Forensic Psychiatry Research Articles

Gratitude despite unease among Swedish male forensic psychiatric patients with substance use disorders: an interview study

ABSTRACT Purpose Forensic psychiatric inpatient care in Sweden is characterized by strict regulations and adherence to court-mandated rules, with a median care time of 7 years. Comorbity has significant clinical implications, impacting health and well-being, violent behaviour and criminal recidivism, and prolonging inpatient stays. This study investigated the individual experiences and perspectives of Swedish patients in forensic psychiatric care with substance use (SU) disorders, focusing on past, present and future orientations. Methods Ten male forensic psychiatric inpatients were individually interviewed following a semi-structured interview guide. A qualitative content analysis was conducted to inductively analyse the participants’ experiences. The study adhered to the Standards for Reporting Qualitative Research. Results Under the main theme of “embracing harmony in opposition”, three categories emerged: (1) unveiling the beginning of SU and its impact on navigating challenges in care, (2) exploring current confined care and gratitude despite unease and (3) yearning for a somewhat normal life. Conclusions Participants’ subjective perspectives underscored the importance of factors such as forensic nurses/healthcare providers in forensic psychiatry considering the patients’ life narratives, their aspirations for the future, their need for a secure environment and patient—staff relationships. These findings highlight the need for structural interventions that emphasize the importance of tailored and comprehensive health plans within rehabilitation.

Italian Evaluation and Excellence in REMS (ITAL-EE-REMS): appropriate placement of forensic patients in REMS forensic facilities

BackgroundWe set out to assess the appropriateness of current placement of mentally disordered offenders allocated by the courts in Italy to REMS or to forensic community residences. We hypothesised that as in other countries, the match between a standardised assessment and the decision of the court would be imperfect.MethodsThe DUNDRUM Toolkit was translated into Italian. The translation had good psychometric properties. In order to compare the current level of therapeutic security with a calculated safest current placement, we compared the DUNDRUM-1 triage security assessment of need for therapeutic security prior to treatment, with evidence for progress made in treatment (DUNDRUM-3) and forensic recovery (DUNDRUM-4). The more conservative of these two would be taken as the safe current level of need for therapeutic security.ResultsThe Italian translation of the DUNDRUM Toolkit had good internal consistency and mean scores had a Reliable Change Index less than one unit. 3.7% of those in REMS (medium security) were assessed as needing high security and 38% were ready to move to a less secure place. In low secure places, 56% were assessed as needing a higher level of therapeutic security and 6% could have moved to open non-secure places.ConclusionsThe Italian translation of the DUNDRUM Toolkit allows an assessment of the current working of the model of care for forensic psychiatry following the reforms of 2015. Most patients are safely placed. A small but important proportion needed high secure places that are not currently available. (3.7% of 604 nationally, 95% Confidence Interval 1.2% to 8.4%, 7 to 50). A greater use of such measures would enable better health gains and safer outcomes.Trial registration ClinicalTrials.gov ID: NCT06018298 Unique Protocol ID: ITAL-EE-REMS.

Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review

Background: This scoping review examines the risk factors considered in assessing the dangerousness of individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canadian administrative courts. This review aims to identify the factors used by mental health review boards during annual case reviews to guide decisions on detention or release. Methods: Using a scoping review approach following PRISMA guidelines, this study analyzed research across multiple databases to identify relevant studies focusing on risk assessment for NCRMD cases. Results: The findings indicate that five primary categories of risk factors—historical, clinical, behavioral, legal, and miscellaneous—are influential in the decision-making process. Historical factors, such as past violence and early psychiatric contacts, are critical in predicting future risk. Clinical factors, including psychiatric diagnosis and treatment adherence, are key to evaluating current and potential future risks. This study reveals variability in the application of standardized risk assessment tools, highlighting a need for more consistent practices across Canadian jurisdictions. Conclusion: This review concludes that, while a multifaceted approach to risk assessment is essential for balancing public safety with individual rehabilitation, further research is needed to refine these processes and establish more uniform standards for managing NCRMD cases in forensic psychiatry.

