Andrew Carroll

Clinical hopes and public fears in forensic mental health

Forensic mental health services are charged with two potentially conflicting tasks: public protection and ethical patient care. The challenge to fulfil these dual roles is most acute when considering the prolonged detention of patients who have been acquitted of serious violent offences on grounds of insanity, or found unfit to stand trial. The duration of their hospital stay often far exceeds that required to treat the most acute manifestations of their illness. Despite this, it is often argued that the seriousness of the offence should not be taken into account when determining duration of hospitalization. This paper argues that risk assessment is a complex process, involving consideration of many factors in addition to acute symptomatology. All such assessments carry an inherent level of uncertainty, which can be minimized by lengthy rehabilitation and assertive community care. It is argued that authorities are justified in considering the seriousness of the index offence when making judgements as to what level of uncertainty in risk assessment can be considered acceptable in the long term management of forensic patients. The implications of this for services, legislators and politicians are discussed.

Are violence risk assessment tools clinically useful

Despite increasing concerns regarding the prevalence of violent behaviour in mainstream mental health settings, the impressive body of forensic research on violence risk assessment has thus far had only limited impact on front-line general mental health practice. The common objection raised by clinicians that risk assessment tools lack utility for clinical practice may contribute to this. The present paper argues that this objection, although understandable, is misplaced. Usage of appropriate, validated risk assessment tools can augment standard clinical approaches in a number of ways. Some of their advantages derive simply from having a well-structured approach, others from consideration of specific kinds of risk factors: ‘static’ and ‘dynamic’. The inappropriate use of tools without a firm evidence base, however, is unlikely to enhance clinical practice significantly.

Community outcomes of mentally disordered homicide offenders in Victoria.

Objective: The aim of the present study was to describe characteristics and post-release outcomes of Victorian homicide offenders under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 (and/or its forerunner legislation) released from forensic inpatient psychiatric care since the development of specialist forensic services. Method: A legal database identified subjects meeting inclusion criteria: hospitalized in forensic psychiatric care due to finding of mental impairment or unfitness to stand trial for homicide in Victoria; released into the community; and released between 1 January 1991 and 30 April 2002. Using clinical records, demographics, index offence, progress in hospital, diagnosis, psychosocial and criminological data were obtained. Outcomes (offending or readmission into secure care) were obtained from the clinical records. Results: Of the 25 subjects, 19 (76%) were male. Primary diagnoses on admission to forensic hospital care were schizophrenia, n = 16 (64%); other psychotic disorder, n = 5 (20%); depression, n = 3 (12%); and personality disorder, n = 1 (4%). Mean time in custodial supervision was 11 years and 2 months, less for those whose offence occurred after the development of forensic rehabilitation services. In the first 3 years after release, there was a single episode of criminal recidivism, representing a recidivism rate of 1 in 25 (4%) over 3 years. Twelve subjects (48%) were readmitted at some point in the 3 year follow up. Conclusion: There was a very low rate of recidivism after discharge, but readmissions to hospital were common. Lengths of custodial care were reduced after the introduction of forensic rehabilitation facilities. Recidivism is low when there are well-designed and implemented forensic community treatment programmes, consistent with other data suggesting a reciprocal relationship between safe community care and a low threshold for readmission to hospital, lessening re-offending at times of crisis. Further research should be directed at timing of release decisions, based on reducing identified risk factors to acceptable levels.

Managing aggression and violence: the clinician's role in contemporary mental health care.

Objective: From time to time misconceptions about violence risk assessment raise debate about the role mental health professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This paper will address some of the misconceptions about risk assessment in those with serious mental illness. Methods: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowledge and discussion they have reviewed the literature to form their opinions. Results: This paper reflects the authors’ views. Conclusion: There is a modest yet statistical and clinically significant association between certain types of mental illness and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of case-specific factors to inform appropriate management interventions to reduce the identified risk.

Risk Assessment and Management in Practice: The Forensicare Risk Assessment and Management Exercise:

Objective: There is an emerging consensus that the assessment and management of adverse outcomes in mental health, such as violence and self harm, is best achieved by approaches which incorporate validated tools using “structured professional judgement”. Although several useful tools have emerged from the literature, there is no clear consensus on the best way to integrate these with clinical practice. This paper describes a framework, the Forensicare Risk Assessment and Management Exercise (F.R.A.M.E.), employed by a statewide community forensic mental health service, which incorporates two structured professional judgement tools, and explicitly integrates these into case management and psychiatric treatment. The potential benefits of the framework are discussed in the context of contemporary trends in risk assessment and management. Conclusions: The F.R.A.M.E. appears to assist with the task of integrating risk assessment with clinical management. Formal evaluative research is indicated before it can be recommended for use by other services.

Treatment and security outside the wall: Diverse approaches to common challenges in community forensic mental health

This article describes the Community Forensic Mental Health Services in Australia and their different service models. It discusses the service models used and why they have developed this way. The interface between CFMHS, mainstream mental health and secure inpatient forensic mental health services needs to be clear and common issues are outlined. The future directions for CFMHS are suggested, which include demonstrating that CFMHS are effective in delivering what they profess to do.

Drug-associated psychoses and criminal responsibility.

At present, the law draws a distinction when assigning criminal responsibility to those who commit offences while experiencing psychotic symptoms: if the symptoms are believed to arise because of ingesting drugs (an external cause), the offender is generally convicted of the offence; if the symptoms arise from a mental illness (an internal cause), the offender may be afforded a defence of insanity. In practice, drawing such a distinction can be problematic. There are difficulties for example in determining criminal responsibility when the use of drugs is followed by the emergence of a psychotic illness process that then continues to have an independent existence even in the absence of the ongoing substance use. This article analyses legal, policy, and expert witness perspectives relating to liberal, conservative, and intermediate approaches to this problematic area of jurisprudence.

Monitoring in clozapine rechallenge after myocarditis

On day 26 post-rechallenge, while the patient was on a daily clozapine dose of 137.5 mg, a troponin rise to 0.04 μ g/L was noted. The troponin level peaked at 0.17 μ g/L and returned to normal within one week. This coincided with mild elevation in CRP that peaked at 16.2 mg/L. During this time, three echocardiography studies were performed, all of which showed normal systolic function and the dose of clozapine was maintained at 137.5 mg daily. The patient did not complain of any cardiac symptoms and no remarkable fi ndings were noted on physical examination or ECG.

Depressive Rage and Criminal Responsibility

Violence committed in the setting of rage poses particular challenges with respect to determining criminal responsibility. One such challenge relates to the fact that even moderately severe, nonpsychotic depressive disorders can increase the risk of episodes of violent rage. A recent Victorian case demonstrates two of the issues raised in such circumstances: the possible conflation of lowered impulse control with disordered reasoning, and the distinction between fleeting mental states and enduring severe mental disorders. The possible implications of a broad interpretation of mental impairment defences are discussed.

Risk management in public mental health.

The Medical Colleges can take a leading role in the process of advocating for better healthcare for severe eating disorders. This is happening in the UK, where a group of psychiatrists, physicians and general practitioners have written guidelines for the ‘Management of Really Sick Patients with Anorexia Nervosa’, which have been adopted by their medical colleges.2 The working group was convened after a series of avoidable deaths and ‘near misses’ among patients with eating disorders in UK hospitals. They identified the main causes of fatalities as the unrecognised severity of the medical problems associated with eating disorders, inadequate capacity in specialist eating disorder services within the National Health Service and the poor delivery of liaison psychiatry. Equally, senior members of our medical colleges might take a similarly constructive role around Australia and New Zealand to address problems with the combined medical and psychiatric care for young people with severe eating disorders.