardianship-related evaluations were mainly associated with mental disorders due to acute brain injury. In this acute hospital setting, lack of decision-making capacity was most commonly associated with delirium and dementia, whereas guardianship considerations primarily involved patients with acute brain injury or severe medical illness. These findings underscore the distinct clinical profiles underlying forensic capacity and guardianship evaluations in hospitalized populations.

Working in forensic psychiatry can lead to complex feelings, including countertransference reactions, in professionals who are attempting to provide care and containment for offenders. If these feelings go unrecognised and unexplored, then they may interfere with therapeutic care. In this paper, we describe case reflections which could be discussed in a Balint style reflective practice group, for clinicians caring for people within the forensic psychiatry system. Group processes are described, to demonstrate the essence of the work that occurred, via case vignettes. We describe seven fictionalised cases, considering a selection of factors that may be reflected on, demonstrating the process of the group. We highlight a general theme of each group, including intense feelings of loss and grief, contrary views leading to chaos, denial of reality, loss in suicidal ideation, psychosis as an escape from reality, therapeutic nihilism and complex moral dilemmas. In forensic psychiatry, professionals are dealing with some of the most traumatised people in society, which can be very emotionally triggering. Use of Balint groups and other forms of reflective practice invite clinicians to process such trauma and avoid burnout.

Bottlenecks in the Belgian forensic care system: A qualitative study on residual patients.

A collaborative framework for mental health and forensic psychiatry to prevent disruptions upon release from detention

BackgroundThe use of seclusion and other restraints in forensic mental health settings are intended to be employed as a last resort and for the shortest time possible to achieve therapeutic effect. And yet, in Canadian forensic hospital settings, patients can remain in seclusion for weeks, months, even years. An ambiguous legal framework across Canadian provinces lacks mechanisms to limit or forbid the long-term seclusion of patients, which we define as any continuous confinement lasting 15 days or longer.Research objectivesThe paper undertakes a critical examination of long-term seclusion practices in forensic hospitals, based on the results of a qualitative study examining nursing practices with 'difficult' patients. Agamben's concepts of homo sacer and bare life and Guenther's concept of social death provide the framework for this critical examination.Research designA qualitative research design was employed, utilizing a critical discourse analysis methodology.Participants and context7 nurses working in a high security forensic hospital setting in Canada participated in qualitative interviews.Ethical considerationsThe paradox of custody and caring is central to the considerable ethical challenges nurses face with patients in long-term seclusion.Findings/resultsIntegration of study findings with existing (limited) studies of this phenomenon illustrate that, though rare, patients in forensic hospital settings may be subject to lengthy and legally ambiguous periods of seclusion. Nursing practices and interventions are aimed at providing patients temporary reprieve from a state of bare life and to alleviate their social death. However, no mechanisms exist to prevent the use of long-term seclusion.ConclusionsLong-term seclusion represents a regrettable practice in forensic hospital settings aimed at the management of 'difficult' patients but is devoid of therapeutic value or intent. Existing nursing practices can only temporarily relieve patients from this state. More substantive and lasting solutions are proposed, focusing on the role of the nurse.