High Security Hospital Patients Research Articles

Effectiveness of paliperidone depot injection in seriously violent men with comorbid schizophrenia and dissocial personality disorder in a UK high-security hospital.

High-security hospital patients are often complex in presentation and are characterized by treatment resistance, medication nonadherence and history of violence. Paliperidone is licensed both as an oral and depot antipsychotic medication in the treatment of schizophrenia. Clinical trials have shown that paliperidone depot is well tolerated with similar efficacy to risperidone depot but with additional practical advantages. Whilst data exist for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder. Our aim was to evaluate the effectiveness of PP on violence, aggression and personality disorder symptoms. This project was a retrospective service evaluation involving 11 patients, carried out in a high-security hospital. A combination of patient records and interviews with the treating consultant psychiatrist were used to ascertain a Clinical Global Impression (CGI) score, the effect of PP on specific personality disorder symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation) and incidents of violence and aggression. Engagement with occupational and psychological therapies was also evaluated. Metabolic parameters were reviewed. A total of 6 out of 11 patients continued on PP, most of whom had schizophrenia and dissocial personality disorder with histories of violence. All showed improvement in the CGI score with associated benefits in the three personality symptom domains. Overall, two patients demonstrated a reduction in the risk of violence. There was improvement in engagement with occupational therapy and psychological work. No significant effects on metabolic parameters were noted although hyperprolactinaemia, albeit asymptomatic, was consistently recorded. This pragmatic service evaluation of a small but complex patient group demonstrated, for the first time, that PP was effective in reducing violence as well as improving personality pathology across all dimensions: a finding which could have significant implications for management of such high-security patients.

Religious conversion among high security hospital patients: a qualitative analysis of patients’ accounts and experiences on changing faith

ABSTRACTResearch has shown the importance of religion in recovery from mental illness. Previous studies have investigated why individuals change faith during custody in prison, but there has been no research to date on religious conversion in forensic-psychiatric hospitals. The aim of this study was to understand the experience of religious conversion among patients detained in a UK secure hospital. Thirteen patients who had converted their religion were interviewed and the resultant data were analysed using thematic analysis. Three superordinate themes (“reasons for changing faith”, “benefits of having a new faith” and “difficulties with practising a faith”), incorporating eight subordinate themes, emerged. Understanding patients’ reasons for religious conversion is important for the treatment and support not merely of these individuals, but more broadly with patients in forensic-psychiatric care.

Eight decades of mortality in an English high‐security hospital

Psychiatric patients are known to have poorer physical health than the general population and to have premature mortality, but the impact of institutional care on the physical health of patients is less clear. This study aimed to compare mortality rates and causes of death between a high-security psychiatric hospital cohort and the general population in England for the periods 1920-1961 and 1972-2000. Data were obtained from various clinical and non-clinical archives and death certificates. Standardised mortality ratios were calculated for all causes of patient death for each International Classification of Diseases, 10th Edition category. Mortality rates of men ever resident in Rampton Hospital were similar to those of men in the general population, but women in Rampton Hospital had nearly twice the national death rate. Younger men in the latest time period (1972-2000), however, had a higher mortality rate. Higher mortality rates in the hospital than in the general population were accounted for by infectious and parasitic diseases as well as diseases of the nervous system; rates of neoplasms and diseases of the blood and of circulatory or respiratory diseases were lower among the patients. Specific-cause mortality rates were compatible with our working hypothesis that the hospital could in some ways pose risks and in other ways be protective. Morbidity and causes of premature death may be environment-specific, so recognition of the types of illness linked to premature death among high-security hospital patients could inform improvements in the physical health of long-stay patients. Further longitudinal studies should be undertaken to monitor trends and inform changes needed to reduce premature mortality. Copyright © 2015 John Wiley & Sons, Ltd.

The Index Offence Representation Scales; a predictive clinical tool in the management of dangerous, violent patients with personality disorder?