Fitness to stand trial: 415 consecutive defendants assessed by a New Zealand forensic psychiatry service.

New Zealand defendants found unfit to stand trial following a Court-ordered forensic mental health assessment cannot be detained in prison and must either be released, or made subject to a mental health or intellectual disability order. There is increasing awareness of the need to identify these people and protect their rights. Retrospective audit of 8years of Court-ordered health assessor reports addressing fitness to stand trial prepared by a New Zealand regional forensic mental health service with a catchment area of around 850,000. Between 2014 and 2022, Courts referred 415 defendants for assessment of fitness to stand trial. The number of reports requested increased by 20% between 2014 and 2022. Report subjects were 81% male and had a median age of 31. Commonest primary diagnoses were psychotic disorders (37%), intellectual disability (13%) and acquired neurocognitive disorders (15%). Few people with foetal alcohol spectrum disorder were identified. Despite the increase in assessments, the number of defendants considered unfit by report writers remained stable over time. The increasing number of referrals for assessment of fitness to stand trial has resourcing implications for forensic mental health services.

Mental healthcare in South Tyrol

Mental healthcare in South Tyrol, as everywhere in Italy, is still characterized by Law 180, which came into force in 1978 under the leadership of Franco Basaglia and Bruno Orsini. The Ministry of Health subsequently set atarget number of beds of 10/100,000 inhabitants. Unlike in other parts of Italy, private clinics play aminimal role in South Tyrol. The "Psychiatric Services" are part of the state healthcare system responsible for all citizens and are also responsible for compulsory outpatient care. According to the concept of community care, also due to the small number of inpatient beds, agreat deal of care is provided on an outpatient basis. Coercive measures can only be used in the case of an illness requiring urgent treatment that the patient refuses, without recourse to endangering circumstances (self-endangerment or danger to a third party). Inpatient hospitalization is only possible if treatment also takes place and the principle of "outpatient before inpatient" also applies in this context, i.e., coercive treatment can only take place as an inpatient if it cannot be carried out as an outpatient. Forensic psychiatry has very few places and mentally ill offenders are often in prison or occupy beds in general psychiatric wards. Compared to Germany there are fewer beds available but staffing levels are better, particularly for nursing. In relation to the number of inhabitants, compulsory treatment is more frequent than in Germany, whereas involuntary hospitalization and physical restraint are much rarer (only possible in Italy by court order).

Parricide and homicide NGRI offenders: How do they differ?

The aim of the present study was to provide a forensic psychiatric characterization of perpetrators of parricide who were found not guilty by reason of insanity (NGRI). We conducted a study involving 52 NGRI patients who had committed homicide or attempted homicide within the Department of Forensic Psychiatry in Thessaloniki, Greece, between January 2015 and 2020. Subjects were categorized into two groups: parricide (n = 21) and a control group (n = 31). Our findings revealed that in the parricide group, the majority of patients were unmarried males in their thirties, with a history of prior contact with mental health services and nonadherence to treatment. Additionally, they had a background of substance abuse and exhibited violent behavior before the index crime. A notable trend observed among parricide offenders was the tendency to seek hospitalization, possibly as a means of distancing themselves from stressful family environments, based on information obtained in the interviews conducted as a part of this research. All instances of parricide involved the use of sharp weapons, and the crimes were consistently committed in private settings. Symptomatology among parricide patients was assessed as moderate to severe, with a significant long-term risk observed following the crime. The primary differences identified between the two groups were the higher pre-crime voluntary admissions and the elevated estimated postcrime risk observed in the parricide group. Early intervention, comprehensive assessment of risk factors, family support, and assistance in resolving conflicts and reintegrating patients into society are emphasized as critical interventions that can potentially prevent future tragedies.

