Alec Buchanan

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

BACKGROUND Although mental incapacity is becoming increasingly important in clinical practice, little information is available on its frequency in medical inpatients. We aimed to estimate the prevalence of mental incapacity in acutely admitted medical inpatients; to determine the frequency that medical teams recognised patients who did not have mental capacity; and to identify factors associated with mental incapacity. METHODS Over an 18-month period, we recruited 302 consecutive acute medical inpatients. Participants were assessed with the MacArthur competence tool for treatment and by clinical interview. Cognitive impairment was measured by the mini-mental state examination. FINDINGS 72 (24%) patients were severely cognitively impaired, unconscious, or unable to express a choice and were automatically assigned to the incapacity group. 71 (24%) refused to participate or could not speak English. Thus, 159 patients were interviewed. Of these, 31% (95% CI 24-38) were judged not to have mental capacity. For the total sample (n=302), we estimated that at least 40% did not have mental capacity. Clinical teams rarely identified patients who did not have mental capacity: of 50 patients interviewed, 12 (24%) were rated as lacking capacity. Factors associated with mental incapacity were increasing age and cognitive impairment. INTERPRETATION Mental incapacity is common in acutely ill medical inpatients, and clinicians tend not to recognise it. Screening methods for cognitive impairment could be useful in detecting those with doubtful capacity to consent.

Rates of violence in patients classified as high risk by structured risk assessment instruments

Background Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies. Aims To analyse the variation in rates of violence in individuals identified as high risk by SRAIs. Method A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity. Results Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study. Conclusions After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.

Costs of criminal justice involvement among persons with serious mental illness in connecticut.

OBJECTIVE This study sought to describe patterns and costs of criminal justice involvement among adults with serious mental illness who received services across public agencies within a single state. Costs were examined from the perspective of state agencies providing mental health, substance abuse, and criminal justice services. METHODS Administrative records for 25,133 adults who were served by the Connecticut Department of Mental Health and Addiction Services (DMHAS) during fiscal years 2006 and 2007 and who had a diagnosis of schizophrenia or bipolar disorder were matched with records of the state Medicaid program, Judicial Branch, Department of Correction, and Department of Public Safety. Unit costs for service events were combined with utilization data to calculate costs per person. RESULTS About one in four individuals was involved with the justice system during the two-year period. The justice-involved group incurred costs approximately double those of the group with no involvement-

Violence in psychosis: estimating the predictive validity of readily accessible clinical information in a community sample.

48,980 compared with

Forensic psychiatry and public protection

24,728 per person. Costs were shared by several state agencies and Medicaid. DMHAS bore the largest proportion of state service costs, covering 49% of total costs for persons with justice involvement and 69% of costs for those without involvement. CONCLUSIONS Criminal justice involvement is a complex and costly problem that affects a substantial proportion of adults with serious mental illness who receive services across state agencies. Applying per-person cost estimates in other states could help mental health and criminal justice systems to better plan, coordinate, and deliver cost-effective services to individuals with serious mental illness who become involved with the criminal justice system.

Violence risk assessment in clinical settings: being sure about being sure.

OBJECTIVE This study sought to assess the validity of different combinations of readily available clinical information in predicting assaults by patients with psychosis, predominantly in the community. The combinations of information were: a) age and sex, b) age, sex and history of criminality/violence c) age, sex, history of violence and drug use and d) age, sex, history of violence, drug use and personality disorder. METHOD 708 subjects were followed for 2 years. Assaults were measured using multiple sources of information. Prediction validity was measured using the area under the receiver operating curves (AUC) and the number needed to detain (NND). A simple prediction tool was developed. RESULTS The AUC values using the four combinations of information were a) 0.65, b) 0.70, c) 0.71, and d) 0.73. Prediction based on combination b), c), and d) implied a NND of 3. A rule based on c), the most accessible information, is suggested as a simple screening tool. CONCLUSIONS Readily available clinical information allowed the prediction of assault over 2 years, in a sample of general psychiatric patients with psychosis, with a level of predictive accuracy comparable to that described using more detailed risk assessment tools. The information used in the predictive model was: age, sex, having committed an assault in the last 2 years (self-report) and having used any drug in the last year (self-report).

Descriptive diagnosis, personality disorder and detention

The prominence of risk in UK social and criminal justice policy creates opportunities, challenges and dangers for forensic psychiatry. The future standing of the specialty will depend not only on the practical utility of its responses to those opportunities and challenges, but also the ethical integrity of those responses.

CRIMINAL CONVICTION AFTER DISCHARGE FROM SPECIAL (HIGH SECURITY) HOSPITAL: THE CIRCUMSTANCES OF EARLY CONVICTION ON A SERIOUS CHARGE

Psychiatrists and psychologists have available structured risk assessment instruments to assess the risk of patient violence. These instruments are also used to help make important legal decisions, including which prisoners will be evaluated for continued detention at the end of their sentence. The predictive validity of structured instruments has been demonstrated in operationally defined groups. Their application to individual cases has led to objections that the standard deviations for the risk categories generated by the instruments overlap significantly. This debate has paid insufficient attention to the differences between aleatory (statistical) and epistemic (degree of confirmation) approaches to uncertainty. The approach to uncertainty in psychiatric violence risk assessment is, of necessity, largely epistemic. Providing statistical data can only be part of establishing the precision of an estimate of the probability of someone acting violently.

Does ‘like predict like’ when patients discharged from high secure hospitals re-offend? An instrument to describe serious offences

By contributing to the detention of people who could not otherwise be detained, psychiatric diagnoses differ from diagnoses elsewhere in medicine. Legal changes in the US and draft legislation in the UK extend the role that the diagnosis of personality disorder plays in authorising detention. This paper examines the degree to which the diagnosis is valid for purposes beyond description. The criterion most frequently invoked to demonstrate that psychiatric diagnoses are valid for purposes other than description is dysfunction. Two aspects of the personality disorders have limited the ability of dysfunction to distinguish normal from abnormal personalities. These are the relative temporal stability of a sufferers level of function and the absence of characteristic patterns of dysfunction associated with particular symptoms and signs. Continued efforts to improve the validity and reliability of diagnostic categories should be accompanied by explicit descriptions of the uses for which those categories are valid. Appropriate structuring of legislation can minimise the difficulties that attend the use of systems of classification in settings for which they were not designed.

Predicting violent offences by released prisoners

Forty patients who left the three high security (“special”) hospitals for England and Wales between 1987 and 1991 went on to be convicted of a serious offence by 31 January 1993. The aims of the study were to describe their characteristics, their psychiatric care and the circumstances of the offences. A comparison group, matched for time at risk but unmatched on other variables, was generated by identifying, for each subject, the next patient to be discharged who had not re-offended by 31 January 1993. Eight of the 40 who went on to be convicted of a serious offence left special hospital with no psychiatric follow-up and for a further five only informal arrangements were made. Of the 27 who left special hospital under supervision, 11 dropped out of that supervision in the period (mean 1.7 years) between discharge and offence. [Compared with patients discharged at the same time and not convicted the 40 were significantly younger, less likely to have been educated in ordinary schools, more likely to have a history of alcohol withdrawal and had more criminal convictions. In special hospital the 40 were more likely to have been detained under the legal category of psychopathic disorder, had shorter admissions and their discharge had more often been disputed by their clinical team. At discharge, the 40 were less likely to be prescribed neuroleptic medication and they were more likely to have been discharged directly into the community.] Most instances of serious re-offending after discharge are not the result of patients stopping taking medication and are not the consequence of mental state changes being observed and ignored by treating teams.