Forensic mental health professionals attach considerable importance to their patient's description of his or her index offence. Despite this, there is no systematic approach to examining and formulating the patient's offence narrative. To use the index offence narratives and capacity to mentalize of violent offender-patients with personality disorder to develop a tool to predict their progress and to evaluate that tool. In a prospective, cohort study, the index offence narratives of 66 violent high security hospital patients with personality disorder were obtained from a semi-structured interview and used to generate the Index Offence Representational Scales (IORS). The predictive validity of these scales was investigated across a range of outcome variables, controlling for the association between initial and final value of the dependent variable. The degree to which patients held internal representations of interpersonal violence and malevolence, as measured by the IORS, predicted subsequent violent behaviour. In contrast to their actual aggressive behaviour, these patients rated themselves as having fewer symptoms on the Symptom Checklist-90-R (SCL-90-R) and fewer problems in interpersonal relationships on the Inventory of Interpersonal Problems. A more empathic victim representation on the IORS predicted better engagement with treatment. The IORS show promise for helping clinicians formulate the early institutional pathway of seriously violent people with personality disorder, particularly with respect to their overt aggression and prosocial engagement. Replication studies are, however, indicated.

Group psychoeducation for long‐term offender patients with schizophrenia: An exploratory randomised controlled trial

Psychoeducation is now commonly provided in forensic settings, but its effectiveness among long-term offender patients with schizophrenia has not yet been established in randomised controlled trials (RCTs). To test the effects of a brief group psychoeducation programme for offenders with schizophrenia (n = 39) resident in a high-security hospital (Niuvanniemi Hospital, Finland). High-security hospital patients were randomised into either eight sessions of group psychoeducation or 'treatment as usual' (TAU). Outcome measures, made at baseline, immediately post-treatment, and 3 months after that, included knowledge about illness, insight, compliance, attitudes towards medication, psychiatric symptoms and ward behaviour, self-esteem, health-related quality of life and perceived stigma. Three months after completing treatment, or an equivalent time under TAU, patients in the intervention group showed a positive treatment effect in terms of knowledge about illness, self-esteem and insight into the illness. The only possible adverse effect was a slight increase in irritability, but this did not translate into behaviour of concern to staff. Our sample size was small, and the findings must be regarded as preliminary, but the positive treatment effect of psychoeducation, and the absence of alarming side effects, suggests a full scale trial would be worthwhile. Most encouraging was that even the most severely ill patients were able to join the groups.

Suicide in high security hospital patients

People with mental disorder and people who are violent are separately recognised as being at high risk of suicide. People detained in high security hospitals are recognised for their violence to others, but perhaps less so for their suicide potential. We aimed to investigate suicide rates among such patients during and after their high security hospital residency, and to establish risk factors for suicide. We extracted data from the Special Hospitals' Case Register on each person resident at any time between 1 January 1972 and 31 December 2000. Suicide rates were calculated for the whole period. We compared rates to the general population using standardised mortality ratios (SMRs). We used poisson regression to estimate the effects of gender, legal category of detention, offending history and length of admission on the suicide rate. Of the 5,955 individuals, 218 completed suicide. The suicide rate was nearly 7 times higher among resident men (SMR 662, 95% CI 478-845) and over 40 times higher in resident women (SMR 4,012, 95% CI 2,526-5,498) than in the general population; it was 23 times higher (SMR 2,325, 95% CI 1,901-2,751) and 45 times higher (SMR 4,486, 95% CI 2,727-6,245) among post-discharge men and women, respectively. The suicide rate was significantly higher among women than men inside high security but not after discharge. The suicide rate among high security hospital patients was significantly higher than in the general population. Women were especially at risk while resident, whereas for men, the risk was higher after discharge.

Usefulness of the CANFOR‐S for measuring needs among mentally disordered offenders resident in medium or low secure hospital services in the UK: a pilot evaluation

The short form of the forensic version of the Camberwell Assessment of Needs (CANFOR-S) (Thomas et al., 2003) is of potential value in all clinical forensic settings, but so far reported mainly with high security hospital patients. To conduct a pilot study of the feasibility of using the CANFOR-S in medium and low security hospital units and to report preliminary findings there. Thirty-six of 38 patients on one medium secure ward for women, one low secure ward for women and one low secure ward for men, all in the same hospital, agreed to participate in the study. Staff and patients completed the CANFOR-S as part of a larger formal assessment package. All the women and 18 of the 20 men completed the CANFOR-S. It was found to be easy and quick (25 minutes) to use, and acceptable. Staff and patient ratings were similar on all but one item: needs with regard to safety to others, with staff consistently rating more. Men and women were similar in number of needs, but had different needs profiles. Those in medium security were generally more needy than those in low security. The CANFOR-S is feasible for clinical practice, with results perceived as useful in treatment planning by patients and staff. More widespread use could improve service planning.