The Bharatiya Nyaya Sanhita Act (BNSA) 2023: Implications for Forensic Psychiatry in India

The Bharatiya Nyaya Sanhita Act (BNSA) 2023: Implications for Forensic Psychiatry in India

Forensic Psychiatry Analysis and Methods for Assessing The Mental Health of A Serial Killer.

Psychosis is a mental illness that causes an alteration in the notion of reality, where a world of its own is formed in the mind of the psychotic, in other words, he lives in a delirium and suffers hallucinations, hearing voices and having bizarre visions. Objectives: To carry out a literature review on Forensic Psychiatry and how to assess the mental health of a serial killer. Method: The methodology used was a literature review. The research was carried out by means of an electronic search for scientific articles published on the Scielo (Scientific Electronic Library Online) and Lilacs (Latin American Health Sciences Literature) and Pubmed websites. The health terminologies consulted in the Health Sciences descriptors (DeCS/BIREME) were used; regarding Forensic Psychiatry and how to assess the mental health disorder of a serial killer.The inclusion criteria were: original article, published in Portuguese and English, freely accessible, in full, on the subject, in electronic format and published in the last years (2010 to 2024), totaling 26 articles. Results and Discussion: While antisocial personality disorder is a medical diagnosis, the term “psychopathy”, which belongs to the psychiatric-forensic sphere, can be understood as a “legal diagnosis”. There is still no effective treatment for so-called “serial killers”. Conclusion: Personality disorders, especially the antisocial type, still represent a real challenge for forensic psychiatry today. The most appropriate and fair place for its sufferers, as well as homogeneous treatment recommendations, are still unanswered questions.

Criminal intent and psychiatric evidence

SUMMARY Although forensic psychiatrists are often asked to comment on a defendant's capacity to form the necessary mens rea for their alleged offence, little has been written on how mental disorders map onto legal concepts of mens rea, particularly those of intention. In this article we explore legal concepts of mens rea and the relevance of mental disorders and alcohol intoxication. We briefly consider philosophical approaches to intentional action and a variety of common mental disorders. We conclude that despite the presence of significant psychopathology it is rare for mental disorders to cause a defendant to lack the ability to form mens rea. Experts should therefore be cautious about coming to the conclusion that they do lead to a lack of capacity to form mens rea and should make clear the limits of their expertise, given the difficulty of translating clinical mental states into legal concepts of liability.

Self-Reported Perceptions of Patients and Staff on Participation and Verbal and Social Interactions in High-Security Forensic Psychiatric Care in Sweden.

Studies suggest that experiences of patient participation, as described by both patients and staff, are associated with a significant caring relationship of high quality. This study aimed to investigate staffs' and patients' self-reported perceptions on participation and the frequency and importance of verbal and social interactions in high-security forensic psychiatry. The questionnaire Verbal and Social Interactions (VSI) was used together with the subscale Participation from Quality in Psychiatric Care (QPC). The study was conducted at a large forensic psychiatric clinic in Sweden. Staff and patients rated the frequency of VSI differently while reporting the same perceived degree of patient participation. All categories of VSI were significantly correlated with perceived level of participation with medium or small effect size for the patients. Patients' perceived participation seems to depend on verbal and social interaction within the specific categories 'Showing interest in the patients' feelings, experiences, and behavior' and 'Helping the patients establish structure and routines in their everyday life'. There was, however, a negative association for the latter. The results give a better understanding of what kind of interactions that affect patients' perceived level of participation. Patient participant is a prioritised area for development in forensic psychiatry. The study contributes to a better understanding of what types of interactions that affect the perceived level of participation, while at the same time, it shows important similarities and differences between patient and staff perspectives.

The uptake and utility of a reflective practice group for psychiatry registrars in a state-wide forensic service.