Mentally disordered offenders in Zimbabwe and in England and Wales: a socio-demographic study

Our aim was to compare socio-demographic, clinical and criminal characteristics of mentally disordered offender patients in a special institution in a developing and a developed country. Zimbabwe data from 1980-1990 was obtained from a hospital patient survey, in a written semistructured format. The English special (high security) hospital patients' data for the same period was obtained from the case register. The sample size for Zimbabwe was 367 patients (337 males, 30 females) and for England and Wales it was 1,966 patients (1,643 males, 323 females). The average age for Zimbabwean patients was 36 years, with standard deviation of 9.7; for England and Wales the average age was 29.7 with standard deviation of 9.6. There was significant difference in marital status in the two countries. Seventy-eight per cent of patients were single in England and Wales, compared with 49% in Zimbabwe. There were 20% illiterate patients in Zimbabwe, compared with 4% in England and Wales. Thirty-seven per cent of the patients in England and Wales had a diagnosis of personality disorder, compared with 6% in Zimbabwe. There were 53% of homicides in Zimbabwe, compared with 20% in England and Wales. Employment in the two countries was similar: 34% in Zimbabwe and 33% in England and Wales. There were differences in the socio-demographic characteristics in the two countries, except for employment status. Differences were also noticed in the diagnoses of the patients, types of crime and the methods of assault.

What's in a name? Reasons for changing names among english high security hospital patients

Up to one fifth of offender patients change names, but their reasons for this have not been studied. This study investigates reasons for name change among serious offender patients. All patients resident in an English high security hospital with documented name changes were approached for interview. Semi-structured interviews were conducted by one person (BV). Audio-transcripts were analysed using qualitative methodology. Two main groups emerged: those who changed name(s) once or twice and those who had multiple name changes. For the former, three major themes of changing emerged: making or breaking family ties, wanting a fresh start, and difficulties with the name itself. Multiple changers were more idiosyncratic in their reasons for name changing and choice of name and achieved little satisfaction with the changes. We conclude that understanding the reasons for name change among people with mental disorders is important for their continuing treatment, as it may indicate internal mental change.

A form of relapse prevention for men in a high security hospital

Marlatt and Gordon's relapse prevention model has evolved, and been applied to many repetitive problem behaviours, including drug use, gambling and sexual offending. High security hospital patients often present with a number of such behaviours. To evaluate a relapse prevention group in one high security hospital. Nine patients were selected on clinical need for the group. In a naturalistic study design, each completed several self-report questionnaires pre- and post-group. Analysis of group results demonstrated a significant increase in guilt and acceptance of responsibility for offences (GBAI ratings), and reduced endorsement of pro-offending thinking styles (PICTS). Movement towards increased empathy, and decreased impulsivity and venturesomeness, did not reach significance. All participants showed some changes in desired directions but effects were small. Both relapse prevention and its evaluation are limited in high security hospitals by the restricted opportunities for testing out new skills. The feasibility of delivering an RP programme and evaluating it in high security has nevertheless been established. The small effects found may be promising, and suggest both justification and need for a randomized controlled trial of this approach in that setting.

A Re-Conviction Study of Special (High Security) Hospital Patients

Reliable patient re-conviction data after leaving high security hospitals are of public interest, but official statistics are without context and sometimes incomplete. Some patient sub-groups are rarely studied. Our study describes re-convictions for a complete national annual high security hospital discharge cohort. We hypothesized that: established community living would precede re-conviction and that more people with personality disorder would be re-convicted, with a higher rate, than people with other disorders, even allowing for community time. Cases were identified using the special hospitals' case register; follow-up data were from multiple records sources. Seventy-four patients (38 per cent) were convicted after discharge, 26 per cent of serious offences. All 10 multiple reoffenders (>9 offences) were men. Fourteen per cent of those re-convicted had offended during institutional residence. Median time to first community re-conviction was under two years. Logistic regression analysis confirmed that people with personality disorder were seven times more likely than people with mental illness to be convicted of a serious offence after discharge. Methodological procedures that maximize validity of findings are discussed.