It is essential that mental health clinicians have access to reflective processes where they may understand and make sense of emotional responses to patients, teams, and organisations. The authors share their experience of initiating and successfully running a reflective practice group, framed with Balint principles, for psychiatry registrars working in forensic settings across Victoria. We describe the process of setting up a Balint group for this professional population. Qualitative feedback was obtained from group members. The data was analysed thematically, regarding motivating factors for group attendance and feedback post pilot group. Overall, feedback on the pilot Balint group was positive, which led to the group being extended for recurring 6-month periods. We share an illustrative example of a complex case which could be formulated in a forensic psychiatry Balint group setting, alongside reflections of the facilitators of the group. Reflection is paramount for safe, effective mental health treatment, particularly in the context of forensic psychiatry. Our pilot results highlight areas where the approach of setting up a fledgling Balint group has been successful. We hope to inspire others to engage and participate in routine reflective practice.

Balancing on a slack line - Staffs' experiences of talking about sexuality and sexual health with patients cared for in forensic psychiatry in Sweden.

Sexuality is a central part of being human, however, talking about sexual health is generally avoided in forensic psychiatry. The aim of this qualitative study was to explore how healthcare professionals experience talking about sexuality and sexual health with patients cared for in forensic psychiatry. Individual interviews were conducted with eighteen healthcare professionals from ten different forensic psychiatry care units in Sweden. The interviews were semi-structured, and the data was analyzed with qualitative content analysis. The findings showed the overarching theme "Balancing on a slack line". The conversations the healthcare professionals have about sexuality and sexual health with patients in this setting are affected by forensic psychiatry's dual mission; to provide care and at the same time protect patients and society. These conversations can be about opening up for having responsive conversations, but also closing conversations since the field of sexuality and sexual health is fraught with norms and preconceptions. To be able to conduct these conversations can be a challenge since the professionals can experience uncertainty due to a lack of competence, indicating that knowledge and resources are needed to facilitate conversations. In conclusion, the study indicates that there is a lack of support and structure for performing conversations about sexuality and sexual health in forensic psychiatry care, and there is a need for increased knowledge among healthcare professionals. In order to support staff, the forensic psychiatry services need to acknowledge the national guidelines for sexual and reproductive health and rights and to develop and adapt the local guidelines.

Court-ordered forensic psychiatry treatment in prison: determinants of outcome and risk mitigation.

Court-ordered forensic psychiatry treatments (COT) are specifically designed to reduce the risk of violence in mentally disordered offenders. Given their high costs and ethical issues, mental health professionals need admission criteria to be able to select those candidates with optimal benefit. This study analyses offender-related and treatment-related determinants of COT outcome and risk mitigation. This two-year longitudinal study assessed the evolution of 117 adult offenders admitted to a specialized medium-security forensic psychiatry clinic. Treatment outcome included court-ordered discharge locations and the Historical Clinical Risk Management (HCR) score evolution. Treatment progress was assessed every six months across five time-points including measures of protective factors, work rehabilitation and security. Outcome determinants included psychiatric diagnosis and type of offence. Discharge locations are predicted by pre-treatment risk level. Lower HCR scores are associated with discharge into low-security psychiatry wards independently of the psychiatric diagnosis. Risk reduction follows diagnosis-specific and offense-related patterns and reveals that mentally disordered offenders with Cluster B personality disorders or those sentenced for drug crimes are significantly less prone to benefit from COT. Our findings indicate that criminological characteristics at baseline as well as diagnosis of personality disorders are the main determinants of treatment outcome in our care setting. Inmates with concomitant higher violence risk at baseline and presence of Cluster B personality disorders might benefit the least from court-ordered forensic inpatient psychiatric care in prison.

Attitudes of Forensic Fellowship Psychiatry Directors towards an Applicant Match.

Forensic psychiatry fellowship programs recruit applicants through a nonstandardized process that differs by program. Although there are deadlines, informal guidance, and more recent communication guidelines, perceived differences in recruitment practices persist between geographic regions, small and large programs, and newer and more well-established programs. In the wake of a survey of fellowship applicants that found mixed opinions surrounding the application process, U.S. forensic fellowship directors undertook a mixed method quantitative-qualitative survey of their colleagues to assess interest in a match as a potential improvement and factors influencing that interest (e.g., program size, age, and unfilled positions). With responses from all 46 active U.S. programs, results indicated broad support for principles of fairness, transparency, and minimizing pressure on applicants, with an almost perfectly divided interest in a match. Respondents supported the use of a centralized database to standardize the application process and favored certain exceptions for internal applicants. Hypotheses about the reasons underlying program directors' attitudes toward a match did not yield significant results, with only the size of a program approaching significance. This novel comprehensive survey of forensic fellowship directors offers a model for assessing and monitoring the evolution of application processes for medical subspecialties interested in expanding and improving their recruitment.

Sociodemographic Variables in Offender and Non-Offender Patients Diagnosed with Schizophrenia Spectrum Disorders-An Explorative Analysis Using Machine Learning.

With the growing availability of medical data and the enhanced performance of computers, new opportunities for data analysis in research are emerging. One of these modern approaches is machine learning (ML), an advanced form of statistics broadly defined as the application of complex algorithms. ML provides innovative methods for detecting patterns in complex datasets. This enables the identification of correlations or the prediction of specific events. These capabilities are especially valuable for multifactorial phenomena, such as those found in mental health and forensic psychiatry. ML also allows for the quantification of the quality of the emerging statistical model. The present study aims to examine various sociodemographic variables in order to detect differences in a sample of 370 offender patients and 370 non-offender patients, all with schizophrenia spectrum disorders, through discriminative model building using ML. In total, 48 variables were tested. Out of seven algorithms, gradient boosting emerged as the most suitable for the dataset. The discriminative model finally included three variables (regarding country of birth, residence status, and educational status) and yielded an area under the curve (AUC) of 0.65, meaning that the statistical discrimination of offender and non-offender patients based purely on the sociodemographic variables is rather poor.

Self-induced extreme intoxication akin to automatism: A psycholegal tug of war.

Self-induced extreme intoxication akin to automatism (SIEA) is a complicated and controversial legal concept resistant to jurisdictional consensus. In the United States, SIEA has, at times, been considered under the concept of "settled insanity.". In the United Kingdom, the defense may be allowed for specific intent crimes, though the defendant's awareness of the foreseeability of risk is addressed at trial. In Canada, recent jurisprudence has led to legal and practice landscape changes related to self-induced extreme intoxication. Here, we provide an overview of automatism and an update on the Canadian perspective with a review of the facts and an analysis of the Supreme Court of Canada's landmark decision in R v. Brown, where the court permitted the SIEA defense to be utilized for general intent crimes and acquitted Matthew Winston Brown, a 26-year-old male with no history of mental illness, with respect to two counts of "break and enter" and one count of "aggravated assault." We review the social and legislative response to the changing case law as well as related implications for expert testimony, which may be provided by forensic mental health professionals. Given the judicial and legal implications of the recent changes for both perpetrators and victims of violent crime and given the dynamic international landscape on extreme intoxication in criminal law, the review is thought to be of interest to a broad category of stakeholders including policymakers and those working in forensic psychiatry and law.

Organization of Work on Collecting an Empirical Base for Clarifying the Biological Criteria of Sanity, Limited Sanity, and Insanity (Pilot Project)

The science of criminal law and forensic psychiatry do not draw clear boundaries between the biological criteria of sanity, limited sanity, and insanity. The paper is devoted to the consideration of the prospects for using modern achievements of neuroscience to clarify the boundaries of biological criteria of sanity, limited sanity, and insanity. The paper provides information on the current state of development of neuroscience in terms of research using neuroimaging methods of the brain of individuals committing criminal offenses. The feasibility of conducting relevant research in Russia is substantiated and an option for organizing such work in the form of a pilot project is proposed. In particular, it is proposed to create a single information database, which is supposed to reflect brief information about persons who have committed criminal acts, about the acts they are accused of, and the results of neuroimaging of the brains of these persons. Several stages of organizing work on collecting an empirical base to clarify the biological criteria of sanity, limited sanity, and insanity are identified and described. Particular attention is given to the issue of the legality of compulsory neuroimaging studies in relation to persons who have committed criminal offences.