Personality disorders, psychopathy and other mental disorders: co-morbidity among patients at English and Scottish high-security hospitals

Mental health legislation in Britain has traditionally encouraged a distinctionbetweenpersonality disordered andmentally ill offenders, butresearchon co-morbidity indicates that few patients exhibit an Axis I or an Axis II disorder in isolation. This study compared male high-security hospital patients in the English Mental Health Act categories of psychopathic disorder (n=54) and mental illness (n=61) and the Scottish legal category of mental disorder (n = 60), using structured instruments to assess personality disorders, psychopathy and Axis I disorders. The mental illness and psychopathic disorder categories were not differentiated by personality disorders, psychopathy, or Axis I disorders, except for more lifetime drug abuse and more lifetime and current psychosis among the mentally ill. A majority of patients with mental disorder under Scottish legislation also exhibited personality disorders. Grouping by primary clinical diagnosis of personality disorder or mental illness produced few differences on Axis I or Axis II, and overall there was a relatively strong correlation between thepresence of an Axis I and an Axis II disorder. Legal and clinical attempts to separate personality disordered and mentally ill offenders may be ill-conceived because Axis I and Axis II disorders tend to coexist.

Name change among offender patients: an English high security hospital sample.

There is scant literature on change of name among psychiatric patients but a more substantial amount on the use of aliases among offenders. No one to our knowledge has explored name changes among offender patients. This study was undertaken to establish the prevalence of name change among high security hospital patients and to compare those who changed name with those who did not. It was hypothesized that name change would be associated with male gender, repeated offending and a diagnosis of personality disorder. The clinical records of all patients resident in one high security hospital on 31 January 2000 were searched. As all such patients are compulsorily detained, all name changes must be recorded. Any change prior to that date was also noted, together with basic demographic and diagnostic information; supplementary data were obtained from the special hospitals' case register. Seventy-one patients (17%) of the resident population changed names (exclusive of a woman changing her surname on marriage). Name changing was associated with disrupted upbringing. Patients with personality disorder were more likely to change names than those with psychosis, regardless of sex, age or ethnic group. Those with psychosis were more likely to select unusual or symbolic names. On the evidence of previous literature, people from this serious offender patient population were more likely to change names than other psychiatric patients but less likely than non-mentally-disordered offenders. Changes by people with psychosis seemed related to their illness, whereas changes by those with personality disorder might reflect childhood disruptions in rearing patterns.

Follow-up of serious offender patients in the community: multiple methods of tracing.

Longitudinal studies of people with mental disorder are important in understanding outcome and intervention effects but attrition rates can be high. This study aimed to evaluate use of multiple record sources to trace, over 12 years, a one-year discharge cohort of high-security hospital patients. Everyone leaving such a hospital in 1984 was traced until a census date of 31 December 1995. Data were collected from several national databases (Office for National Statistics (ONS), Home Office (HO) Offenders' Index, Police National Computer Records, the Electoral Roll) and by hand-searching responsible agency records (HO, National Health Service). Using all methods, only three of the 204 patients had no follow-up information. Home Office Mental Health Unit data were an excellent source, but only for people still under discharge restrictions (<50% after eight years). Sequential tracing of hospital placements for people never or no longer under such restrictions was laborious and also produced only group-specific yield. The best indicator of community residence was ONS information on general practitioner (GP/primary care) registration. The electoral roll was useful when other sources were exhausted. Follow-up of offenders/offender-patients has generally focused on event data, such as re-offending. People untraced by that method alone, however, are unlikely to be lost to follow-up on casting a wider records net. Using multiple records, attrition at the census was 38%, but, after certain assumptions, reduced further to 5%.

Route of discharge for special (high-security) hospital patients with personality disorder. Relationship with re-conviction.

A considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals. To examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security. Re-conviction data for a five- to nine-year follow-up were collected for a four-year (1988-1991) special hospital discharge cohort of patients with personality disorder. Individuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals. Formal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

Mental disorder and violence. A special (high security) hospital study.

From a first clinical description of a complete resident sample of special (high security) hospital patients, we examined the association between mental disorder and violence. A record survey of all 1740 patients resident at any time between 1 January and 30 June 1993, inclusive, and, for most, the official criminal record. 1015 patients (58%) had functional psychosis, one-quarter of whom also had an independent personality disorder; 461 (26%) had personality disorders uncomplicated by psychosis, and 264 (16%) had learning disabilities. Pre-admission substance misuse, which was probably under-recorded, had been most common among those with psychosis and an independent personality disorder. Less than 10% had never been convicted of a criminal offence, although 25% had been admitted directly from other hospitals. Direct personal violence was more common among men, and fire-setting among women. Schizophrenia was most strongly associated with personal violence. More than 75% of those with a psychosis were recorded as being driven to offend by their delusions. In the absence of delusions, hallucinations had no such effect. For people with personality disorder better clinical descriptions seem essential. For people with a pure psychosis, as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health.