Investigation of bias in the automated assessment of school violence

ObjectivesNatural language processing and machine learning have the potential to lead to biased predictions. We designed a novel Automated RIsk Assessment (ARIA) machine learning algorithm that assesses risk of violence and aggression in adolescents using natural language processing of transcribed student interviews. This work evaluated the possible sources of bias in the study design and the algorithm, tested how much of a prediction was explained by demographic covariates, and investigated the misclassifications based on demographic variables. MethodsWe recruited students 10–18 years of age and enrolled in middle or high schools in Ohio, Kentucky, Indiana, and Tennessee. The reference standard outcome was determined by a forensic psychiatrist as either a “high” or “low” risk level. ARIA used L2-regularized logistic regression to predict a risk level for each student using contextual and semantic features. We conducted three analyses: a PROBAST analysis of risk in study design; analysis of demographic variables as covariates; and a prediction analysis. Covariates were included in the linear regression analyses and comprised of race, sex, ethnicity, household education, annual household income, age at the time of visit, and utilization of public assistance. ResultsWe recruited 412 students from 204 schools. ARIA performed with an AUC of 0.92, sensitivity of 71%, NPV of 77%, and specificity of 95%. Of these, 387 students with complete demographic information were included in the analysis. Individual linear regressions resulted in a coefficient of determination less than 0.08 across all demographic variables. When using all demographic variables to predict ARIA’s risk assessment score, the multiple linear regression model resulted in a coefficient of determination of 0.189. ARIA performed with a lower False Negative Rate (FNR) of 15.2% (CI [0 – 40]) for the Black subgroup and 12.7%, CI [0 – 41.4] for Other races, compared to an FNR of 26.1% (CI [14.1 – 41.8]) in the White subgroup. ConclusionsBias assessment is needed to address shortcomings within machine learning. In our work, student race, ethnicity, sex, use of public assistance, and annual household income did not explain ARIA’s risk assessment score of students. ARIA will continue to be evaluated regularly with increased subject recruitment.

"Prototypic personality disorder" and the social issue: The category of psychopathy in Polish psychiatry in the interwar period.

The category of psychopathy has a long history, and its meaning has undergone a notable evolution since its conception in the 19th century. The history of psychopathy has been concentrating mainly on English- and German-speaking psychopathology. This article investigates definitions of psychopathy, its classification, and social issues associated with this category in Polish psychiatry in the interwar period. Polish definitions of psychopathy were influenced predominantly by Ernst Kretschmer's constitutional theory as well as by Eugen Kahn's, William Stern's, and Kurt Schneider's ideas. The term was generally understood as a borderline category denoting states between health and mental illness. As those states could manifest differently, it was thought to be many psychopathies. Two Polish psychiatrists, Maurycy Bornsztajn and Jakub Frostig, presented comprehensive classifications of psychopathies. Social issues associated with the category of psychopathy concentrated on three topics: psychopathy in children as a problem of the prevention of mental disorders; psychopathy as a problem of the justice system, the penitentiary, and military systems; and psychopathy as an issue of eugenics and social usefulness. Polish psychiatrists highlighted the need for the development of national institutions for the care of psychopathic children. Issues of accountability and insanity of psychopaths from the point of view of forensic psychiatry were also discussed. In conclusion, psychopathy in interwar Polish psychiatry was not just one of the personality disorders-it denoted the whole spectrum of characterological disturbances; thus, it rather corresponds to the modern category of personality disorders than to the contemporary understanding of psychopathy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Value of Social Positioning Inside a Forensic Psychiatry Service. An Ethnographic Account from a Residence for the Execution of Security Measures (REMS)

The Value of Social Positioning Inside a Forensic Psychiatry Service. An Ethnographic Account from a Residence for the Execution of Security Measures (REMS)